SD0000021 SUDAN UNIVERSITY OF SCIENCES
A complementary project for B.Sc. degree in Radiation Therapy Technology
THE AFFECT OF MEASUREMENT OF ANGLES AND DlAMENTION : : IN • THE TREATMENT OF CARCINOMA OF THE BREAST USING COBALT-60 TEL-THERAPY MACHINE
SUPPERVISEDBY: Mr. Mohamed El Fadil Department of Radiation therapy Technology College of Medical Radiological Sciences
PERPARED BY: Saeed Mohamed Ibrahim Bafarag Fourth Year (Therapy Section)
31-18 I dedicate this research to the staff of radiotherapy who help and assistant me to succeed and fullfil what I hope to do,
Also I pay my own thanks to everyone who apply help to me particularly MR MOHAMED EL FADIL whose played a major role in building and formation of this issue. Contents:
Chapter One: Research plan 1 Chapter Two:
Anatomy of the breast 7 Physiology of the breast 23 Pathology of the breast 25 Etiology of the breast . 28 Planning of the breast 34 TN pre 'treatment clinical classification 38 Evaluation of treatment 52 Chapter Three:
Data Presentation 55 Chapter Four:
Analysis and result 81 Chapter Five:
Conclusion and recomendation 97 Reference 99 Index . loo Chapter One
First topic: ResQarch plan
Title:
Measurement of dimensions and angles and its affect on cancer of breast treatment
Preface:
Of course cancer is a very harmful word which make people whom attacted by this diseas in bad situation and so their relation.
Breast cancer is a common universal tragedy, maligninant and monstrously destructive of women in their prime of life. It is an ancient an elusive diseas which has claimed its many victims throughout the world and form time immemorial.
By the way we must know that, the trends which are of major significence from a practical point of view in the present day management of breast cancer are the following:
1- Early diagnosis as a result of public education., mammography, sonography, nuclear magretic resonance, self examination technique and other reliable methodes of cancer delection.
2- Pathologic recognition of minimal and very early (subclinical) breast cancer,
3- Trend tov/ard more concerative breast surgeny combined with effective radiotherapy.
4- Chemotherapy as an adjuvant to surgery and radiotherapy in the treatment of primary breast cancer improved programs for post operative care and rehabilitation.
(1) Problem: of the study:
Breast cancer is the most common famale malignancy of midlife and is aleading cause of death amongwomen, that makes it a subject of considerable interest to all concerned.
It is the commenest disease which can be detected early by women, so that can improved treatment methodes such as advances in surgery, radiotherapy, chemotherapy, immunetherapy and hormonetherapy as well as prognosis and rehabilitation.
This research give an information about the experience of the RICK* IN treatment and control of cancer of the breast, Inaddition to that it trys to found an answer and result for the following tobies:
- Evaluation of ca breast* treatment in RICK during year 1989.
- To find out the important of demareation the ideal angle of tangential field.
- To find out the important of dimensions of treatment region. •5 - To find out the danger of missing the wright angle and distance durina treatment the tangest field.
* Satiation i Isotop centre of Khartoum * Cancer of breast .
(2) .Reasons of problem selection:
- Because of heinous of cancer of the breast and its greates damage in human society, in addition to:-
1- Increment of the cancer of breast among Sudanease women. 2- Increment of recurrence among Ca. breast patients. 3~ Carelessness of fields angles and diamention in treatment sheet. 4- Defferential in tangential field treatmed because of dependence in breast shadow sitvation.
All the previous points and others motivate me to cast round for the importance of demarcation angles and dimension in treatment cancer of the breast and to find out its connection with the result of treatment as a fact of success or goff at half cock of the treatment and I have left the other factors as an odds for others studies.
Aim of the study:
The hypothesis which I put it on for this study is that, the use of worg angles and dimension of tangential fields in the treatment of Ca breast lead to;
1- Eccentricity in the entrance and exit of beam. 2~ Missing of homogenous distribution of the radiation in the treatment volume. 3~ Un neccessary irradiation for accessory tissue which may induced certian problem. 4- Increment the possibilities of recurrent,
Objective of the study:
To clear out the importance od demarcation the ideal angles of the tangestial field,
To show the necessity of measuring the requA-r-emnt dimension.
To test out type of the problem arising from the absence of angles demarcation in the treatment sheet. (3) Previous studies:
1- Ca. Breast & self examination techniques Aims and objective of the study:
- To find out the ratio of incidence in Sudan and other contries. -Give a general idea about anatomy and physiolog of the breast. - Build a certain mechanism for self examination.
Study assumption:
The absence of self examination practice lead to late detection of the disease.
Results:
Complete absence of self examination technique practice duto the absence of health education.
Un pleasent feeling caused by the result of detection the disease.
2. Care of cancer's patient;
Aims and objective of the study:
To study the care of patient and the psychology of cancer's patient in RICK and the treatment circle which he came across it and his reception in virous units and how to face sign, symbtom and complication, in addition to the relation ship between the team work and the patient.
Result;
There is no a certain system for care of cancer's patient.
(4) Different between this study and others;-
In this study I aw trying to find the relation between non ideal angles and dimansions in the treatment of Ca. breast and outcame of the treatment.
Research Methodology:
Resources of information:- From information available sources:- - Text books & reference. - Specialist in the field. - Technician/Technologist. - Observation.
Location of research:
Radiation and Isotope centre of Khartoum (RICK) where ionizing radiation is used to treat cancers.
Period of research:
Four monthes from September 1995 to December 1995.
Sampling:
The method of sampling is the random method, that means ages of the patients, social status and level of education are different of the different cases. Second topic:
Articles of Knowlege Gathering:
I have followed the following steps:
1- Observation: Of course I have used scientific observation in which I followed the behaviour of treatment patient in the treatment room in RICK and during this I registered the angles of tangential field which occure duto the shadow of the breast and variety appear clearly between this one and the ideal one later on. (5) 2- Interview:
It is an oral talk between two person in confrontation manner where the interview tries to extractsome information or gestures from the person whom the regearch is concerning. In this research I used open interview by preparing questions,
3- Avialable resources:
These include all text books., reference journals .... etc.
Research dividing:
Chapter One:
First topic- Research plan
Second topic: Articles of knowlege gathering
Chapter two:
Literature Review
Chapter three:
Presentation of data
Chapter Four:
Data analysis and result
Chapter Five:
Conclusion and recomendation Reference Index
(6) Chapter Two
Anatomy of the Breast J*) Form: The human breast has adistinctive and unique protuberant concial form. This conical form is most marked in younger nulliparovs women with advancing age the breast usually become some what flattened and pendulous and less firm. Obesity is the most important factorconcerned with variation in the size, shape and density of the breasts. As women gain weight their breasts become more massive and pendulous. They become so firm and dense that it is much more difficult to detect disease in examining them. Extent: The upper edge of the protuberant breast is usully at the level of the second or third rib and its lower edge is at the level of the sixth or seventh costal cartillage. Medial border is at the edge of the sternum. Lateral border at the anterior axillary line. The actval extent of the mamary tissue is considerably greater. It is spread out as a thin layer that often reaches the lower edge of the clavicle above. The mid line of the sternum medially and the anterior edge of the latissimus dorsi muscle laterally. The upper outer sector contains more breast tissue than the remainder of the breast. The mamary tissue is also extends into the axilla to avariable degree. Size: There is some different in the size of the two breasts. If it is slight it may not be have been noticed by the women because she does not have as good a view of her breasts as a care full examiner. (*) C.D. Haagensen, M.D - Diseas of the Breast -P. (1-2) - Third edition - WB; Saunders Company, Philadephia London Turanto - Mexico City Rioclejaneiro Sydney - Tokyo Hong Kong. (7) Anomalies!*): Abnormal in form or number or position or the absence of normal breast, should be classified as anomalous. Differences in size of entirelly normal breasts or extention of breast tissue into the axilla or so frequant that they can hardly be classified as anomalies. The anomalies of the human breast include the following:- - absences of the breast - rudimentary - definitely abnormal - accessory breasts or nipples. The absence or in complete development of breast is the result of complete or imperfect suppression of the breast anlagen in the embryo. Accessory breast or nupple represent reversion to a mor primitive type of mammary arrangement in which more than a single pair of breast anlagen persist, Amastia(*) Complete absence of one or both breast. Accessory breast tissue(*): Accessory breast tissue is an anomaly that is clearly hereditary. It may occure as any compination of three components of the breast -its glandular and ductal parynchyma, the areola, or the nipple - or as a single element. The most frequent combination is a small areola and a nipple. Abnormal breast form(*): Is protrusion of the areola to form dependent sessile tumour. Breast sturcuture(*); In affit ion to its epithelial parenchyma of acini and ducts and their supporting moscular and fagical elements the breast contsists of avarying amount of Fat, blood vessels, nerves, and lymphatics. (*) CD, Haagensen., M.D - Diseas of the Breast - P. (5-8) - Third edition - WB; Saunders Company, Philadephia London Turanto - Mexico Citv Riocleianeiro Sydney - Tokyo Mono Kona. (8) Pectoralis major
Pectoral
,\\
J
br d.
or
obli ue
its relation underline muscles
(9) The epithelial parenchyma is made up of 20 or mor lobes, each emptying into aseparate excretory duct terminating in the nipple. The tabes in their turn are divided into a multitude of lobules, or gland fields, each made up of from 10 - 100 or more acini grouped around acollecting duct. The lobule is thus the basic structural unit of the mammary gland. Fig (2) tell us the following;- The radial arrangement of the lobes glandular tissue. These lobes are comprise of smaller lobules and are seperated from one another by fat and the supporting connective tissue. The lactiferous duct system. Each of the 15-20 lobes has its own duct which opens by means of small orifice onto the nipple. The mammary gland separated from the pectoralis major muscle by the pectoral fascia. The blood supply of the Breast(*): ARTERIES:- The main blood supply is from the perforating branches of the internal" mammary artery. The first, second, third and fourth perforating branches perforate the chest wall near the sternal edge in the corresponding interspaces, and travers the pectorales major muscle to reach the mammary gland a long its medial edge. In the upper interspace there is a series of much smaller perforating oesselse which emerge from the inter costal muscle plane 2 or 3 cm lateral to and paralled with the main perforators. Several branches of the axillary artery also share in providing blood for the breast. The pectoral branch, of the thoracoacromail artery, some of its branch reach the deep surface of the mammary gland, (*) CD. Haagensen, M.D - Diseas of the Breast - P. (17-22) - Third edition - WB. Saunders Company, Philadephia London Turanto - Mexico City Riocleianeiro Sydney - Tokyo Nona Kona. (10) Fat body of
Lactiferous sinus
Lactiferous ducts
Nipple
Mammary lobes'1—^"—•--
Mammary lobules\
Sagital Section thorough mammary gland
(11) Cross section through the breast to show its facials relation ship.
Epidermie 3-4 mm.
Level o£ flap . Saporficial layer of dissection superficial fascia.
Subfascial Coopers ligom&nts vessels
tissue
p yer of superficial fascia R^tromamroaru space Deep £asci {*) Jane Dobbs MRAP, FRCR - Ann Barrett MD, MRCP, FRCR - Daniel Ash ND, MRCP, FRCR. Practical Radiotherapy planning P. (150 - 160), 2 Edition - Edward Arnold - London Melbourne Augkland (13) Grand central lymph .Axil Itiry v Capillary network: 7 V e venous routes of metastases from carcinoma of the breast to the capillary net work of the lung. (14) The axillary lymph nodes:- There are six maingroub of axillary lymph nodes:- 1- The external mammary nodes. 2- The scapular nodes. 3- The central nodes. 4- The axillary vein nodes. 5- The interpectoral nodes. 6- The subclavicular nodes. (1) The external mammary nodes are: - Chain of nodes liebeneath the lateral edge of the pectoralis major, a long the medial side of the axilla, - Following the course of the lateral thoracic artery on the chest wall from the sixth to the second rib. (2) The scapular nodes; - Lies dosely applied to the subscapular vessels and their thoracodorsal branches. - Extent from the point of origine of the subscapular vienfrom the axillary trunk to the insertion of these vessels into the latissimus dorsi muscle and the lateral chest wall. - They cross the axilla toward the arm. - The intercostobrachial nerves thread their way through the nore cephalad of these scapular nodes. (3) The central nodes: . Lies embedded in fat in the centre of the axilla. . One or more of there may be situated surprisingly superficially beneath the skin and fascia of the center of the axilla, half way between the posterior and anterior axillaries folds. . Most easily palpated in the axilla. . They are the largest and the most nevmerous of the axillary nodes. . They are the group of nodes in which metastases most often are found. (4) The interpectoral nodes: . Firs describe by Grossman. . Today called Rotters nodes. . Situated between the pectoralis majar and minor, along the pectoral branches of the thoracoacromail vessels. , They are small and from one to four in number. (15) (5) The axillary vein nodes: . Lies along the lateral portion of the axillary vien, on its caudad and ventral aspects, from the white tendon of the latissimus muscle to apoint just medial to the origin of the thoracoacromail vien, (6) The subclavicular nodes; . The most medial group of the axillary nodes, . Stuated along he venteral and caudad aspects at the axillary vien. , From the a point just medial to the origin of the thoracoacromail vien to the very apex of the axilla, , There are usually several small nodes belonging to this sub clavicular group lying in the areolar tissue in the cervice between the highest point of the axillary vien and the chest wall. The Interal Mammary lymph nodes;- . Are very small, usually measuring between 2 and 5 mm in diameter. . They are found interspersed along the course of the internal mammary trunk lymphalics. . They lie in the fat and areolar tissue upon the endothoracic fascia in the inter space between the costal cartilages. . The typical distribution was four on one side and five on the other, with one node in the upper three inter spaces on each side, and an extra node in one of the upper spaces. (16) Interpectoral or •Rotter nodes Transpcctoi'ai route Axillary veia nodes External, momwotj Mcun colLectmc} lymp>iatic «.. The main groups of Cross section for Lymphatic drainage of the breast 14 (18) 1- Pectoralis major muscle. 2- Pectoralis minor muscle, 3- Serratus mangus muscle. 4- External intercostal muscle, 5- Internal intercostal muscle. 6- Lymphatics from breast to axillary lymph nodes. 7- External intercostal lymphalics, 8- Lymphatics from spinal muscles, 9- Lymphatics from vertebra. 10- Lymphatics from parietal plevra. 11- Lymphatics from posterior intercostal lymph nodes to thoracic duct. 12- Thoracic duct. 13- Internal intercostal lymphatics. 14- Lymphatics from breast to internal memonary 4N. 15- Axillary lymph nodes, 16- Posterior intercostal lymph nodes. 17- Internal mammary lymph node. 18- Lymph nodes of pulmonary pedicle. (19) A. _ B. Clavicl?. Subcutaneous fat Costal car tila Skin Pectoyalis Internal mammary m. lymph nod.es Ext. intercostal Internal mammary art. fascia. Intercostal muscle Endothoracic fascia Transvar.sc thoracic Parietal pleura L—-Skin —Thin medial edge of breast [—Pectoralis major miascle External intercostal fascia [•"Intercostal muscle Internal mammary fascia Encbthoracic fascia and parietal pUura. Visceral pleura. lntemai mananary vein, art«nf alymphr&de Internal mammary lymphatic route: (A) Anterio view (B) Vertical cross section (C) Horizontal cross section, (19) Ventral root Dorsa| roQt Dorsal ramus *•-»., Ventral Ventral root Lateral cutaneous nerve — Dorsal root Dorsal root ganglion ,.- Spinal nerve Dorsal ramus Sympathetic trunk--, (ganglia) ,' Ventral ramus Two roots of greater-<•''' Meningeal branch splanchnic nerve -Ant. cutaneous nerve fi'Nr^C Sympathetic ganglion Rami communicantes - Ramus communicans My. 6 Breast and spinal nerves Figs. 4, 5, 6 I Two Txpical spinal Nerves: Their origin., Bramches and connection to the sympathetic trunk. 1- Each spinal nerve attaches to the spinal cord by two roots; An afferent or sensory dorsal root. An afferent or motor venteral root. Each dorsal root contain aspinal gangtion compraised of afferent nevron cell bodies. 2- The two spinal roots join to form the spinal nerve, which in turn divides into adorsal ramus coursing posteriorly and aventeral ramus cousing anteriorly. During their course, these rami divide further to innervate the body sigment with both sensory and motor fibres. 3- The spinal nerve communicates with the sympathetic trunk carrying preganglionic sxmpathetic fibres to the trunk (white ramus) and post ganglionic fibers from the trunk (gray ramus). . (22) Physiology!*) The breasts are an integral part of the reproductive system and under the control of the same nevroendocrine system. Origin and status in adoleccence: Mammary gland originate early in embryonal life from the same apocrine epithelium from which the axillary sweat glands eventually develop. The fetal breast development has been stimulated by the prolactin, estrogen, and progesterone of placenta! origin, Shortly after birth there is temporary evidence of slight degree of breast secretory function in most babies, The rudimentary breasts appear to enlarge and there is a slight secretion of milky malerial from the nipples. The breasts then relaps into an inactive phase that characterizes them during childhood. The epithelial elements consist of small ducts scattered throughout atibrous stroma. There are no lobules. Change associated with puberty:- Puberty begins with lengthening and branching of ducts from which lobules bud out to form the normal breast structure. This chang produce rather rapid increas in the size and density of the breast as the result of coordinated action by several hormones prolactin, estrogen, progestrone, adrenal steroid, insulin growth hormone and thyroid hormone. Estrozen promotes primarily duct growth, Prolactin & progestron are responsible for tobular development. Menopavsal changes in the breast:- The breast decreas somewhat in size and become less dens and the nodularily diminishs. (23) Changes Associated with the Menstrval Cycle: A few weeks after conception the effect of pregnancy are evident in the breast. They enlarg rapidly and became more firm. The areolar skin glands becames more prominent and the areolur skin darkens. The nipple enlarge and became more erect. These changes are the result of high blood level of estrogen and progestron as well as concentration of prolaetin originaling in the pituitary. (24) Phythology Of The Breast Benign tumours of the Breast: 1. Fibroadenoma. 2. Adenoma of the Breast. 3. Giant fibroadenoma 4. Cystosarcoma phylloes. 5. Intraduet papilloma. (*) Fibroadenoma: 1. Common benign tumour. 2. Around the age of 25 years, 3. Mobile nodule about 2-3 cm. up to 8-10 cm sized giant fibroadenoma may form. 4. The nodule/nodules composed of a mixture of ductal and connective tissue elemenls, 5. Fibroadenoma or fibroadenosis also occure as a part of the fibro cystic diseas. (*) Adenoma of the Breast: 1. Nipple adenoma 2. Tubular adenoma 3. Intro duct papillomon. Nipple adenoma: - Small ill defined nodule growing in lactiferous duct under the areola. It is in fact an intraduct papilloma. - Composed of lightly packed small tubules lined by a single or at time double layer of cell. Tubular adenoma: Is a fibroadenoma in which the fibrous component is minimal. Intraduct papilloma: - Benigne polypoid adenomes growing whithin aduct. - The duct is distendeds and is distorted. - The papilloma consist of branching net worll of simple glandular space. - Tumour less than 3 cm in benign and over 5 cm is malignant. (25) (*)• Cystosarcoma phyllodes: - Large firm fibrous tumour which has both the component of fibro adenoma. - The stroma shows considerable atypia and looks like a sarcoma hence the name a cystosarcoma. - It is not agiant fibro adenoman. Carcinoma breast: •1- The second most lethal of famale after cervical cancer. 2- Commoner in the west than in the eastern hemishere countries. 3. Majarity of cancinoma are ductal in origin and a few are lobular carcinoma. Classification of the Breast cancer: (A) Non invasive cancer: 1- Intraduct carcinoma. 2- Intraduct carcinoma. 3- In situ labular carcinoma. (B) Invasive carcinoma: 1- Invasive duct carcinoma. 2- Medulary carcinoma. 3- Colloid or mucindus carcinoma. 4- Tubular carcinoma. 5- Pagets disease of the Breast 6- Comedocarcinoma. 7- Papillary carcinoma. 8- Fobular carcinoma. * Cancer is common in the lobe breast * Most frequent site in either breast is upper auter quadrant. * The tumour is palpated as a firm to hard. * Fixed mass fixed to deeper structure and or overline skin. * Tumour spread in lymphalic node of the Breast induces fibrosis so that it cavses: 1- Retraction of nipple into the breast surface. 2- An orange peel like dimpled surface dutopoin point retraction of skin. (26) On histology, the feature that are considered indicative of better prognosis are;- 1- Better tubular differentiation. 2- Less pleomorhism of cells. 3- Less hyperchromatism of nuclei. 4- Adens lympho cytic infiltration along the edges of the tumour. "Better Immune Respons to tumour (*) C.D. Haagensen, M.D - Diseas of the Breast - P. (1-2) - Third edition - WB: Saunders Company, Philadephia London Turanto - Mexico City Riocle Janeiro Sydney - Tokyo Hong Kong. (27) Etiology Of Breast Cancer* Breast cancer was the subject of several epidemiologic studies in the last to deades in many areas of the world. The possible etiological factors; 1- Reproductive experience. 2- Overian activity. 3- Effect of age. 4- Race. 5- Age at first birth. 6- Benign Breast Disease. 7- Familial aggregation. 8- Multiple primary cancer. 9- Nutrition. 10- Obesity. 11- Viruses. 12- Ionizing radiation. 13- Genalic predisposition. 14- The role of hormones in developmenr breast cancer. (*) Sherif Omar Breast Cancer, p. 19 —> 31 KORBA (International) Company Ltd. LONDON UK 1988. (28) (1) Reproductive Experience: (a) Pregnancy: The most important aspect seems to be the age at which the women have thier first termchild. The average age at diagnosis was higher in nulliparavs patient than in those who carried at least one pregnancy to term. The average age decreased with the increase in number of births. Women who first deliver be for age 18 have about one - third the breast cancer risk of those whose first delivary is delayed until age 35 or older. The incidence of breast cancer during pregnancy is rare. (b) Laetalion: Mothers who breast fed theirbabies were found to be three times less at risk of deveoloping breast cancer than those who did not nurse. The longer the period of laelalion the lower the risk of breast cancer, (2) Ovarian activity: (a) Ophorectomy: According to the relation of ovarian activity with Breast they found that bilaleral overiectomy before age 44 may still project against breast cancer by approcimalely 50%. Removal of the ovaries at the time of metastasis,, may bring about remission in approximakly 40% of premenopusal women with advance advance breast cancer. (b) Age at menerche: Menerche at before age 17 was associated with a 75% increase in the breast cancer risk. (c) Age at natural menopavies: Late natural menopuse have increased breast cancer risk. (29) (3) Effect of age: In high risk population risk generally increase progressively with age. (4) Race: Ca Breast rates are 5 or 6 times higher in Western Europe and North America than Jaban and nalive African population, (5) Age at first birth: Risk increase regularly with age at first birth. First pregnancy and birth before age 20 year have less than 50% of breast cancer risk than that of the general population. * Benign Breast Disease: Women with fibro cystic disease of the breast or at a 2,64 times increased risk of developing breast cancer, Women with ductular a typia is subiect to a five time greater risk of developing breast cancer than women with no evidence of a typical changes found in the biopsy of a benigna lesion. * Familial Aggiegation: Daughters of affected, women experience the diseas at a younger age than did- their mother. Bilateral disease among young patients with a family history of breast cancer excess. The risk of breast cancer for women with a family history of breast cancer is increased 1,8 fold. * Multiple primary Cancers: 7-10% of women with breast cancer evenually develope contralateral lesion, Premenoprusal women with breast cancer and a familly history of the disease have a bilaterality rate as high as 15,5%, Women with the cancer of uterine corpus have a breast cancer risk 1-2 time mot than that of the population. Breast cancer increase amony women with prior colon cancer. (30) * Nutrition: Breast cancer is a disease of high scioeconomic status, with good quality food. Association between breast cancer and a high-fat diet may include the hypo thesis that intestinal bacteria produce oestrogens from ingested fat, the possibility that fat srves a vehicle for in viromental carcinogens must also be considered. * Obesity: Obese women have increased pripheral conversion of and rostenedoine to estron (El). Obese postmenopausal women produce exessive amounts of oestrogen from this prehormone pathway. * Viruses: Three animal models exist for the viral induction of breast cancer: (a) The mouse mammary tumour virus (M.N.T.V.) (b) The mason pfizer monky virus (M.P.M.V). (c) That rat mammary tumours virus (R. 35 virus). M.M.T.V. : It is now accepted that mouse mamary cancer occuring spontaneously in certain "susceptible mice strains, is a systemic diseas produced by divers factor such as genes or genetic factor. M.P.M.V,: Has the morphological and biochemical characteristics of an RNA tumour virus. It seem to be common in rhesus monkey. R. 35.V: It is not a "B" type particle, unlike M.M.T.V. Ionizing radiation: There is strong evidence that high dose of ionizing radiation can cause breast cancer. Women undergoing repeated fluoroscopies during vneumathorax treatment for tuberculosis. (31) Also radiation therapy for a cat pastpartum mastitis increas the risk of developing breast tumour. Genatic Predisposition; First degree relative of bilateral breast cancer patient had a breast cancer frequancy 5,4 times than that in control. If the index patient was both premenoposal and had bilateral breast cancer, the relative ris to her sister, mother and daughter increased to 8,8. In contrast, the risk to relative of the patient with unilateral disease, whether pre monepausal or post moneparsal ranged from 1,2 to 1,8 times the control population prevatence. * The role of Hormone in the development of Breast Cancer: (a) Oestrogen: is necessary for the development of mamary cancer in mice only in the presence of other factor such as hereditary predisposition, progestrone, and specific virus. Use of oestrogen in treatment of cancer prostute produce cancer breast in experimental mice. (b) Progesterone: Is a mammary cocarcinogen in the mouse, and it enhance carcinogenic activity of other hurmones as well as chemical carconogems. The incidence of breast cancer and endmetarial cancer is increased in anovulatory patients with long term progestrone unopposed oestrogen secretion. (c) Androgens: An androgen of potential importance to the l hormonal milieu of women with breast cancer is A-- androstenedione. The averge androstenedione production rate is 3mg/day in young women and 1-2 mg per day in postmenoposal women. (32) In postmenoposal women androstenedione secreted by both a drenals and avaries is transformed to El, which in fluenced by a going as well as by obesity. * Role of adrenal activity: The adrenal gland is a major source of oestrogen and androgen in postmenopavsal women. * Role of thyroid activity: The previous induction of hypothrodism^ will increase the incidence of hormon sensitive, chemically induced, mammary cancer in non variectomized rats. Pateint with breast cancer have a higher incidence of hyothyrodism, and that breast cancer is uncommon with hyper thyroid women. ( ) Pituitary hormones and breast cancer: The pituitary hormones have a directation on the avary and the breast, Reserpine (drug stimulales release of prolaction) usage was associated with' higher incidenece rates of breast cancer. (33) Planning(*) Role of Radiotherapy: 1- Radiotherapy is given for primary carcinoma of the breast to reduce the risk of loco - regional recurrence. 2- Early Tl 12 No lesion may be treated by wide local excission followed by radiotherapy to the breast, or by simple mastectomy depending on: - Sit of the tumour. - Size of the tumour. - Size of the breast. - Oxtent of insito change. 3- If the size of the tumour is more than. 5 cm, radiation to the chest wall is recomended after mastectomy. 4- T3 lesion may be treated by primary radiotherapy with subsequent surgery if indicated. 5- For T4 tumour and inflamatory carcinomas, systamic treatment may be given as initial therapy befor proceeding to radiotherapy. 6- If axillary nodes are involved radiation is given to axilla and supraclavicular fossa. 7- For centrat or medial quadrant tumours, the internal mammary chain may be irradiated in addition. 8- Intersitial implants may be used for; 1- A boost to the site of excision following lumpectomy and external beam radiation as a part of primary breast conservation therapy. 2- A boost to residual tumour after external beam radiation for bulky in operable disease. 3- Salvage therapy for local recurrence to improve local controle in patients with the following high risk factors for recurrence:. 1- incomplete tumour excision. 2- extensive in traduct carcinoma in addition to in vasive disease. 3- patient under the age of 40. 4- Grade 111 tumours. 5- Tumours areater than 3 cm in diameter. (34) 9- Primary lymphoma of the breast is usually associated with deffu.e histology and is treated by chemotherapy. Assessment of primary disease: It is importan that patient to be examined preoperatively. Breast examination include; 1- Inspection for nipple or skin retraction, discharge, ulceration. 2- Palpation for site and size of the lump and fixation to adjecent structure, 3- Aracliograph is usefull to illustrate the exact possition of the lesion, 4- Mammography is performed to demonstrate the tumour and todetect multifocal disease and bilateral involoement. 5- Histological review determines types of tumours, grad, node involvement and oestrogen resepter status. Physical Examination of the breast: Superaclavicular and axillary region: 1- Patient on the examin table. 2- Search for the sentinal nodes at the confluence of in ternal jugular and subclavien viens, hiden deep behind the medial and of the clavicle, 3- For the axilla the examiner suppport, the patients arm by his own hand to relax the pectoral muscles, 4- Number consistency and movabily of the axillary modes should be noted, also their diameter in cross. 5. Palpation of both axillae is essential. (*) Jane Dobbs MRAP, FRCR - Ann Barrett MD, MRCP, FRCR - Daniel Ash MD, MRCP, FRCR. Practical Radiotherapy planning P. (150 - 160}, 2 Edition - Edward Arnold - London Melbourne Augkland (35) Investigation of a breast lump* Lump Clinical examination Fine need aspiration Cystic suspicious Solid Cytology Mammegram Cytology Tru cut Benian Drill Benian Ree examin 6 week open leiopsy Follow UP (*) Karol Sikora & Keith E. Hainan Treatment of cancer - Page Second edition Londn - Chapman and Hall Medical (36) Inspection of the breast: 1- Good light is needed. 2- First it don with patient's arms at her sides. 3- Then above her head. 4- Look for rednes, ulceration, edema, dilated vien and surface erosion. Palpation of the breast: 1- Patient lies supine. 2- Examined the nipple for thickening redness or cosion. 3- Place the nipple between your index finger and thumb and gently apply pressure to elicit discharge. 4- Start palpation over the medial half of the breast with patients arm above the head to tense the pectoral muscles. 5- For lateral half palpation patients arm at her side. (37) T N Pre treatment Clinical Classification?*) T - Primary tumour. T is: pre invasive carcinoma (carcinoma in situ), non infiltrating in traductal carcinoma or Poget's disease of the nipple with no demonstrable tumour. To : No evidence of primary tumour. Tl : Tumour of 2 cm or lessin its greatest dirrention. Tla; with no fixation to under lying peatoral fagcia and/or muscle. Tib: with fixation to underlying pectoral fascia and/or muscle, T2 : Tumour more than 2 cm but not more than 5 cm in its greatest diomention. T2a: with no fixation to under lying pectoral fascia and/or muscle. T26: with fixation to underlying pectoral and/or muscle. T3 : Tumour mor than 5 cm in its greatest diomention. T3a: with no fixation to underlying pectoral fascia and/or muscle, T3b: with fixation to underlying pectoral fascia and/or muscle, T4 : Tumour of any size vnth direct extent ion to chest wall. T4a: with fixation to chest wall, T4b: with oedema , infiltration or ulceration of skin of breast (including peau d'orange) or salellit skin nodule confined to the same breast. T4c: both of above, Tx : The minimum equirement to assess the primary tumour contrat toe met. (38) N - Regional lymph nodes No : No palpable hamolateral axillary lymph nodes, Nl : Moivable homolateral axillary lymph node. Nla; Nodes not considered to contain growth. Nib: Nodes not considered to contain growth N2 : Homolateral axillary lymph nodes fixed to one a nother or to other structure, and considered to contain growth. N3 : Homolateral superclavicular or infraclavicular lymph nodes considered to contain growth or oedema of the arm. Nx : The minimum requirement to assess the regional lymph node can not be met. Stage grouping: Stage 0 Tis No Mo Stage 1 Tl No Mo Stage II A To Nl Mo Tl Nl Mo T2 No Mo Stage II B T2 Nl Mo T3 Nl Mo Stage- III A To N2 Mo Tl N2 Mo T2 N2 Mo T3 Nl, N2 Mo Stage III B T4 Any N Mo Any T N3 MO Stage IV Any T Any N Ml (*) B. Sviessl 0. Scheibe G. Waaner TNM - Atlas, P. 53, 54, 55 Sprinaer - Verlacr Berlin Heidelberg New York 1982. (39) Fig. ^ Fig. 7 (40) 'b findings" 1-2 cm-j Fig. 79 Fig. 80 (41) ''•^>:'-:V--'i ; r :•••"••••' : ' ••• V •;' IMi'' '•'' ; I. Rg. • Fig. Target volume(*): * Breast or chest wall: 1- The superior border covers as much breast tissue or chest wall as possible and lies at the level of the suprasternal notch medially and just below the level of the abducted arm lateraly. 2- The inferior border leis 1-2 cm below the breast or at the same level after mastectomy. 3- The medial and lateral border are determine by the site of primary lesion and the size of breast or position of mastectomy scar. 4- The medial border is usually in the midline or 1 cm to the contralateral. 5- The lateral border in the mid axillary lines unless proximity of the primary site to this border reguire extention of the volume laterally. 6- The volume includes the breast tissue and chest wall at depth but dose not attempt to include lymphatic channels in the fascia overlying pectoralis major. Tumour bed(*): This volume must be determined by taking accound of the initial site and size of the tumour determined clinically and by mamography. Lymph nodes(*): Target volumme includes the lymphatic drainge to the axillary and supra clavicular nodes in continuity. The volume leying anteriorly in the supra clavicular fossa at its upper border and extending more postriorly at the lower border to include all groups of axillary nodes. Field arrangements(*): General Consideration; 1- All field, should be treded with the patient in the same position. 2- The slope of the chest wall can be corrected by insertion of triangular wedge under the head & shoulder. (44) 3- The epsilateral arm should be abducted to hold abale which has scale to ensure are producible position. 4- Use a foot board to reduce patient movement. 5- Careful consideretion must be given to matching field edges to avoid in homogenciety of dose distribution. 6- Use additional dose from a posterior field to give uniform dose distribution for different depth of lymph nodes. Treatment Technique(*) Chest wall & breast only: Two Field Technique: 1- Patient lies supine on a breast wedge with the arm ficed in abduction and head turned to the contralateral side. 2- Mark the border of the target volume on the skin. 3- Define the centre boint of the medial and lateral field, 4- An isocentre technique is planned by using simulater. 5- Take the isocentre as the mid point between medial and lateral entry points at 1.5 —> 2 cm below the skin. 6- Chose the width field to cover the breast. 7- Take patient contour to measure field width and position of the isocentre. 8- Aligned the medial and lateral entry points by screening. 9- Lowered the couch to correct the part of lung included, if it is more than 2-3 cm and record the new FSD & determin the isocentre, 10- Use half beam blot if independent collimators are available to reduce divegence at the posterior porder of the field. 11- Take a check film of the tangential field to confirm the target volume is correct and dose distribution prepared. (45) 12- Take outline of the breast throug the centre of the volume and 5 cm above and below where it is large. Chest vail or breast and lymph nodes(*): Four field technigue: 1- The tangential field used to treat or chest wall. 2- The axilla and superclavicular fossa are treated with the patient with the same position. 3- The medial border of an anterior field is placed 1 cm lateral to the midline avoid the larynx. 4- The lateral border lies at the insertion of the pectoral muscle. 5- The superaclavicular nodes are covered leaving a margin of skin above the superior border. 6- Inferiorly the border must be matched with the temgential field. 7- Protect the head of humerus by lead shielding. 8- Shield the apex of the lung if the interior border of the superaclavicular field lies low. 9- Add aposetior field (approximatly 8x6 cm) to achieve a midblane dose to the axillary nodes, 10- Define the posterior axilla field by palpating the apex of the axilla and marking this point of on the anterior skin surface. 11- Using this poin as a centre arectangular field is then aligned so that the intro-medial margin lies a long the upper border of the rib cage. 12- Mark the field margin on the anterior skin surface, 13- Tattooed the two interior corner, 14- Then the gantry angle rotated through 180° for treatment, Non standard technigue(*): This procedure use duto the site of disease or where there is impossible to implement because of patient anatomy, (46) In case of disease in the axillary tail a three field technique may allow irradiation of the breast and axilla in contiuity with an anterior field added to treat suparclavicular nodes. The patient lies rolated towards the contra lateral side to facilitate entry of the large lateral tanential field (Figer.) Since the supraclavicular field has to be treated with patient supine The change in treatment position make field matching imposible leading to uncertainty about dose distribution and the risk of overlap. If internal mamary node irradiation is considered essential, a seperale direct anterior field approximately (12 x 6) centred on the misline is added. For medial quadrant disease the tumour bed may lie at the junction between this field and the tanaential field. It is than imposible to treat both target volumes homogeneously and treatment to the primary tumour alone is given by moving the tangenlial field further a crosse the midline on to the contrlateral side where bliateral irradiation is indicated a combination of two or four field techniques is used with particular care to prevent overlap of the tangential fields in the midline by leaving appropriate gab. Irradiation of tumour bed or residual disease(*); Further irradiation is given to a small volume using either electrones, small opposing tangential field or an intersitial implant. The electron energy is chosen according to the depth of the target volume. Interstitial implanlation(*): The distribution of sources to cover the target volume is chosen and suitable perspex templates made. Under general aneasthesia. - Rigid needles are passed through the breast and fixed at each and with a lemlate. - Avoid undue pressure on the template to prevent severe scarring. (*) Jane Dobbs MRAP, FRCR - Ann Barrett ffl), MRCP, FRCR - Daniel Ash MD. MRCP, FRCR, Practical Radiotherapy planning P. (150 - 160), 2 Edition - Edward Arnold - London Melbourne Auckland (47) The requiste length of iridium wire is loaded into aplastic tube so that the end of the active wire lies 5-10 mm from the skin when it is inserted into the hollow needle. The super ficial plane of wire should be approx- imately 1 cm below the skin surface. These measure done to avoid telangiectasia or skin necrosis. For peripheral tumours or chest wall recurrence where there is only sufficient tissue for a single plane implant, a striaght plastic tube technique can be used. Surgical of Breast Cancer'*' surgical Technique; 1- Biopsy and lumpectomy. 2- Simple mastectomy. 3- Radical maitectomy. 4- Extended Radical Mastectomy or super Radical mastectomy. Biopsy and lumpectomy(*): Excision biopsy has a diognositic and therapeutic value - Biobsy is dobe eithert by a direct approach, or by aretromommary one, if the tummour in the outer quadrant. The three primary indications for breast biopsy are: 1- Apalpable mass or erea of different consistency. 2- A mammographicall suspicious area. 3- Bloody or spontaneous nipple discharge occuring from a single duct in the absence of a mass. Definition of terms(*): - Local excision or excisional biopsy or tumourectomy, is a simple excision of the tumour, with out regard to the microscopic margins of resection. - Wide local excision or wide tumourectomy, is aresection of the tumour, with 1 to 2 cm of adjacent breast tissue designed to provide clear matgine of resection. - Quadrantectomy is aresection of the tumour, a long with involved quadrant of breast including the overlying skin. (48) Simple Mastectomyf*): A horizontal elliptical incision is done with removal of the mammary gland and the cutaneous covering in relation to the tumour. The deep excision reaches the pectoralis major fascia. The axillary tail should be removed carfully. This simple mastectomy is indicated in intraductal carcinoma. Radical Mastectomy(*): (a) Ha Is ted operation: This is the classical operation since 1894 for the treatment of operable cancer, removing the skin, the breast, the pectoral muscle and the axillary nodes. (b) Modified Radical Mastectomy of patey: This is the most widly practised operation nowaday. Pectoralis mucles are preserved together with their vascular and nerve supplies. The pectoralis minor may be removed as well, to facilitate complete axillary dissection. Exterded Radical Mastectomy or super Radical Mastectomy(*): This include; 1- Mastectomy with removed of internal mammary nodes. 2- Superclavicular and mediastianal evacuation are a bandoned. Indication of surgery: 1- Primary surgery: • It is indicate in primarily operable cases i.e tumour less than 7 cms in diameters, not fixed to mucles of fascia, with no skin invation, not palpable or mobile lymph node. 2- Secondary Surgery; If follows pre operative irradiation of the breast and lymph nodes in the following cases: 1- Tumour more than 7 cms. 2- Tumour fixed to pectoral muscles. 3- Presence of fixed lymphnodes. 4- Phase evolution, with out distant metastases (bioloaicallv active tumour. (49) Complication of surgery: 1- Early complication: Postoperative infection are rare. Lymphorrhea is frequent but of no sequelae. Stiffeness of the shoulder musy be prevented by active exercise starting of on the next day of the operation. 2- Psychological effect duto mutilation: May be slight or severe, but in different degrees. The help of apsychologist and aplastic surgeon is useful in a unit of breast cancer therapy. 3- Lymphoedema: It is more frequent when surgery is associated with radiotherapy. 4- Brachial plexus syndrome: Occure some time several year following operation and may produce serious motor troubles and intolerable pains. Treatment of such cases is disappointing whether surgically medically or by physiotherapy, 5- Stewart - Treves Dyndrome. This is a rare complication. It may be duto lymphalic metastatic recurences at the level of the arm. This syndrome occurs several years after surgerly and irradiation of breast cancer. Its treatment is very disappointing, whether_ by chemotherapy., radiotherapy, surgery, or even by disarticulation. Un usual special situation (Rare case): 1- Microcalcifications with out palpable tumour: These cases are classified as TO and^ are discavered by mamonography in the following condition: a) In females having a systematic check up, b) Microcalcification in patient having a follow up for mastitis in the contralateral breast of patient having a treated cancer of the breast. 2- Carcinoma in situ of the breast intra duct carcinoma is more common than an intra lobular one. Most specialistis prefer to perform simple mastectomy in such cases, because multicentric local foci are as frequent as 75%. Others prefer wide tumour excision with or with out a ssociated irradiation. (50) 3- Nipple discharge: Clear or citrous discharges are considered benign and if mammagraphy and cyto logical study of such discharge are negatioe, these cases are just under observation. Sangvinous discharges always require surgical verification, because about 10% of these cases turn out to be intraduct or invasive carcinoma. Pathological examination by frozen section technique is difficult, there for we depend in such cases on paraffine section result. 4- Paget's diseaseof the nipple: Excision of the nipple and of the netroareolar region is done for pathological examination. If it proves to be an intraduct carcinoma, the pectoral of operable cases is followed. 5- Bilateral breast cancer: It could be simultaneous, if bilaterality occurs wthin two years, otherwise it is considered as successive, In simultaneous cancer, if the tumar are less than 25 mm, bilateral conscrative treatment is indicated. Bilateral radical mastectomy has to be followed in T2 or T3 cases less than 7 cms. In successive cancer: mastectomy with axillary evacuation is the treatment of choice. 6- Sarcoma of the breast: These are rare tumour. Lymphoma (reticulun cell sarcoma; lymphosarcoma; breast affection by lodgkin's disease), and rhabdomyo-sarcomas of the children are rarely treated surgically. Specific treatment of these cases should be done i.e chemotherapy and radiotherapy. 7- Cancer of the breast in male: They are rare (1% of all cancers in male) and a hundred times less frequent than breast cancer in female, Generally they occure in males a round 60 years old and they are commonly bilateral and of the intraduct type. Early invasion of skin and in pectoral muscles occurs. ______Breast Cancer, p. 73 —>88 KOEBA. London. (51) Evaluation of Treatment* Effect on tumour: Adequate evaluation and assessment is important as new anticancer are being evaluated. It is essensial for this to be exact objective and numerical rather than sujective and qualitative. There are three essential parameters of tumour response: 1- Tumour size which can be measured as the mean of two perpendicular diameters. 2- The duratio of remission 3- The duration of survival since the start of therapy. Four standard difinition of response in solid tumour are used; 1- Complete remission (CR): Disappearance of all tumour for a period of at least 4 weeks. 2- Partial remission (PR): Tumour shrinkage to more than 50% of initail size for a period of at least 4 week. 3- No change (NC) or stable disease (SD). 4- Progressive disease (PD) increase in tumour size during treatment. Effect on patient: The evaluation of general condition of the patient before storting treatment and at definitive time point during therapy is often helpful. The Karnofsky performance status is commonly used scalle,_ although it is compelex in the number of cotogries aviable for classification. Good statistical analysis result is essential when comparing new treatment with existing therapy. Many drugs will only be partially effective in inducing complete respone, let alone. A long - term cure. For this reason comparison with altermalive treatment is often very difficult. Historical controles have their drawbacks. (52) First referral patterns and' pre-study investigation patterns chang even whithin a single ceatre leading to differentces with time in overall response and survival. Karnofsky, UICC and MRC performance status scale: Karnofsky SWISS 100 Normal, no complain 0 Able normal to cary on normal activity. 90 Normal activity minimal sign or simptoms 80 Normal activity with 1 able to leave at effort, some symbtom. with to lerable sybtoms 70 Caring for self, unable to work 60 Needs occasional asstente 2 disabling symbtom but able to care for most but less than 50% of needs. time in bed. 50 Needs considerable assistantce and freguent medical care. 40 Disabled, needs special 3 Severely disabled, care greater than 50% of time in bed but able to stand. 30 Severely disabled needs hospital care. 20 Very ill,• in hospital 4 Verv ill confmd to supportive care. bed . 10 Moribund 5 Dead. 0 Dead (*) Karol Sikora & Keith E. Hainan Treatment of cancer - Page 9 Second edition Londn - Chapman and Hall Medical (53) Mechanism responsiple for local disease recurrence(*): 1- Transect ion of the peripheral extensions of the primary lesion. 2- Wound implantation from cut vessels that ooze blood or from lymph containing viable tumour embli. 3- Retrograde movement of tumour ceas to edges of the operative wound. Patients at high risk for such recurrence can identity as those with the following; 1- Large primary lesion (> 3 cm). 2- Fixation of the primary lesion to the skin, skinedema, or ulceration. 3- At least four or at least 20% of the resected avillary lymph nodes involved with metastases, particularly when histological examination of the primary lesion reveals a poorly deferentiated tumour or blood vessel in vasion. 4- Fixation of the primary lesion. * Three important quastion that must be considered in establishing indication for post operative irradiation of regional nodes: 1- What is the incidence"of metastases to the regional chain of nodes on the various clinical vircumstance? 2- Dose irradiation in well tollerated doses eradicate sub clinical metastases in regional nodes? 3- Does irradiation of sub clinical metastases in regional nodes modify subsequent problems related to local disease recurrence and does it increase free survival rates? (*) Karol Sikora & Keith E. Hainan Treatment of cancer - Page Second edition Londn - Chapman and Hall Medical (54) Chapter Three Angular range for the breast: gantry angle assume that simulator and treatment units are scaled so that 0° means vertical (down ward) and 90° means horizontal (left to right) on a supine patient. In the following diagram wecan notice that: - Medial tangentional angle of right breast is in the range of 0 - 90°'. - Lateral tangentional anale of right breast is in the range of 180 - 270°. - Medial tangentional angle of left breast is in the range of 270 - 360. - Lateral tangentional angle of the left breast is in the range of 90 - 180°. (55) for ideal angle demarcation/ consideration must be taken to certain points such as in the following digram: PI Medial border of the tangenial field. P2 Lateral border of the tangenial field. S Separation (chest wall) A Chest wall angulation. W Wedth of the tangest field. TSD Tumour skin distence. Shift Patient will be shifed left for a right breast setup, or right for a left treast setup. (56) Complete sample Angle Worksheet-Breast Tangents Nam Date Sim. Tech. Dr. Measure: horizontal- Separation S=. Angle A=.. prox.) Width of tangents W=.. FADofRxunit=.. CALCULATE: KS3. t. a - tM~Hl/2 ¥11/FAB W TSD=[FAD-l/2(SsiliA - WcosA)] ( -1I2{ sis - cos !ISBIFT= GANTRY ANGLE Riant Breast: MEDIAL= SH*q= 1Q- + = ET. MED.= LATERAL^ 270-A-q^~2~70 - - = FT. LAT.= Left Breast: MEDIAL=270+&-q=??C+ - = IT. MED.= LATERAL=90+A+q=90- + = LT. LAT,= (57) There are certain situation which I noticed in the treatment room during my participating in the treatment of Ca. breast patient. I centred my observation at a certain point in tangential field treatment such as follow:- - The centre of entrance point for both medial & lateral tangential field are both medial & lateral tangential field are fixed - that mean no change. - Defferentials is taking place duto the various degree of enterance angles of beam for both field which lead to occupy different exist of radiation beam for both fields. So, the previous observation motivate me to follow four patient of Ca breast during their treatment inside the treatment room and registered the tangential field angle by read it from the gantry angle. Of course the angles which I registered were different from the ideal angle which should demarced in the treatment sheet. This differentials are clearlyshown in Fia 1.1 > 4.2. By the other hand, in addition to that I collected an information 84 patient's files (total number of Ca. breast patients registered during year 1989 according to sensus of RICK) to evaluate Ca. breast treatment during this year. To find out" where if there is arelation between the result which I gained from those files and missing the ideal angles and dimension of treatment field specially the tangentials one. (58) Fig 1.1 Show us the following information V (1) Ideal dose distribution. (2) Right breast Contour. (3) Patient serial number, 26429 (4) Field size 5 x 18 cm (5) Ideal medial angle = 58,4 (6) Ideal lateral angle = 225,6 PI • entrance point for Medial tangential field. P2 ; exit point for Medial tangential field. P2 : entrance point for lateral tangential field. PI •• exit point for lateral tangential field. (59) Fig 1.2 Show us the following information - Non Ideal dose distribuation, - R. Breast contour for the same patient of Fig 1.1. - Pi = entrance point for the Medial tangential field. - X = exit point for the Medial tangential field, - P2 = entrance point for the lateral tangential field. - Z = exit point for the lateral tangential field. Notl: PI at the same distant from L for both contour ( 1.1 - 1.2) P2 at the same distant from M for both contour (1.1 - 1.2) Deferent is in the interance angle for both field (Medial & tangent). Medial angle = 50 Lateral angle =235 Field size = 5 x 18 cm. (60) Fig 2.1 Show us the following information (1) Ideal Dose distribution. (2) Right Breast Contour, (3) Patient serial number 26413 (4) Field size 5 x 15 cm (5) Ideal medial angle =62,7 (6) Ideal lateral angle = 229,6 PI • entrance point for the Medial tangential field. P2 : exit point for the Medial tangential field. P2 ; entrance point for the lateral tangential field. PI ; exit point for the lateral tangential field. (61) Fig 2.2 Show us the following information - Non Ideal dose distribution, - Right Breast Contour for the same patient of fig 2.1. PI = entrance point for the Medial tangential field. P2 = exit point for the Medial tangential field. P2 = entrance point for the lateral tangential field. PI = exit point for the lateral tangential field, Notl: PI at the same distant, from L for both contour (2.1 2.2) P2 at the same distant from M for both contour (2.1 2.2) - Medial angle = 55 - Lateral angle =235 - Field size = 5 x 15 cm. (62) Fig 3.1 Show us the following information - Ideal Dose distribution. - Left Breast Contour. - Patient serial number 26413 - Field size 6 x 20 cm Ideal medial tangential angle = 231 Ideal lateral tangential angle = 129 PI = entrance point for the Medial tangential field. P2 = exit point for the Medial tangential field. P2 = entrance point for the lateral tangential field. PI = exit point for the lateral tangential field. (.63) Fig 3.2 Show us the following information - Non Ideal dose distribution. - Light Breast Contour for the same patient of fig 3.1. PI = entrance point for the Medial tangential field, P2 = exit point for the Medial tangential field. P2 = entrance point for the lateral tangential field. PI = exit point for.the lateral tangential field. Not: PI, at the same distant from L for both contour (3.1 3.2) P2, at the same distant from M for both contour {3,1 3.2) - Medial angle = 310 - Lateral angle = 130 - Field size = 6 x 20 cm. (64) Fig 4.1 Show us the following information - Ideal dose distribution, - Left breast contour. - Patient serial number 22533 - Field size 6 x 18 cm Ideal medial angle = 2985 Ideal lateral angle = 131,529 PI = entrance point for the Medial tangential field. P2 = exit point for the Medial tangential field. P2 = entrance point for the lateral tangential field. PI = exit point for the lateral tangential field. (65) Fig 4.2 Show us the following information - Non Ideal dose distribution. - Light Breast Contour for the same patient of fig 4,1, - PI = entrance point for the Medial tangential field. - X = exit point for the Medial tangential field. - P2 = entrance point for the lateral tangential field. - Z = exit point for the lateral tangential field. Not: PI, at the same distant from L for both contour (4,1 - 4.2) P2 at the same distant from M for both contour (4.1 - 4.2} Medial angle 280 Lateral angle 135 Field size 6 x 18 cm. (66) * Table No (1.1) show as the relation between the sex and incidence ratio of Ca. breast in year 1989 among Sudanease Society. Note, about 96.4% of all cases occured in famal and 3,6% in male. For more information see the table 1.2. * Table 1.1 SEX Valid Cum Value Label Value Frequency Percent Percent Percent Famale 0.0 81 96.4 . 96.4 96.4 .Male 1.00 3 3.6 3,6 100.0 TOTAL- 84 100.0 100.0 * Table 1.2 COUNT VALUE 81 0,0 ! 3 1.00 !_ I, ..I. ..I. ..I. ...I 0 20 40 60 80 100 Histogram Frequency SEX Mean .036 Std Err ,020 Median 0 ,0 Mode 0 .0 Std Dev .187 Variance .035 Kurtosis 24 ,544 S E Kurt .520 Skewness 5.095 S E Skew . 263 Range 1.000 Minimum 0.0 Maximum 1.000 Sum 3.000 Valid Cases 84 Missine Cases 0 (67) * Table No (1.1) show as the relation between the sex and incidence ratio of Ca. breast in year 1989 among Sudanease Society. Note, about 96.4% of all cases occured in famal and 3,6% in male. For more information see the table 1.2. * Table 1.1 SEX Valid Cum Value Label Value Frequency Percent Percent Percent Famale 0.0 81 96.4 96.4 . 96.4 Male 1.00 3 3.6 3.6 100.0 TOTAL- 84 100.0 100.0 * Table 1.2 COUNT VALUE I 81 0.0 i 3 1.00 1 .,.,, r,,,, .... .r.... I I. .. , r 0 20 40 60 80 100 Histosram Frequency SEX Mean ,036 Std Err .020 Median 0,0 Mode 0.0 Std Dev .187 Variance . 035 Kurtosis 24 .544 S E Kurt .520 Skewness 5.095 S E Skew .263 Range 1.000 Minimum 0 .0 Maximum I.000 Sum 3 .000 Valid Cases 84 Mi55ins Cases 0 (68) Table No (2.1) show us the relation between the age and incidence ratio of Ca. breast in year 1989 among Sudanease Society. Note; peak of incidence appear among the age 34 - 40 in 24 patients and represent about 28,6% of all cases. Second level of incid- ence apper in the rang age of 55 - 61 year and this represent about 19% of all cases. Minimum level of incidence appeared in the range age of 16 - 82 and this represent about 1,2% of all cases. There is a missing information about age of patients to be recorded in certain file and that was about 8.3% of all patient's file. * Table 2.1 AGE Valid Cum Value Label Value Frequency Percent Percent Percent 20- 1.00 3 3,6 3.6 3,6 27- 2.00 8 9.5 9.5 13.1 34- 3.00 24 28.6 28.6 41.7 41- 4.00 8 9.5 9.5 51.2 48- 5.00 7 8.3 8.3 59.5 55- 6.00 16 19.0 19.0 78.6 62- 7.00 7 8.3 8.3 86.9 69- 8.00 3 3.6 3.6 90.5 76- 9.00 1 1.2 1.2 91.7 non 11.00 7 8.3 8.3 ' 100.0 TOTAL. 84 100.0 100.0 * Table 2.2 AGE COUNT VALUE .00 8 .00 24 .00 .00 "s ,00 ,00 ,00 8.00 1 9.00 o 10.00 11.00 T, I I ...1, ..I. 0 5 10 15 20 25 Histogram Frequency AGE Mean 4.917 Std Err .284 Median 4.000 Mode 3.000 Std Dev 2.603 Variance 6.776 Kurtosis .246 S E Kurt .520 Skewness . 883 S E Skew .263 Range 10.000 Minimum 1.000 Maximum 11.000 Sum 413.000 [691 Valid Cases 84 .Missing' £&§es 0 (69) * Table No (3.1) show us the relation between the home of patients and incidence ratio of Ca. breast in year 1989 among Sudanease Society. Note; Middle region of Sudan represent the peak level of incidence and represent about 39,3% of all cases occured in Sudan weast region of Sudan came in the second level of incidence and represent about 20,2% of all cases occured in Sudan. The incidence ratio in South region is very weak and represent about 1,2% of all cases ossured. Formore information see the table 3.2 * Table 3.1 HOME Valid Cum Value Label Value Frequency Percent Percent Percent Middle ,00 33 39.3 39.3 39.3 East .00 4 4.8 4.8 44.0 Weast .00 17 20.2 20. 64.3 Soush .00 1 1.2 1. 65.5 North ,00 16 19.0 19.0 84.5 Non .00 13 15.5 15.5 100.0 TOTAL 84 100.0 100.0 Table 3.2 HOME COUNT VALUE 33 .00 4 .00 17 .00 1 .00 16 .00 13 .00 I. .[.....,...!.... I, ..I 0 8 16 24 32 40 Histogram Freouencv Mean 3.024 Std Err .214 Median 3.000 Mode 1,000 Std Dev 1,95" Variance 3.831 Kurtosis -1.503 S E Kurt .520 Skewness .312 S E Skew . 263 Range 5.000 Minimum 1.000 Maximum 6.000 Sum 254.000 Valid Cases 84 Missins Cases 0 (70) * Table 4.1, show us the relation between the type of Ca. breast and its incidence ratio among Sudanease Society in year 1989. Note; Adeno carcinoma represent the peak level registered in (46) patient and represent about 54,8% of all cases, Sirrhours carcinoma came in the second level registered in (13) patient and represent about 15,5% of all patient. There is a missing of recording the type of cancer in some patient's file and this represent about 25% of all cases and this unfortunately is a high ratio. For more information see table 4.2 * Table 4.1 TCA Type of Cancer Valid Cum Value Label Value Frequency Percent Percent Percent Adeno car c i noma 1.00 46 54.8 54 .8 54.8 Sqamous Cell Carcino 2.00 2 2.4 2,4 57.1 Lymphoma 3,00 1 1.2 1 .2 58.3 Sirrhous Carcinoma 4.00 13 15.5 15 .5 73.8 N'on 5.00 21 25.0 25 .0 98.8 Fibrosarcoma 6.00 1 1.2 1 .2 100.0 TOTAL- 84 100.0 100 •0 * Table 4.2 TCA Tvpe of Cancer COUNT VALUE 46 1.00 ! 9 2.00 j 1 3.00 ! 13 4.00 ! 21 5.00 ! 1 6.00 j T. . r,...... I. ... r T I 0 io :20 30 40 50 Histogram Frequency Mean 2.571 Std Err 1.99 Median 1.000 Mode 1.000 Std Dev 1 825 Variance 3.332 Kurtosis -1.708 S E Kurt 520 Skewness .406 S E Skew .263 Range 5 000 Minimum 1.000 Maximum 6.000 Sum 216 000 Valid Cases S4 Missins Cases n (71} * Table 5.1, show us the relation between the stage of Ca. breast and its incidence among Sudnease Society in year 1989. Note: Missing of recording the stage of cancer in patients file during this year was high and represent about 60,7% of all cases unfortunatelly. 20.2% of all cases registered as stage III and 6% was stage I. Stage II was regestered for (1) patient and that represent just about 1.2%. For more information see table 5.2. * Table 5.1 STAGE Valid Cum Value Label Value Frequency Percent Percent Percent Stage I 1.00 5 6.0 6.0 6.0 Stage II 2.00 1 1.2 1.2 7.1 Stage III 3.00 17 20.2 20.2 27.4 stage IV 4.00 10 11.9 11.9 39.3 Non 5.00 51 60.7 60,7 100.0 TOTAL. 84 100.0 100.0 * Table 5.2 STAGE COUNT VALUE. 5 1.00 ! 1 1 2.00 1 _ 17 3.00 1 i 10 4.00 1 I 51 5.00 1 I 1 . I...... I . .T, . . I 0 12 24 36 48 60 Histogram Frequency Mean 4,202 Std Err .128 Median 5.000 Mode 5.000 Std Dev 1 . 1 70 Variance 1.368 Kurtosis 1.078 S E Kurt .520 Skewness -1 .378 S E Skew .263 Ranse • 4.000 Minimum 1.000 Maximum 5.000 Sum 353 .000 Val id. Cases 84 Missins Cases 0 (72) * Table 6.1, show us the relation between the grade of Ca. breast and its incidence among Sudanease Society in year 1891. Note; Unfortunately 96,4% of all cases had mis recording the grade of cancer in patients files. Just 3,6% of all cases registered as grade (3). For more information see table 6.2. * Table 6.1 GRADE Valid Cum Value Label Value Frequency Percent Percent Percent Grade 3 3.00 3 3.6 3.6 3.6 Non 4.00 81 96.4 96.4 100.0 TOTAL. 84" 100.0 100.0 * Table 6.2 COUNT VALUE 3 3.00 !_ 81 4.00 ! I I I I I I 0 20 40 60 80 100 Histogram Frequency GRADE Mean 3.964 Std Err .020 Median 4.000 Mode 4.000 Std Dev .187 Variance .035 Kurtosis 24.544 S E Kurt .520 . Skewness -5.095 S E Skew .263 Range 1.000 Minimum 3.000 Maximum 4.000 Sum 333.000 Valid Gases 84 Missins Cases 0 (73) * Table 7,1 show us the relation between the occupation of patient and incidence ratia of Ca. breast among Sudanease Society in year 1989. Note; 98.8% of all cases registered as a house wife and just 1,2% of cases as farmer and those are male. See table 7.2 for addition in formation. * Table 7.1 OCC Occupation Valid Cum Value Label Value Frequency Percent Percent Percent House wife 1.00 83 98.8 98.8 98.8 Farmer 2,00 1 1.2 1.2 100.0 TOTAL- 84 100.0 100.0 * Table 7.2 COUNT VALUE 83 1.00 ! 1 2.00 !_ I I, I I I I 0 20 40 60 80 100 Histogram Frequency OCC Occupation Mean 1.012 Std Err .012 Median 1.000 Mode 1.000 Std Dev .109 Variance .012 Kurtosis 84,000 S E Kurt .520 Skewness 9.165 S E Skew .263 Range 1.000 Minimum 1.000 Maximum 2.000 Sum 85.000 Valid Cases 84 Missing Cases 0 (74) * Table 8.1 show us the relation between type of treatment applied and number of Ca. breast patient amang Sudanease Society in year 1989. Note, Unfortunatelly about 41.7% of all cases had mis recording the type of treatment in patients files. 35.7% of all cases registered as radical treatment and 22.6% of cases as paliative. For more information see table 8.2 * Table 8.1 TRE Treatment Valid Cum Value Label Value Frequency Percent Percent Percent Radicl 1.00 30 35 .7 35 ,7 35 .7 Paliative 2.00 19 22 .6 22 .6 58 .3 No 3.00 35 41 .?• 41 .7 100 .0 TOTAL 84 100.0 100.0 Table 8,2 COUNT VALUE 30 1.00 19 2.00 35 3.00 I. .1 I I. ..I. 0 8 16 24 32 40 Histogram Frequency TRE Treatment Mean 2,060 Std Err .096 Median 2.000 Mode 3.000 Std Dev .883 Variance .780 Kurtosis -1.722 S E Kurt .520 Skewness -.118 S E Skew . 263 Range 2.000 Minimum 1.000 Maximum 3.000 Sum 173.000 Valid Cases 84 Missing Cases 0 (75) Table 9.1 show us the relation between the prescibed dose and number of patient treated by it, during year 1989 among Sudanease Society. Note; 38,1% of all patients treated by a dose equal 4500 CGy as radical treatment in addition to 16.7% of patient with a dose of 3900 CGy. 15,5% of patient treated by a dose 3000—>4000 CGy as paliative treatment in addition to 2.4% of patient with a dose of 2100—>3000 CGy. 15.3% of all cases registered as mis recording the prescribed dose in patient files. For more information see table 9.2. * Table 9.1 DOSE Valid Cum Value Label alue Frequency Percent Percent Percent 4500 CGy 1.00 32 38.1 38.1 38.1 3900 CGy 2.00 14 16.7 16.7 54.8 1000-2000 CGy 3.00 11 13.1 13.1 67.9 2100-3000 CGy 4.00 2 2.4 2.4 70.2 3000-4000 CGy 5.00 13 15.5 15.5 85.7 Non 6.00 12 14.3 14.3 100.0 TOTAL- 84 100.0 100.0 * Table 9.2 DOSE COUNT VALUE 32 1.00 14 2.00 • 11 3.00 i 7 i 4.00 i i 13 5.00 i 12 6.00 T I ,1 ,,, ,T , .1.., I 0 8 16 24 32 40 Histogram Frequency Mean 2.833 Std Err . 208 Median 2.000 Mode 1.000 Std Dev 1 .906 Variance 3.635 Kurtosis -1.283 S E Kurt .520 Skewness .554 S E Skew .263 Range 5 .000 Minimum 1.000 Maximum 6.000 Sum 238.000 Valid Cases 84 Missing Cases 0 (76) * Table 10.1 show usthe relation between the duration of treatment and number of Ca breast patients during year 1989 among Sudanese Society. Note; Unfortunately, 35,7% of all cases registered as mis recording the duration in the patients files. 25% of patient registered that they are treated in 20 session in four week, five fraction per week (4W, 5F/W) as radical treat- ment in addition to 1,5% of patients whom treated in 12 session in four week, five fraction per week ( 4W, 5F/W). 11,9% of patient treated in one session as single dose for paliative treatment, in addition to 4,8% of patient in 6 session during two week, three fraction per week. 3,6% of patient in ten session during two week five, fraction per week and 2,4% of patient in five session during one week five, fraction per week. For more information see table 10.2. * Table 10.1 DURATION Valid Cum Value Label Value Frequency Percent Percent Percent 1 W/5F 1,00 2 2.4 2.4 2,4 2 W.5F/W 3.00 3 3.6 3.6 6.0 2 W.3F/W 4.00 4 4.8 4.8 10.7 4 W.5F/W 7.00 21 25.0 25.0 35.7 4 W.3F/W 8.00 13 15.5 15.5 51.2 Single Dose 9.00 10 11.9 11.9 63.1 Non 10.00^ 30 35.7 35.7 98,8 (77) * Table 10.2 SE PR RA CP) 0 6.00 21 7.00 13 8.00 10 9.00 30 10.00 0 11.00 0 12.00 0 13.00 0 14.00 0 15.00 0 16.00 1 17.00 I, 1 .1. I .I ..I 0 6 12 18 24 30 Histogram Frequency DURATION Mean 8.155 Std Err .259 Median 8.000 Mode 10.000 Std Dev 2.372 Variance 5.626 Kurtosis 3.051 S E Kurt .520 Skewness S E Skew .263 Range 16.000 Minimum 1.000 Maximum 17.000 Sum 685.000 Valid Cases 84 Missing Cases 0 (78) * Table 11.1, show us the relation between the use of chemotherapy in addition to radiotherapy in the treatment of Ca. breast and number of patient during year 1989 among Sudanses Society. Note: 48.8% of all cases treated as combination of radiotherapy+ chemotherapy. 51,2 of cases treated without chemotherapy see table 11,2 for more information * Table 11.1 CT Chemotherpy Valid Cum Value Label Value Frequency Percent Percent Percent Yes 1.00 41 48. 8 48 .8 48 .8 No 2 .00 43 51. 2 51 .2 100 .0 TOTAL 84 100.0 100.0 * Table 11.2 COUNT VALUE 41 1.00 ! 43 2.00 ! r .,,,... .1 .1 ... .1 1, I 0 10 20 30 40 50 Histogram Frequency CT Chemotherpy Mean 1.512 Std Err .055 Median 2.000 Mode 2.000 Std Dev . 503 Variance .253 Kurtosis -2.047 S E Kurt ,520 Skewness -.049 S E Skew- .263 Range 1 .000 Minimum 1.000 Maximum 2.000 Sum 127.000 Valid Cases 84 Missing Cases 0 (79) Table 12.1,2 show us the relation between prognosis and number of patient during year 1989 anong Sudanese Society. * Table 12.1, 2 PROG Prognosis COUNT VALUE 21 1.00 ! 29 2.00 ! 10 3.00 ! 9 4.00 ! 1 5.00 ! 0 6.00 ! 14 7.00 ! I .1, .1, .1. ..I. ..I 0 6 12 18 24 30 Histogram Frequency Mean 2,952 Std Err .224 Median 2.000 .Mode 2,000 Std Dev 2.053 Variance 4.215 Kurtosis -,111 S E Kurt .520 Skewness 1.093 S E Skew 263 Range 6.000 Minimum 1.000 Maximum 1.000 Sum 248.000 Valid Cases 84 Missing Cases 0 (80) Chapter Four Analysis and result In this chapter I am going on to analyse briefly the data which presented in the previous chapter, to gain certain result. According to the information gained from the interview question done with specialist in the field I found that no one agree with the technique that proctice in the treatment room during treatment of tangential field depending on the shadow viewed in the beam absorber, because this technique lead to miss the maximum dose distribution, in the treatment volume and occupy cold and hot area. So demarcing of the ideal tangential field angles in the treatment sheet is very important that to prevent the technologist to treat depending on the shadow technique. But the things that obstruct the physist to demarc the ideal angles and dimension is seem to be the absence of treatment planning systems in RICK. Fig 1.1, 2.1, 3.1, 4.1, show us the ideal dos distribuation depending on the ideal demarcing of tangential fields angles - obtimum distribution is clearly shown. Fig 1,2, 2,2, 3.2, 4.2, show us the different in angle field and dose distribution applying duto the technologist depend on the shadow of the breast viewed on the beam absorber. Not; in fig 1-1 comparing with fig 1.2 for the same patient that the level of isodose line 130% is lowered in fig 1.2. Duto the entrance of beam angles, although the entrance point is not change. Of course this- mean that the apex of the breast will have in creased dose and lead to hot spot and skin reaction may be develop. Fig 2.1 comparing with fig 2.2 we find that a pex of the breast and chest wall will have increased dose which will lead to hot area and radiation reaction later on. Not the isodose line 140% is lowered in fig 2.2 to cover the middle of treatment region instead of apex one. (81) Fig 3.1 comparing with 3.2 we find that the apex of breast recieve dose of about 150% in fig 2.2 instead of 140% and this may lead to skin reaction later on in the hot area and recurrce on the cold one. Fig 4.2 is a good example for of cold area formation. Not; the isodos line 110% is mised away from the chest wall and this mean reduce dose will reach this area in addition to the treatment volume under the chest which suspected to be a point of recurrence lateron. Out of my statistical data which is concerning in the treatment data during year 1989 among Sudanese Society including the information presented in tables 1.1 —> 12.2 I found that there are a weak correlation between the data and this can be shown clearly throughout the table 1, 2., 3. Inaddition to that and out of the cross tabulation tables I gained the following information; - Table 4 show us that the relation between the prognosis and applied dose. Table 5 show us the relation between prognosis and stage. - Table 6 show us the relation between prognosis and type of cancer. - Table 7 show us the relation between prognosis and age of patient. - Table 8 show us the relation between prognosis and the use of chemotherapy in treatment mode. Five year servival was registered such as following: 20% for 21 patient out of 84 patient 20% for 29 patient out of 84 patient 40% for 10 patient out of 84 patient 60% for g patient out of 84 patient 80% for 1 patient out of 84 patient *?% for 10 patient out of 84 patient ? Patient with absence of well - documented report. (82) * Table 1 of 1 Correlations; SEX AGE HOME TCA STAGE GRADE SEX 1.0000** .1549 .0966 -.0253 -.0887 .0370 AGE .1549 1.0000** .2534 .1800 .0729 -.0062 HOME .0966 .2534 1.0000** .0063 -.0232 .2002 TCA -.0253 .1800 .0063 1.0000** .0185 -.0101 STAGE -.0887 .0729 -.0232 .0185 1.0000** -.0217 GRADE .0370 -.0062 .2002 -.0101 -.0217 1,0000** EAB * t OCC .5704** . 1732 -.1142 .1469 -.1135 .0211 TRE .0600 -.0502 .2781* .0235 .0465 .0861 DOSE .0169 -.0053 .0011 .1316 .0693 -.0846 DURATION -.0670 .0626 .1757 -.1208 . 1883 .1759 CT .0596 .1066 -.1839 .0975 -.0349 .0688. PROG -.0898 -.0053 .1022 -.0473 -.0060 .0269 N of cases: 84 1-tailed Signif: * - .01 ** - .001 " . " is printed if a coefficient cannot be computed * Table 2 of i Correlat ions; HAB OCC TRE DOSE DURATION CT SEX .5704** .0600 .0169 -.0670 .0596 AGE- .1732 -.0502 -.0053 .0626 .1066 HOME -.1142 .2781* .0011 .1757 -.1839 TCA .1469 .0235 .1316 -.1208 .0975 STAGE -.1135 .0465 .0693 .1883 -.0349 GRADE .0211 * .0861 -.0846 .1759 .0688 HAB OCC 1,0000*^ -.0074 .1255 -.2400 .1072 TRE -.0074 1.0000** ,4927** .2774* -.2323 DOSE . 1255 .4927** 1.0000** -.1035 -.1361 DURATION -.2400 .2774* -.1035 1.0000** -.0773 CT . 1072 -.2323 -.1361 -.0773 1.0000** PROG .0026 .1744 .0010 .0560 .2223 N of cases; 84 1-tailed Signif; * - .01 ** - .001 . " is printed if a coefficient cannot be computed (83) * Table 3 of 1 Correlations: PROG SEX -.0898 AGE -.0053 HOME . 1022 TCA -.0473 STAGE- -.0060 GRADE .0269 HAB OCC .0026 TRE .1744 DOSE .0010 DURATION .0560 CT .2223 PROG 1.0000** N of cases; 84 l-tailed Signif: * - .01 .** - .001 n n is printed if a coefficient cannot be computed (84) Crosstabulation: PROG Prognosis By DOSE Table 1 of 1 Count 14500 CGy!3900 CGyi1000-200!2100-30013000-400 DOSE-> !0 CGy !0 CGy 10 CGy Row 1.00! 2.00! 3.00! 4.001 5.00 Total PROG 1.00 1 ! 21 <20% 25.0 + + 2.00 12 ! 29 20%- 34.5 I __, T 3.00 6 10 40%- 11.9 +••I. . . , I •- f '-- . .. r- f .— I I 4 .00 6 ! 3 I 1 9 I 60%- t 10.7 i | i 1 _i_ T X T T T Column 32 14 11 13 84 (Continued) Total 38.1 16.7 13.1 2.4 15.5 100,0 Crosstabulation: PROG Prognosis By DOSE Table 2 of 1 Count iNon DOSE-> Row 6.00 Total PROG -+- 1,00 ! 21 <20% 25.0 2.00 ! 29 20%- i 34.5 3.00 ! 10 40%- 4.00 ! 60V- 10.7 Co lu •••.•• 12 u Total 14.3 (85) Crosstabulation: PROG Prognosis Bv DOSE Table 3 of 1 Count 4500 CGy!3900 CGy!1000-200!2100-300!3000-400! DOSE-> 1 JO CGy !0 CGy !0 CGy ' Row 1.00! 2.00! 3.00! 4.00! 5.00} Total PROG 5.00 1 80%- 1.2 7.00 1 14 No 16.7 -+ •—+ Column 32 14 11 2 13 84 (Continued) Total 38.1 16.7 13.1 2.4 15.5 100.0 Crosstabulation: PROG Prosnosis Bv DOSE Table 4 of 1 Count DOSE-> Row Total PROG 1 80%- 1.2 7.00 14 16.7 Column 12 84 Total 14.3 100.0 Number of Miss ins Observations = (86) Crosstabulation: PROG Prognosis By STAGE - • Table 1 of 2 Count Stage I Stage II!Stage II stage IViNon STAGE-> !I Row 1.00 2.00! 3.00 4.00! 5.00 Total PROG 1.00 1 5 5 ! 10 21 <20% 25.0 2.00 1 21 29 20%- 34.5 + _ _L 3.00 1 10 40%- 11.9 4.00 9 60%- 10.7 Column 5 1 17 10 5! 84 (Continued) Total 6.0 1.2 20.2 11.9 60.7 100.0 Crosstabulation: PROG Prognosis By STAGE Table 2 of 2 Count !Stage I Staee IIJStage II!stage IVjNon STAGE-> I ! Row i.oo 2.00! 3.00! 4.00! 5.00! Total PROG 5.00 1 1 80%- 1.2 I I i_ j i I I ! T i 7,00 14 No 16.7 Column 5 1 17 10 51 84 Total 6,0 1.2 20.2 11.9 60.7 100.0 Number of Miss ins Observations = 0 (87) Crosstabulation: PROG Prognosis By DOSE Table 1 of 1 Count 4500 CGyl3900 CGyl1000-200 2100-30013000-400 DOSE-> 1 10 CGy 0 CGy 10 CGy Row 1.001 2.001 3.00 4.001 5.00 Total PROG + +— T T 1.00 4 1 11 4 11 6 21 25.0 <20% -+- i 2.00 12 i 29 i i 34.5 20%- i -+ 3.00 10 11.9 40%- +- + 4.00 1 6 i 3 9 i 10.7 60%- + i +- +- Column 32 14 11 2 13 84 (Continued) Total 38.1 16.7 13.1 2.4 15.5 100.0 Crosstabulation: PROG Prosnosis BY DOSE - - Table 2 of 1 Count 1Non 1 DOSE-> 1 1 Row 1 6.001 Total PROG + + 1.00 1 5 ! 21 <20% 1 1 25.0 i i 2.00 1 2.1 29 20%- ! 1 34.5 i i 3.00 ! ! 10 40%- 1 1 11.9 + h 4.00 1 ! 9 60%- ! ! 10,7 + + Column 12 84 (Continued) Total 14.3 100.0 (88) Crosstabulation; PROG Prognosis By DOSE Table 3 of 1 Count 4500 CGy!3900 CGy!1000-200!2100-300!3000-400! DOSE-> ! JO CGy !0 CGy 10 CGy !| Row 1.00! 2.00! 3.00! 4.00! 5.00! Total PROG I I i . i__ _ j 5.00 1 1 80%- 1.2 7.00 1 1 ! 14 No 16.7 + i j i Column 32 14 11 . 2 13 84 (Continued) Total 38.1 16.7 13.1 2.4 15.5 100.0 Cros s t abu1at i on; PROG Prosnos i s Bv DOSE Table 4 of 1 Count !Non ! DOSE-> { ! Row 1 6,00! Total L j. T.— r 5.00 ! ! l 80%- ! ! 1.2 J I v.00 I 5 ! 14 No ! ! 16.7 + + Column 12 ^84 Total 14.3 100.0 Number of Mis-sins Observations = (89) Crosstabulation: PROG Prognosis Bv STAGE Table 1 of 2 Count !Stage I Stage II!Stage II!stage IVjNon STAGE-> jI ! J Row ! 1.00 2.00! 3.00! 4.00! 5.00! Total i • PROG T i1—~ T• r r 1 1.00 ! 1 1 5 ! 5 ! 10 ! 21 1 I 1 <20% 1 1 1 25.0 1 j 4. , _ , ,, ln _., . _ T 1 2.00 ! l 1 1 3 ! 3 ! 21 ! 29 1 1 1 20%- 1 1 1 34.5 4!- IV- 4_ 1 1 _ 4- + — 1 T r V I t 3.00 1 3 ! ' 1 6 ! 10 ! * 1 1 1 40%- t 1 11.9 1 1 rf r 4.00 I 2 i 2 ! 1 5 ! 9 I 1 1 60%- I t 1 10.7 I ______i______i. ______.!_-______(_,__ J Column 5 1 17 10 51 84 (Continued) Total 6.0 1.2 20.2 11.9 60.7 100.0 Crosstabulation: PROG Prognosis By STAGE - - - --Table 2 of 2 Count Stage I Stage IliStase II!stage iv!Non 1 STAGE-> :i 1 Row 1.00 2.00! 3.00! 4.oo! 5.00 Total L _i_ _ PROG t T - i 1 1 5.00 i 1 1 | 1 1 1 80%- i 1 ! 1.2 1 1 7,00 ! 4 1 2 1 S 14 1 1 1 No 1 1 ! 16.7 ____L_.__ _L.-__— __. . „ i + Column 5 1 17 10 51 84 Total 6.0 1.2 20.2 11.9 60.7 100.0 Number of .Missing Observations = (90) Crosstabulation: PROG Prognosis By TCA Type of Cancer Table 1 of 3 Count Adenocar!Sqamous !Lymphoma!S i rrhous!Non TCA-> cinoraa [Cell Car! ! Carcino! Row 1.00! 2.00! 3.00! 4.00! 5.00 Total PROG +— + 1.00 9 ! 1 6 21 <2Q% 25.0 +- + 2.00 17 1 ! 1 29 20%- 34.5 + ,..... i. 3.00 6 ! •3 10 40%- 11.9 .j —_. [ ._ -|—. — — [_ — —j- __—__ 4.00 3 9 60%- 10.7 i +— — T + +- Column 46 1 13 21 84 (Continued) Total 54.8 2.4 1.2 15.5 25.0 100.0 Crosstabulation: PROG Prognosis BY TCA Type of Cancer Table 2 of 3 Count jFibrosar! TCA-> Icoma ! Row ! 6.00! Total PROG + + 1,00 ! ! *21 <20% ! ! 25.0 + + 2.00 ! ! 29 20%- ! ! 34.5 + + (91) 3,00 ! ! iO .-• 40%- ! ,' 11.9 4.00 ! ! 9 60%- ! ! 10.7 + + Column 1 84 (Continued) Total 1.2 100.0 (91) Crosstabulation: PROG Prognosis By TCA Type of Cancer Table 3 of 3 Count !Adenocar! Sqamous !Lymphoma! Sirrhous!Non TCA-> Scinoma iCell Car! ! Carcino! Row 1.00! 2.00! 3.00! 4.00! 5.00 Total .___!_ _ __J __„ _i_ _L „ — ~_ L .—_ PROG — 1 I J V I 5.00 1 1 I 80%- I 1.2 +- 7.00 I 14 No 16.7 Column 46 2 1 13 21 84 (Continued) Total 54.8 2.4 1.2 15.5 25.0 100.0 Crosstabulation: PROG Prognosis Bv TCA Type of Cancer Table 4 of 3 Count [Fibrosar TCA-> coma Row 6.00 Total PROG I 5.00 ! 80%- 1.2 +- 7.00 '14 No 16.7 Column 1 84 . Total 1.2 100.0 Number of Missing Observations = (92) Cros s tabu1at i on: PROG Prognos i s By AGE Table 1 of 4 Count 20- 27- 34- 41- 48- i AGE-> ! Row 1.00 2.<30 3.00 4.00 5.00 ! Total L L. PROG .- ——— _____ ——-____—.__r 1.00 2 9 1 1 ! 21 • <20% ! 25.0 L „__ i —— 2,00 1 2 6 5 ——— ._. 29 20%- 2 ! 34.5 L L — 3.00 2 5 10 40%- 11.9 - . HI- — — 1- 4.00 1 4 9 60%- 10.7 L L _i L _ .... — o 8 8 7 84 (Continued) ColumTotaln 3.6 9.5 282.46 9.5 8.3 100.0 Crosstabulation; PROG Prognosis By AGE - - - - Table 2 of 4 Count 55- 62-, !69- 76- non AGE-> Row 6.00 7.()0 8.00 9.00 11.00 Total PROG — 1.00 3 2 2 21 <20% 25.0 J _i •A 2.00 ' 7 3 1 3 29 20%- i 34.5 4 —* i — 1 - 3.00 ! 1 1 I 10 40%- • 11.9 1 -» —^ -1 — i 4.00 ! 3 1 1 9 60%- i 10.7 I 1 _L ______.X-______^i.___ __™ _{_ Column 16 7 3 1 7 84 (Continued) Total 19.0 8.3 3.6 1.2 8.3 100.0 (93) Crosstabulation: PROG Prognosis By AGE Table 3 of 4 Count 120- 27- 34- 141- 148- AGE-> i i Row i I.OO 2.00 3.00! 4.00! 5.00 Total PROG 1 r i i i 5 .00 i i i 1 1 i i 80%- i t 1.2 O 1 11 7 .00 ! 2 2 J 1 1 1 14 I I No 1 ! 16.7 _i , 1 | 1 i L Column 3 8 24 8 7 84 (Continued) Total 3.6 9.5 28.6 9.5 8.3 100.0 Crosstabulation: PROG Prognosis Bv AGE Table 4 of 4 Count 62- !69- 76- [non AGE-> Row 6.00 V.00! 8.00 9.00! 11.00 Total PROG i_ i j j i 5.00 1 80%- 1.2 i _r | _i_ . | J 7.00 2 14 No 16 , 7 j I j I Column 16 7 3 1 7 84 Total 19.0 8.3 3,6 1.2 8.3 100 .0 Number of Missing Observations = 0 (94) Cross t abu1at ion: PROG Prognosi s By CT Chemotherpy Table 1 of 5 Count iYes No CT-> Row 1. 00 2.00 Total PROG 1.00 12 9 21 <20% I 25.0 2.00 \ 16 13 29 20%- 1 34.5 3.00 6 4 10 40%- 11.9 4.00 1 3 6 9 60%- i ! 10.7 ,_J_ Column 41 43 84 (Continued) Total 48.8 51.2 100.0 Crosstabulation; PROG Prognos i s CT Chemotherpy Table 2 of 5 Count iYes !No CT-> ! Row 1.00! '2.00! Total PROG 5.00 ! ; 1 •.oo I 4 ! 10 14 No 16." Co1umn 41 43 84 Total 4S.3 5!.2 100.0 Number o f M i s s i n 2 Ob s e rva t i on s = 0 (95) Fore more information see the previous table. Finally I can conclude that in • addition to the absence of essential information through out patients files duto: Carelessness of dinition to wrigh down patient identification sheet completely to help in gaining information to continu are search in the field. - Bad system storage in the statistic section in RICK. In addition to that I think the absence of ideal measurement and demarcing of angles and diamension in the treatment of Ca breast as we shown its affect in fig 1.1 —> 4,1 previously, my be the main reason to decline the result of treatment and the prognosis. (96) Chapter Five Conclusion and recomendation As stated in the previous chapters we can see that how it is important to measure and demarcation tangential angles and dimension in Ca. breast treatment. Als it is clearly appear that the follow up of patient during year 1989 was very poor and this may be duto; - Diffeculty in movement specially for patient who lived at further states. - Although, Sudan is a big country there is just only one health unit of cancer. - Weakness of heatlh education among Sudanses Socielty play a wide role in to control cancer. By the other hand the effective methode of collecting data, play an important role to find the outcome of the treatment model/ in order to help on research and improvement of the field. But unfortunately, there is no an effective method which depend on a certain statistical scientific program in RICK for collecting information. The classical method which is used now in RICK to collect and store information lead to miss information which affect directly to continue studies and research and so in improvement of the field. Because of that RICK is the only health unit link with cancer, there fore patient seeking radiotherapy service come from all states, they must get the appropriate treatment which they need. It is important to know that any error of dose distribution surround the treatment volume duto: - Absence of beam direction device Absence of treatment planning system device. Movement of the patient during treatment. Neslecting of dimarcing appropriate angles and dimensions. Leads to various problems such as; - Recurrence. - Radiation reaction lateron. - Excessive irradiation for critical organs. (97) For this and other problems,, I have to menation that for those who are concern should do ther best to provide the necessary treatment planning system, because of their important in localization of treatment volume and to demarc the suitable angles and dimensions. In addition to that, concideration must be taken during the treatment of Ca. breast for the following:- - Keep attention to make the two beams at 18°. The angle on the treatment sheet must not be neglected. Use asimulator system in case of missing one or both of the centres. - Avoid to use shadow technique in the treatment of tangential field. By the way as attempt from me to help the technologist inside the treatment room to take full chest contour to help in alignment of centres, I presented simple by word., in addition to another one for reading tangential angle in case of the centre ro be zbr>ut, (See appendix fig ~1 & 2). Finally I hove th^.t T provide a littl.s aid in v\o the traH I QR Refarnces (1) B. Spiessl 0. Scheibe G. Waaner TNM - Atlas Springer - Verlag Berlin Heidelberg New York 1983 (2) CD, Haagensen, M.D Disease of the breast Third edition WB, Saunders company Philadephia London Toranto Mexico city Riodejaneiro Sydney Tokyo Hong Kong (3) Jane Dobbs MRCP, FRCR Ann Barrett MD, MRCP, FRCR ... Daniel Ash MD, MRCP, FRCR Practical Radiotherapy planning 2 edition Edward Arnold London Melbourne Augkland (4) Karol Sikora & Keith E. Hainan Treatment of cancer Second edition London, Chapman and Hall Medical (5) Sherif Omar & Cenevieve Conksso Breast Cancer First edition KOREA (INTERNATIONAL) Company Ltd. London UK, 1988 Interview Question What is your evaluation about the treatment of the tangential field in Ca breast depending on the shadow of the breast in the beam absorber? What do you think about the important of demarcation the ideal tanaential field anvles on the treatment sheet? What do you think about the things that obstruct the physist to demarc the ideal angles and dimension on the treatment sheet? .1