|Year : 2015 | Volume
| Issue : 7 | Page : 40-52
|Date of Web Publication||24-Nov-2015|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Gynecology. J Can Res Ther 2015;11, Suppl S3:40-52
Clinical outcome in carcinoma vulva: An institutional experience
thK. Mazumder , B. Rai, S. Ghoshal
Postgraduate Institute of Medical Education and Research, Chandigarh, India, E-mail: firstname.lastname@example.org
Background: Vulvar cancer is one of the uncommon gynaecological malignancies. Multimodality treatment with Surgery, Radiotherapy and Chemotherapy required treating the disease. Aim: To evaluate clinical outcome in patients of carcinoma vulva, treated at our institution. Materials and Methods: This was a retrospective cohort study done in 50 Patients with squamous cell carcinoma of Vulva, treated at our institution from January 2008 to December 2014. Data was analysed on the basis of age, stage, type of treatment received & treatment associated toxicity. Disease free survival and overall survival were estimated. Statistical analysis was done by using SPSS software V.20. Results: The mean age of presentation was 61.5 years. Majority of the patients (52%) had presented with stage III disease. Thirty-six of 50 patients underwent surgery: Simple vulvectomy-2; Radical vulvectomy-34. Bilateral Inguinal lymph node dissection was done in 32 patients and one patient underwent ipsilateral inguinal lymph node dissection. Ten patients didn't require any adjuvant treatment after surgery and were thus kept on follow up. Among 40 patients (80%) who received radiotherapy, eight patients received palliative radiotherapy. Post-operative adjuvant radiotherapy was given in 23 patients, eight patients received radical radiotherapy and one received pre-operative radiotherapy. Seventeen patients underwent Intensity modulated Radiotherapy (IMRT) and fifteen patients received conventional radiotherapy. The dose of radiotherapy was 45 to 50.4 Gy. Significantly less G2 or more skin toxicity (P = 0.003) observed in patients who underwent IMRT. Among non IMRT group 8 patients were required treatment break during radiation. Four patients were received chemotherapy: 2 neoadjuvant, one concurrent & one adjuvant. At a median follow up time of 25.5 months, median overall survival was 31 months and median disease free survival was 25 months. 42% patients are alive and free of disease. Conclusion: Radical vulvectomy with inguinal lymph node dissection followed by radiotherapy is mainstay of management of locally advanced carcinoma vulva. Using IMRT we could minimize the side effects of radiotherapy as well as the treatment break.
Six fractions per week of external beam radiotherapy and high-dose-rate brachytherapy for treatment of locally advanced cervical carcinoma
thS. Chandel , A. K. Nigam
Gajara Raja Medical College, Gwalior, Madhya Pradesh, India, E-mail: email@example.com
Aim: This study evaluated the treatment results of external beam radiotherapy administered in six fractions per week and high-dose-rate (HDR) brachytherapy for the treatment of cervical cancer. Materials and Methods: From July 2012 to January 2015, 63 patients locally advanced cervical carcinoma (FIGO staging IIB, III & IVA) were enrolled in this study. The patients received 50 Gy from a Co-60 photon beam using two field when Inter portal distance (IPD) less than 20 and four-field box technique when IPD more than 20 cm to whole pelvis. The daily fraction dose was 2 Gy administered in six-weekly fractions, from Monday to Saturday. After completion of EBRT patient refer for HDR brachytherapy was also delivered at doses of 21 Gy to point A in three fractions on weekly basis. The median follow-up time was 18 months (range, 6-30 months). Results: The median overall treatment time was 51 days for all patients (range, 44-62 days). Fifty two patients (82.5%) achieved complete remission and 9 (14.2%) achieved partial remission and two patients (3.1) had no remission after radiotherapy. Locoregional recurrence occurred in 4 patients (6.3%), and a distant metastasis was encountered in 3 patients (4.7%). The 2-year overall survival, locoregional, and distant metastasis-free survival rates were 87.3%, 93.7%, and 82.5%, respectively. Grade 2 and 3 late rectal complications were encountered in 4 (6.3%) and 2 (3.1%), respectively. There were no Grade 3 late bladder complications. Conclusions: Six fractions per week of external beam radiotherapy and HDR brachytherapy is an effective treatment for patients with a carcinoma of the uterine cervix and can be used as a possible alternative to concomitant chemoradiotherapy in elderly patients or in patients with co-morbidity.
Comparative analysis of treatment outcome between HDR vs LDR brachytherapy in carcinoma cervix patients done at a tertiary care center
thS. Jain , I. Bashir, P. Khullar, G. Arora, N. Dhingra, A. Bhatnagar, A. Thakwani, K. S. Chufal
Batra Hospital and Medical Research Center, New Delhi, India, E-mail: Ssunnyjain@gmail.com
Background: Cervical carcinoma was treated with LDR brachytherapy which is considered radiobiologically more sound. High-dose rate (HDR) brachytherapy was developed to overcome potential disadvantages of LDR brachytherapy Aim: The aim of this study was to compare the treatment outcome of HDR brachytherapy in patients of cervix cancer at one year follow up Vs LDR brachytherapy as reported in literature. Materials and Methods: A total of 45 patients of carcinoma cervix FIGO stage IIB- IIIB were enrolled from June 2010 to May 2011. CT simulation was followed by contouring as per the RTOG guidelines. All the patients received external beam radiotherapy with IMRT technique using non co planar beams for a total dose of 5040 cGy in 28 # over 5.5 weeks with concurrent Inj. Cisplatin 40 mg/m2 on weekly basis. Patients received 3 HDR brachytherapy sessions at weekly interval and received 700 cGy/session to point A. Patients were assessed at an interval of 1 month after completion of treatment and every 3 monthly thereafter for a period of 1 year. Late side effects were defined as sequelae reported 90 days after completion of the treatment. All the toxicities were graded as per the RTOG criteria. Results were compared with LDR brachytherapy as cited in literature. Results: Median age in HDR was 59 years (range 39-65) and maximum patients were in stage IIB 60%. The overall response rate was 91.11% in HDR group vs 60% in LDR group. Complete response was 64.44% vs 43.33%, Partial response was 26.66 vs 16.66%, stable disease or progressive disease was reported to be 8.90% vs 40% in HDR vs LDR group. On follow up after 3 month 60%were disease free in HDR group VS 48.88% in LDR. On 6 monthly follow up 52.85% were disease free vs 45% in LDR. 55% patients vs 63.63% patients at 9 months and 60% Vs 42.85% patients were disease free at 1 year follow up. Skin reactions were comparable. 64.44% vaginal synechiae reported in HDR compared to 57.77% of patients in LDR. 8.88% of patients in HDR vs 10% patients in LDR experienced genito urinary complications. 4.44% Vs 3.33% (HDR vs LDR) suffered from varying degree of rectal complications. 3.33% in LDR developed vesico vaginal fistula whereas none was reported in HDR group. 2.22% patients in HDR developed cystitis vs none in LDR. Conclusion: Overall response rates in HDR group were higher compared to LDR group with comparable side effects profile. However a larger study with longer follow up is warranted.
Clinical and dosimetric comparison of interstitial applications using Martinez Universal Perineal Interstitial Template and Syed Nyblet template for carcinoma cervix and vault carcinoma
thK. Roy , A. Bandopadhyay, S. Sarkar, A. Kabasi, S. Ghosh, P. Dutta, M. Asifulla
Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Background: Cervical cancers are the most important the cancers among female population in India, with majority of patients have locally advanced disease at time of presentation stage IIB- IVA. Radiotherapy plays a very important role in management of locally advanced stages. EBRT followed by ICRT is the standard treatment for cervical carcinoma interstitial brachytherapy is recommended for some cases in which either ICRT is expected to result in suboptimal dose distribution or it is technically not possible. Aim: Compare the clinical and dosimetric parameters, acute & late toxicity and local disease control in patients of carcinom cervix and vault carcinoma treated with interstitial brachytherapy using MUPIT template versus Syed Neblet Template. Materials and Methods: The cohort of eligible patients receiving interstitial brachytherapy for cervical carcinoma or vault carcinoma for radical intent following EBRT to whole pelvis during the period Jan 2010 to Dec 2013 were included. patients were followed for acute and late toxicity and local and distant disease outcomes. Comparative analysis of clinic-demographic parameters, treatment parameters and dosimetric parameters were undertaken between those treated using MUPIT and Syed Neblet. Results: 82 received interstitial brachytherapy during the above mentioned period, of which 21 were of vault carcinoma or vault recurrence. Of these 61 patients were eligible and was included in the study, 37 received using Syed Neblet and 24 using MUPIT. The median age was 45 years and was similar in both groups. The mean EBRT dose was 46.4 Gy in the Syed group and 47.2 Gy in the MUPIT group. The ISRT dose was similar in both groups (7 Gy X3 fractions). The mean number of needles used was 17.2 and 18 in Syed and MUPIT cohort. The mean EQD2 to the 2 cc Bladder and 2 cc Rectum were 75.4 Gy and 72.21 Gy in the Syed Cohort and 76.83 Gy and 75.38 Gy in the MUPIT respectively (p = 0.12 and 0.09 resp). Acute toxicity was mostly Grade 1 and 2 genitourinary or Grade 1 or 2 Rectal. Most common late toxicity was rectal bleeding and dysuria; 13 (35.14%) cases in the Syed Neblet Arm and 8 (33.3%) cases in the MUPIT arm. At the median follow up duration 27 months the local control rate was about 82% in the Syed Arm and 79% in the MUPIT Arm (p = 0.32). Conclusion: Clinical, dosimetric and outcome parameters were found to be similar in both the groups, except that the dose to 2 cc OAR was slightly lesser in Syed when compared to MUPIT.
Dosimetric study comparing intensity modulated and 3DCRT pelvic radiotherapy boost plans in patients with cancer cervix
thM. Gupta , R. Ravikant, S. Bansal, V. Nautiyal, H. Raj, J. Bisht,
S. Saini, M. Ahmad
Cancer Research Institute, Swami Rama Himalayan University, Dehradun, Uttarakhand, India, E-mail: email@example.com
Purpose: This study was to compare 3DCRT conformal technique to the intensity modulated radiotherapy (IMRT) in boosting cancer cervix cases after external beam radiotherapy with respect to target volume coverage and doses to normal tissues. Materials and Methods: Ten previously irradiated patients of carcinoma cervix were retrieved and replanned with both 3DCRT and IMRT boost after 46 Gy/23# box field pelvic radiotherapy. All tumors were situated in the low central pelvis. Two plans were done for every patient; one using the 5 fields IMRT and the second one using 5 fields 3DCRT. A total boost dose of 20 Gy was delivered with a dose/fraction of 2 Gy, five fractions weekly. The two techniques were then compared using dose volume histogram (DVH) analysis for the planning target volume (PTV), bladder, rectum and both femoral heads. Results: Comparing different DVHs, it was found that the Mean values of PTV 95% and PTV 5% in IMRT were 95.73% and 104.74% and for 3DCRT were 92.06% and 105.69% respectively. The dose homogeneity was better in the IMRT (1.089) as compared to 3DCT (1.146) with P value 0.341. Mean of conformity index for IMRT was 0.959 and for 3DCRTwas 0.890. Confirmity index was better in IMRT plan as compared to 3DCRT with p value 0.028. IMRT plans were competitive with 3D-CRT in sparing the urinary bladder and rectum where mean of V50 urinary bladder were 57.39 Gy for IMRT and 56.36 Gy for 3DCRT respectively with p value = 0.310. Mean of V50 rectum were lower with 3DCRT as compared to IMRT plans 56.34 Gy vs. 58.33 Gy respectively, P = 0.28. Mean of V40 right and left femur were 47.86 Gy and 46.34 Gy for IMRT and 53.02 Gy and 50.68 Gy for 3DCRT with p value of 0.05 in rt femur and p value = 0.38 in left femur respectively. Conclusion: From the present study, it is concluded that sparing of OARs (rectum, bladder and, both femoral heads) were comparable in both techniques but IMRT significantly improved the conformality relative to 3DCRT treatment so whenever possible IMRT technique should be used in boosting cases with locally advanced cancer cervix if brachytherapy is not available or patients are not fit medically or technically for brachytherapy.
Adenocarcinoma: A single center experience evaluation of adjuvant treatment strategy in stage I endometrioid cancer
thB. Parmar , B. Rai, S. Ghoshal, V. Suri
Post Graduate Institute of Medical Education and Research, Chandigarh, India, E-mail: firstname.lastname@example.org
Background: The role of postoperative adjuvant RT in Stage I endometrioid adenocarcinoma is still a matter of debate. Here we report our institutional experience with adjuvant treatment strategy followed for these patients. Aim: To evaluate the outcome and pattern of failure associated with adjuvant treatment strategy followed at our institution for Stage-I endometrioid adenocarcinoma and discuss implications for radiotherapy. Materials and Methods: This was a retrospective study in which 140 patients with FIGO Stage I endometrioid adenocarcinoma who underwent primary surgery between 2008 and 2013 were evaluated. Patients with Grade 3 histology, age >60 years, >50% myometrial invasion and LVE were the potential candidates for adjuvant treatment. The adjuvant treatment was in the form of Pelvic EBRT (46 Gy to 50 Gy @ 2 Gy/#) using 3DCRT/4 field box technique or vaginal brachytherapy (VBT) or both (Pelvic EBRT &VBT). Results: A total of 96 patients had FIGO Stage Ia disease while 44 had Stage Ib disease. All underwent surgery with assessment of peritoneal cytology. Pelvic and paraortic lymph node sampling was done in 59 and 9 patients respectively. Average number of pelvic lymph nodes removed was 7. Out of 96 patients with stage Ia disease 29 patients were given adjuvant treatment either pelvic EBRT or VBT or both. Among 44 patients who had stage Ib disease; 2 patients received no adjuvant treatment. Median follow up time was 44 months and disease free survival was 42 months while disease free survival rate was 95%. At a median follow up of 44 months, 6 patients developed recurrence out of which 5 patients had Stage Ia disease while 1 had Stage Ib disease. Out of 6 patients 3 had not received any form of adjuvant treatment. 2 of them had local recurrence and 1 had both local & distant recurrence. 3 patients who had received adjuvant treatment had distant failure. 4 patients had undergone pelvic lymph node dissection. Conclusion : In our patients the most consistent factor associated with relapse was Age >60 years and postmenopausal status. Adjuvant treatment although prevented local recurrence but patients failed at distant sites. Since most of the failures were seen in Stage Ia, individualized risk models are necessary to increase the predictive ability of current staging system. Adjuvant treatment was well tolerated in our patient population. The addition of Pelvic lymph node dissection offered no added benefit.
Different fractionation schedules of high dose rate brachytherapy in carcinoma of cervix
thN. Bansal , A. K. Chauhan, P. Kaur, A. Khurana, Y. Verma
Pt. B.D. Sharma Post Graduate Institute of Medical Science, Rohtak, Haryana, India, E-mail: email@example.com
Background: Intracavitary brachytherapy at high dose rate (HDR), often with the addition of external-beam radiotherapy, has been the treatment of choice for locally advanced carcinoma of the cervix. High dose rate brachytherapy for cervical cancer can be given in various fractionation schedules, though no consensus exists for a single effective regimen. Aim: Efficacy of two different schedules of HDR brachytherapy in the treatment of locally advanced cervical cancer was evaluated. The study compared the effectiveness of the two schedules in terms of response rate, pelvic failure (PF), distant failure (DF), rectal complications and bladder complications. Materials and Methods: A total of 80 patients of stage IIB-IVA of carcinoma cervix were randomised into two arms of 40 patients each. The patient parameters were closely matched in the two arms. Median follow up was of 18 months. All patients received external beam irradiation to the pelvis (50 Gy/25 fractions/5 weeks) on telecobalt machine with concomitant cisplatin 40 mg/m2 IV weekly. HDR intracavitary brachytherapy (ICBT) schedule differs in the two arms. Patients were divided into Arm I: 6 Gy Χ 3 fractions over 3 weeks and Arm II: 7 Gy Χ 3 fractions over 3 weeks. Results and Conclusion: Overall response rate was 92.5% and 87.5% in Arm I and Arm II respectively. Pelvic failure was seen in 7.5% and 12.5% in Arm I and Arm II respectively. Distant failure was seen in 7.5% and 12.5% in Arm I and Arm II respectively. Grade 3-4 late bladder toxicity was observed in one patient in Arm II only. Grade 3-4 late rectal toxicity was seen in 5% and 10% of the patients in Arm I and Arm II respectively. There was no statistical significance in terms of response rate, pelvic failure and distant failure among the two treatment schedules. There was insignificant increase in the late complications in Arm II. The different HDR schedules seem to be safe and effective for the treatment of locally advanced cervical cancer, with 7 Gy in 3 fractions schedule to be little more toxic.
Single institution retrospective study on cervical cancer
thP. Rajmane , S. Shanmuga Kumar
Madras Medical College, Chennai, Tamil Nadu, India, E-mail: firstname.lastname@example.org
Background: Cervical cancer is one of the most common cancers among women worldwide. India accounts for approximately 26% of global prevalence. Cervical cancer is the leading cancer among women in terms of incidence rates in 2 out of the 12. In India the age-adjusted incidence is highest in Chennai, Tamil Nadu. Aim: The aim of the study is to review the clinico-pathological pattern of this disease, the various treatment modalities used in their management and their results. Materials and Methods: Case records of 235 women with cervical cancer treated between Jan 2007 To Dec 2011 available were retrospectively analyzed. FIGO system of staging for cervical cancer was used. Results: Cervical cancer is widely distributed among women of age 30-60 yrs with median age around 48 yrs. Post menopausal 54%, pre menopausal-46%. The most common presenting symptom was vaginal bleeding (49%) followed by white discharge (26%). STAGE: 1A-0%, 1B-4%, 2A-5%, 2B-22%, 3A-2%, 3B-40%, 4A-6%, 4B-19%. Histology: Squamous-91% (well diff-14%, mod diff-56%, poor diff-30%), adeno-3%, adenosquamous-2%, basaloid squamous-1%, transitional-1, small cell-2%. Regional nodes were seen in 15% of the pts. Metastases: 19% of the patients presented with metastasis. The commonest site of metastasis was lung-21% followed by liver-16%. 5% patients showed multiple metastases. Response: Complete response was seen in 83% of 2B pts and 41% of 3B cases. Irrespective of the stage, unilateral parametrial involvement was associated with a better response ie, 60% complete response compared to 40% in bilateral disease. Poor differentiated tumors had a better response. Toxicity: The most common toxicity was skin reaction seen in 24% pts. (grade 1 - 4%, grade 2 - 8%, grade 3 - 8%, grade 4 - 4%), emesis-10%, vaginitis-10%. Relapse: Inspite of treatment relapse was seen in 5% of the cases. Conclusion: Cervical cancer is one of the most treatable and preventable form of cancer as long as it is detected early and managed effectively. Unilateral parametrial involvement has a better response than bilateral parametrial involvement. Concurrent chemoradiation followed by brachytherapy remains the most effective form of treatment in locally advanced cervical cancers. Cisplatin as a single agent showed comparable results.
Pilot study to evaluate acute treatment related toxicities of three-dimensional conformal radiotherapy versus intensity modulated radiotherapy in carcinoma cervix patients treated with concurrent chemoradiation
thA. Elangovan , A. Bahl, F. D. Patel, R. Kapoor, B. Rai, G. Trivedi,
O. Singh, S. Ghoshal
Postgraduate Institute of Medical Education and Research, Chandigarh, India, E-mail: email@example.com
Background: Cervical cancer is the second most common cancer in Indian women. Concurrent chemoradiation is the treatment of choice for locally advanced cervical cancers. Intensity modulated radiotherapy (IMRT) for cervical cancer has been studied to reduce doses to the organs at risk (OAR). Our study was designed to compare 3-Dimensional Conformal RadioTherapy (3DCRT), IMRT and Bone marrow sparing IMRT (BMS-IMRT) techniques in reducing the acute treatment related toxicities in Indian patients. Aims: (1) To evaluate acute treatment related toxicities. (2) To evaluate doses to OAR. (3) To assess overall response at the end of 6 months. Materials and Methods: Thirty six patients of squamous cell carcinoma of cervix stage IB2-IIIB were randomized into three study groups, 3DCRT, IMRT and BMS-IMRT. All patients were treated with External beam radiotherapy (46 Gy/23#/41/2weeks) and concurrent weekly cisplatin (40 mg/m 2 ), followed by Brachytherapy given in a dose of 9 Gy delivered in two fractions, one week apart. 3DCRT plans were generated using 4 field box technique. IMRT plans were generated with 7 field coplanar beams using 6MV photons. Acute toxicity was graded according to CTCAE v3.0. Results: The median age of presentation was 43years. Of the 36 patients, 4 were stage-Ib, 26 were stage-IIb, and 6 were stage-IIIb. In the 3DCRT, IMRT and BMS-IMRT arms, ≥grade 2 vomiting was experienced by 83.3%, 41.6% and 75% of patients (p < 0.07), ≥grade 2 proctitis by 16.6%, 58.3% and 8.3% of patients (p < 0.12) and ≥grade 2 dermatitis by 58.3%, 8.3% and 8.3% of patients (p < 0.005) respectively. ≥Grade 2 anorexia occurred more commonly in the BMS-IMRT arm than the 3DCRT (p < 0.01) and IMRT arms (p < 0.07). Dosimetric analysis showed that doses to bladder were V40 (%) -100, 94.6 & 92.9 (p < 0.25), Rectum V40 (%) -98.6, 90.1 and 89 (p < 0.33), Bowel V45 (cc) 714, 218 and 202.8 cc (p < 0.05) and Bone marrow V10 (%) were 94.6, 90.7 and 93.6% (p < 0.27) respectively. The mean dose to femoral heads was lower in the IMRT group than 3DCRT arm (p < 0.05). 17 patients have completed 6 months of follow up, of which 88.2% showed Complete Response and 11.8% showed Progressive Disease. Conclusions: IMRT showed a trend towards lower acute toxicities with lesser incidences of vomiting and dermatitis. Doses to OAR have also shown a favourable trend compared with 3DCRT.
Routine use of ultrasound guided tandem placement in intracavitary brachytherapy for the treatment of cervical cancer: A South Indian institutional experience
thP. B. Ananda Rao , S. Ghosh
GSL Cancer Hospital, GSL Medical College and General Hospital, Rajahmundry, Andhra Pradesh, India, E-mail: firstname.lastname@example.org
Introduction: Intracavitary brachytherapy requires the insertion of a tandem applicator through the cervical os into the uterine cavity. Blind insertion of the tandem may result in suboptimal tandem placement, which impairs the local tumor control and may also result in uterine perforation. Although routine real-time ultrasound guided tandem placement has resulted in better tumor control and lesser rates of uterine perforation, its routine use is seldom practised. Objectives: To evaluate the role of routine real-time intraoperative trans-abdominal ultrasound guided tandem placement in intracavitary brachytherapy for cervical cancer. Materials and Methods: This is a prospective single institutional study conducted from April 2013 to May 2015. A total of 96 patients of locally advanced cervical cancer were treated with routine ultrasound guidance amounting to a total 282 intracavitary applications. Results: In 78 patients, the cervical os could be easily identified visually, which was then confirmed with ultrasound guidance. In 12 other patients, though the os could be identified visually, uterine sounding was extremely difficult without ultrasound guidance. In another 4 patients, the cervix was flushed with vagina and the os was unidentifiable visually alone. In these patients, the cervical os was accurately identified and tandem was placed successfully by intraoperative ultrasound scanning. In 2 of the 96 patients, ICBT was abandoned and patients were advised for interstitial brachytherapy. In one of these patient, the cervical anatomy was completely destroyed by the tumor, while in the other patient, though the os was identifiable, the os was completely stenosed due to fibrosis and the uterine sound could not be passed even with ultrasound guidance. Out of 96 patients in the study, in 15 patients, the length of the uterine canal changed in the subsequent brachytherapy application. Conclusion: Routine use of intraoperative real-time ultrasound guided tandem placement is strongly advocated for proper placement of the tandem applicator and to avoid uterine perforations. The method is accurate, fast, easily available and cost-effective. Hence it can be incorporated in intracavitary applications for cervical cancers even in the developing countries, where cost, accessibility and time are important issues.
Concurrent chemoradiation with weekly injection cisplatin versus weekly injection carboplatin in locally advanced carcinoma cervix: A prospective randomised study
thS. Saren , A. Basu, K. B. Choudhury, A. Chakraborty, S. Gangopadhyay, K. Ghosh
R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India, E-mail: email@example.com
Background: In locally advanced carcinoma cervix FIGO staging IIB - IVA, the standard of treatment is concomitant chemoradiation with weekly Inj. Cisplatin followed by brachytherapy. But Cisplatin is associated with increased nausea and vomiting as well as altered renal function. Carboplatin, platinum analogue of Cisplatin, serve as an active radio- sensitizer. In patients where cisplatin is contraindicated, the ideal treatment is not known. Therefore we designed a trial to evaluate weekly Carboplatin in comparison to weekly Cisplatin for concurrent chemoradiation of locally advanced carcinoma cervix. Aim: To compare efficacy of two concurrent chemotherapy regimen (weekly cisplatin versus weekly carboplatin) and toxicities in treatment of locally advanced carcinoma cervix. Materials and Methods: In this prospective, randomized, single-institutional study, between November 13 to June 15, non-metastatic SCC of cervix with normal baseline parameters were randomised into two arms 1:1, to receive either inj cisplatin (40 mg/m2) concurrently (arm A control) or inj carboplatin (AUC-2) concurrently (arm B study) weekly during EBRT. After completion of concurrent chemoradiation and brachytherapy, response and toxicities were assessed. Results: 34 out of 80 patients in arm A vs 36 patients in carboplatin Arm B, completed the treatment and were evaluated for response. 30 patients (83.3%) in Arm B completed planned cycles of chemotherapy against 20 patients (58.8%) in cisplatin arm, p value 0.023. EBRT treatment time was prolonged in arm A (median 42 days, range 37-64 days) against median 41 days in arm B (38-61 days), p value 0.029. This translated into prolonged treatment gap (p value 0.001) and overall treatment time (0.001) in cisplatin arm. The time delay however did not convert into loss of tumour control. One month post treatment complete response was seen in 28 patients (77.8%) in carboplatin arm against 24 patients (70.6%) in cisplatin arm, p value 0.137. No significant difference in response rate at the end of study. All grades nausea and vomiting were significantly higher in cisplatin arm 82.4% Vs 52.8% in carboplatin arm, p value 0.008. Cisplatin arm had higher grade 3 nausea and vomiting. Hematological toxicities were non-statistically significantly increased in carboplatin. Late toxicities were no different in both arms. Conclusion: Carboplatin can be used as an alternative to cisplatin without significant variation tumour control rate.
Assessment and comparison of quality of life and sexual functions before and after radical concomittant chemoradiation in cancer cervix
thF. J. Momin , K. B. Choudhury, A. Basu, K. B. Choudhury, P. Dasgupta, K. Ghosh, S. Gangopadhyay
R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India, E-mail: firstname.lastname@example.org
Background: Globally, cancer of cervix is the 3 rd most common malignancy among females, but unfortunately the health care services offered to these patients are mostly aimed at treating the disease and not the patient as whole. Particularly in developing countries like ours, quality of life issues and psychosexual problems is not often addressed properly. This study might help to assess and compare the psychosexual functions and quality of life in these patients before, during and after treatment which might help to find out some treatment specific interventions directed towards information, education and counselling (IEC). Aim: To assess the quality of life and psychosexual function of survivors of locally advanced carcinoma cervix treated with radical chemoradiation. Materials and Methods: Patients of histopathologically proven locally advanced carcinoma cervix and sexually active were included in this study from October 2013 to May 2015. Patients were assessed using 2 structured questionnaire of health related quality of life (The European Organisation and Treatment of Cancer, EORTC QLQ C-30 & Cx-24). It is a cancer-specific 30 item questionnaire, these scores were transformed according to the EORTC QLQ C-30 scoring manual (Fayers et al., 1999). And the sexual activity were measured by Female Sexual Function Index (FSFI), it includes 19 items compiled in six domains. They were calculated according to the recommended scoring system (Rosen et al.). The baseline observation were recorded when patient first reported & 2nd, 3rd, 4th, 5th evaluation was done immediately after treatment, at the end of 3rd, 6th and 12th months respectively. The change in quality of life and sexual morbidity were assessed by comparing before and after treatment by measuring and comparing their mean scores. Results: 66 patients were enrolled in the study with average age around 48 years. The mean score of global health of cervical cancer patients at twelve months post treatment was 78.1, which was significantly higher than the pre-treatment score 66.18. Patients experienced substantial decrease in sexual activity during and post treatment period and gradually improved with time. Conclusion: From this study, it can be concluded that treatment with chemoradiation is significantly affected the quality of life and psychosexual function along with physical problems. Hence, further studies are needed for more information and intervention to improve the problems.
Concurrent chemoradiation with weekly cisplatin and gemcitabine in locally advanced cervical cancers
thP. Rajmane , S. Shanmugakumar, N. V. Kalaiyarasi
Madras Medical College, Chennai, Tamil Nadu, India, E-mail: email@example.com
Background: Cervical cancers represent the major bulk of the gynaecological cancers worldwide. Concurrent chemoradiation with Inj. cisplatin has been the standard of care. Gemcitabine has radiosensitising properties and also enhances the cytotoxicity of cisplatin by increasing the formation of cytotoxic platinum-DNA adducts. Aim: To determine the immediate locoregional control of locally advanced cervical cancers with concurrent chemoradiation with cisplatin and gemcitabine followed by brachytherapy and also to assess acute toxicity to treatment. Materials and Methods: 30 chemotherapy and radiotherapy naοve patients registered during the period of March 2014 to March 2015 with carcinoma cervix stage IIB to IVA with squamous histology were considered eligible. All patients received a whole pelvic EBRT total dose of 50.4 Gy/28#/5 days per week along with weekly Inj. cisplatin 40 mg/sq.m and Inj. gemcitabine 125 mg/sq.m followed by HDR Brachytherapy-30to 35 Gy to point A after 2 weeks. Response assessment was done after 4 weeks of brachytherapy both clinically and radiologically. Results: The average age of presentation was 47 years. Most common presenting symptom was bleeding pv. Most common stage was 2b. Complete response was seen in 24 patients. The most common toxicity was leukopenia seen in 40% patients which was managed with Inj. G CSF. 6 patients needed blood transfusion. No deaths were reported. Conclusion: Concurrent chemoradiation with weekly cisplatin and gemcitabine is a feasible approach with better immediate locoregional control and manageable toxicity. Improvement in overall survival is yet to be documented with further phase III randomised controlled trials.
Scar site metastasis in cervical carcinoma a case report and review of literature
thT. Samani , A. K. Arya, I .Yadav, K. N. P. Kumar
S.N. Medical College, Agra, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Metastasis to the skin occurs rarely in gynaecologic cancer, especially in cervical carcinoma. Although carcinoma of cervix is the second to fourth most common malignancy in women, cutaneous involvement originating from cervical cancer is particularly unusual, even in terminal stage of the disease Brady LW et al. We report a case of carcinoma cervix treated with radical surgery followed by EBRT (50 Gy/25#) with concurrent CTRT with Cisplatin (40 mg/m2) and ICRT (6.5 Gy x 3#). Ten months later patient developed recurrence on the abdominal scar. She then underwent wide local excision with mesh placement. Resected margins were negative and the patient is on follow up. In conclusion incisional cutaneous metastasis is a rarity with carcinoma cervix and is considered as an ominous prognostic sign with short survival after diagnosis.
Dosimetric and clinical outcomes of ct based high dose rate brachytherapy for carcinoma cervix: Our institutional experience
P. G. S. R. Priya, M. G. Janaki, A. S. Murthy, T. R. Arul Ponni,
A. S. Kirthikoushik, R. C. Alva, S. Mohan Kumar
M.S. Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: email@example.com
Background: Cervical cancer is the second most common cancer cause of death among women in India. In our department, cervical cancer forms 13.65% of the total number of cases. More than 80% of the cervical cancers are locally advanced at the time of presentation. Concurrent chemoradiation and HDR brachytherapy is the protocol followed in our department. Brachytherapy in the treatment of carcinoma cervix has changed substantially over a period of time because of the introduction of High Dose Rate (HDR) brachytherapy with intracavitary and interstitial applicators. Before 2013 we were using low dose rate (LDR) brachytherapy, in September 2013 we started BEBIG HDR brachytherapy using cobalt60 source. The aim of this study is to assess the dosimetric and clinical outcomes of CT based HDR brachytherapy in our patients over a median follow up of 17 months. Aims: (1) To document the dose delivered to 2 cc of bladder, rectum, sigmoid colon and percentage coverage of the High risk target volume (HRCTV). (2) Toassess the late radiation toxicities. (3) To assess the locoregional and distant control. Materials and Methods: A retrospective analyses of 49 women with FIGO stage IB to IVA cervical carcinoma diagnosed between july 2013 and January 2014 were treated with definitive external beam radiotherapy to a dose of 45 Gy in 25 fractions with concurrent weekly cisplatin chemotherapy followed by CT guided inverse planned HDR remote after loading intracavitary/interstitial brachytherapy using cobalt60 source, to a dose of 6.5 Gy X 4 fractions or 7.5 Gy X 3 fractions. Bladder, rectum, sigmoid colon were contoured as Organ's at risk. The prescription dose was given to HRCTV. Results: Out of 49 patients, 28 patients underwent intracavitary brachytherapy (ICBT) and 21 underwent interstitial brachytherapy (ISBT). The median follow up time was 17 months, and 6 were lost to follow up. The mean dose delivered to 2 cc of bladder, rectum, sigmoid colon were 4.59 Gy, 3.91 Gy, 2.58 Gy respectively. Mean percentage coverage of HRCTV was 79.7%. The cumulative incidence of locoregional, and distant failure were 0% and 18.6% respectively. The overall and disease free survival rates at a median follow up of 17 months were 83.8%. Two patients experienced grade 2 proctitis for which proctosigmoidoscopic guided APC was done. Conclusion: The results of HDR brachytherapy are promising with excellent local control and acceptable toxicity.
Comparitive evaluation of radiotherapy with concurrent weekly cisplatin versus concurrent daily erlotinib amd weekly cisplatin in locally advanced carcinoma cervix
thS. Rawat , A. K. Saxena, M. K. Advait
Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India, E-mail: firstname.lastname@example.org
Background: Several studies have shown the superiority of platinum based therapy combined with radiation when compared with radiation alone. Based on these premises the concomitant administration of radiotherapy plus weekly cisplatin is a reasonable standard of care. However despite the benefits obtained with addition of platinum based therapy the cure rates have achieved have reached a peak, Cancer progression depends largely upon the activity of cell surface membrane receptors that control the intracellular signal transduction pathways. The epithelial growth factors are increasingly important in understanding the malignant process with prognostic and therapeutic relevance. It has been shown that EGFR pathways plays a major role in cancer progression. 80% of cervical cancer exhibit EGFR receptor which make it a candidate for EGFR inhibitor based therapy. Erlotinb is an oral well tolerated EGFR inhibitor that binds to the intra cellular catalytic domain of EGFR tyrosine kinase, thereby reversibly blocking EGFR phosphorylation, the signal transduction events and tumorigenic effects associated with EGFR activation. Aim: To compare weekly cisplatin versus daily erlotinib plus weekly cisplatin with concurrent radiotherapy in locally advanced carcinoma cervix, to assess the efficacy, tolerability, patient compliance and feasibility. Materials and Methods: Histologically proven case of carcinoma cervix, consent, normal hematological and renal parameters. External beam irradiation will be given up-to 50 Gy. The tablet erlotinb will be started 5 days before irradiation in-order to attain stable blood level and will be continued till the end of external radiation and the patient will also undergo HDR ICBT of 700 cGy. The total duration of treatment will be 56 days in the study arm patients will be given erlotinib and weekly cisplatin till the end of external beam irradiation and in the control arm patients will be given weekly cisplatin along with irradiation. Results: Of the 30 patients who completed the treatment in study arm 28 patients achieved full response and in the control arm of the 30 patients 19 achieved full response and remaing achieved partial response. The major side effct was loose stools which was managed with anti motility drugs. Conclusion: Erlotinib plus weekly cisplatin along with radiation is a better agent in treating advanced cases of carcinoma cervix and side effects were easily manageable proving that erlotinib is a good radiosensitiser.
Unusual metastasis from carcinoma cervix
Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India, E-mail: email@example.com
Introduction: Although the incidence of cancer cervix has reduced in India during the last two decades, still most of the patients presenting in tertiary care centers are in advanced stages. Materials and Methods: At this center, we see 6% of cancer cervix cases every year, and most of these cases are in stage III and IVa. All these patients have squamous cell carcinoma and were treated with a combination of external and intracavitary radiotherapy along with concurrent cisplatin given once weekly. Eighty-nine point nine percent patients had achieved a complete response. Results: Local recurrence was seen in 17.9% at a median duration of 10.5 months, and 8.17% developed distant metastasis involving lung, liver, bone, and supraclavicular lymph nodes. Three patients developed metastasis at unusual sites involving breast, paraspinal muscles, and duodenum which are very rarely involved. These patients were treated with chemotherapy using carboplatin and Paclitaxel combination but succumbed within 8-10 months of development of metastasis. Conclusion: The cause of involvement of these unusual sites is not clear, but it may be hematological spread, and we want to share these reports such that these sites are seen during follow-up of patients of cancer cervix.
Uterine organ motion in gynaecological malignancies and its implications: A weekly CT review
Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India, E-mail: firstname.lastname@example.org
Aim: This study was performed to assess the extent of interfraction uterine motion during Radiotherapy. Materials and Methods: 24 patients of carcinoma cervix and carcinoma body uterus treated on linear accelerator were reviewed. During the course of EBRT, CT Scans were taken once at the start of treatment and then weekly with cone beam (CBCT) till the completion of the course of radiotherapy. Patients were asked to maintain a strict bladder filling protocol. The position of the uterus was defined in the CTV after negating the effect of patient setup error by Offline CBCT imaging. The position of the uterus was then compared in the following weekly scans. The position of the uterus was also correlated with the position and the filling of the bladder. This change in uterus position was measured separately in the A-P (anterio-posterior), S-I (superio-inferior) and Lateral Directions. Results: The mean extent of motion in the uterine position on weekly basis in individual patients in the antero-posterior direction movement ranged from -1.8 to +1.16, lateral movement -0.5 to +0.32 and the superior inferior shift ranged from -0.42 to +0.72. The mean shift in anterio-posterior, lateral and superior-inferior direction was 0.30, 0.06 and 0.06 respectively. The significance was calculated by an unpaired one sample student t-test. The p value is 0.0001 which is highly significant. Conclusions: CBCT at least once a week is necessary to minimize the geometrical miss and deliver the planned doses to the target and normal structure for best results with minimum toxicity which is the primary aim of IMRT treatment. Appropriate and adequate PTV margins are required and may have an asymmetrical PTV conforming to the daily anatomical shift and contour of the patients.
Phase III RCT of postoperative adjuvant conventional radiation (3DCRT) versus IG-MRT for reducing late bowel toxicity in cervical cancer (parcer) (NCT01279135/CTRI2012/120349): Results of interim analyses
thS. Chopra , R. Engineer 1 , U. Mahantshetty 1 , S. Paul, S. Kannan, T. Dora, S. Gupta, S. K. Shrivastava 1
Advanced Centre For Treatment, Research and Education in Cancer, Tata Memorial Center, 1 Tata Memorial Hospital, Mumbai, Maharashtra, India, E-mail: email@example.com
Background: Phase III randomized study of three dimensional conformal radiation (3DCRT) vs. image guided radiation therapy (IGIMRT) was initiated with primary aim to demonstrate reduction in grade ≥ 2 late bowel toxicity in patients undergoing adjuvant chemoradiation for cervical cancer. Materials and Methods: Patients >18 years undergoing adjuvant (chemo) radiation (CRT) were eligible. The study design included permuted block stratified randomization according to type of hysterectomy (Wertheim's hysterectomy (WH) or simple hysterectomy) and use of chemotherapy (CRT vs RT alone). CRT included 50 Gy/25#/5 weeks+/- weekly cisplatin (40 mg/m2) and vainal brachytherapy. Those randomized to 3DCRT and IMRT arm received treatment on linear accelerator and Tomotherapy respectively. At each follow up toxicity was captured using Common Toxicity Criteria for Adverse Event version 3.0. Patients were censored at recurrence or at initiation of salvage treatment. On follow up worst grade of bowel toxicity was considered for statistical analysis. The trial is designed to detect a 13% difference (from 18% to 5%) with an α of 0.05 and β of 0.80. A total of 240 patients will be required. An interim analysis was planned when 50% (120/240) of the patients completed a median follow up of 18 months. Chi square text was used to demonstrate incidence of toxicity between the two arms. At interim analysis p < 0.025 will be required to reject null hypothesis. Results: A total of 120 patients completed a median follow up of 20 months (2-46). Of these 58 were randomized to 3DCRT and 62 to IGIMRT arm. In 3DCRT and IMRT arm 41.3% and 43.5% underwent WH and 91.8% and 85.5% received CRT. Three patients withdrew consent after randomization (2:3DCRT; 1 = IMRT) and did not receive any treatment. There was 1 protocol deviation each in 3DCRT and IMRT arm. A total of 56/58 and 61/62 patients were evaluable for toxicity in each arm. Overall 33/56 (58.9%) and 33/61 (54%) patients experienced grade ≥2 acute bowel toxicity in 3DCRT and IMRT arm (p = 0.59). The late grade ≥2 bowel toxicity was 25% and 11.4% (p = 0.13) and late grade ≥3 toxicity was 17.6% and 3.2% (p = 0.02) in 3DCRT and IMRT arm respectively. No difference in primary endpoint was observed with type of surgery or use of CRT. Conclusions: There is no difference in late grade≥ 2 late bowel toxicity with the use of IG-IMRT. However significant reduction is observed in incidence of late grade ≥ 3 toxicity with use of IG-IMRT.
Cancer cervix with brain metastasis: A case report from a rural center of Maharashtra
thK. Rastogi , V. Jain, B. Nikam, R. Kharde, S. Nagshet, A. Srivastava, C. S. Pethe
Pravara Rural Hospital, Loni, Ahmednagar, Maharashtra, India, E-mail: firstname.lastname@example.org
Background: Cancer cervix is one of the leading causes of cancer deaths among women worldwide and occupies either the top rank or second among cancers in women in the developing countries. The annual incidence of cancer cervix in India is nearly 1,00,000. Brain metastasis from cancer cervix is extremely rare and has poor prognosis. Aim of the Study: The aim of this article is to report a case of brain metastasis from cancer cervix in a rural setup in western Maharashtra and to discuss its clinical features, treatment options and prognosis. Materials and Methods: A 45 years old female patient with squamous cell carcinoma of the cervix presented with solitary brain metastasis and para aortic lymphadenopathy, 12 months after the diagnosis of primary. The presenting symptoms of the metastatic disease were headache, seizures and vomiting. MRI Brain was suggestive of solitary lesion in right frontal region. The patient was successfully treated by surgical excision of the metastasis (Histo-pathologically metastatic squamous cell carcinoma of cervix origin) and adjuvant whole brain radiation therapy followed by palliative chemotherapy. Results: The patient was managed successfully and was disease-free at the 6-month follow-up after treatment of the recurrence. Conclusion: The prognosis of cancer cervix patients with brain metastases is poor. Most studies have reported a median survival of only a few months, but there are a few reports of long-term, disease-free survival in these patients. Our case provides an example of successful management of brain metastasis in a case of carcinoma cervix with the use of surgery and adjuvant radiation therapy.
Effect of bladder volume in intracavitary versus vault brachytherapy for gynecological malignancies
thR. Madhavan , D. Makuny
Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India, E-mail: email@example.com
Background: The size and shape of urinary bladder varies with bladder filling. This can affect the dose distribution of normal tissues like bladder and sigmoid colon during brachytherapy. This effect may not be the same for vault and intracavitary brachytherapy. Aim: This study aims to evaluate the effect of bladder volume on the dosimetry of bladder and sigmoid colon during 3D image based intracavitary and vault brachytherapy for gynecological malignancies. Materials and Methods: This is a prospective study which analyzed the data of 20 women who had undergone vault brachytherapy between September 2012 and April 2013. The data of 11 patients who were treated with intracavitary brachytherapy from September 2014 to February 2015 were collected and compared with that of vault brachytherapy. All patients were treated with HDR brachytherapy using Iridium 192. Foleys catheter was inserted and bladder was filled with varying volumes of normal saline. After each application CT simulation was performed and contouring was done based on CT contouring guidelines for cervical brachytherapy. Image based 3D brachytherapy planning was performed and Dose Volume Histograms were analyzed. Data regarding bladder volume, dose received by 1cc, 2cc, 3cc, 4cc and 5cc bladder and sigmoid colon volumes were recorded. Results and Conclusion: During vault brachytherapy there is a consistent increase in bladder dose with bladder volume. There is 13%. 16%, 14%, 16% and 22% increase in D1cc, D2cc, D3cc, D4cc and D5cc bladder doses with bladder volume more than 250 mL. During intracavitary brachytherapy the bladder dose increases with bladder volume reaching its peak at 100 mL bladder volume. Further increase in bladder volume resulted in a decrease in bladder doses. The D1cc, D2cc, D3cc, D4cc and D5cc reduction in bladder doses at bladder volume more than 250 mL are 22%, 19%, 15%, 16% and 19% respectively. There is consistent decrease in sigmoid dose as bladder volume increases. The D1cc, D2cc, D3cc, D4cc and D5cc reduction in sigmoid doses at bladder filling more than 250 mL are 27%, 28%, 23%, 26% and 25% respectively. To conclude during vault brachytherapy it is better to keep bladder volume below 250 mL to reduce bladder dose whereas during intracavitary brachytherapy it is advisable to keep bladder volume above 250 mL to reduce dose to bladder and sigmoid.
Rectal dose during HDR brachytherapy for cervical cancer: Retractor or gauze packing alone?
thA. Agrawal , P. Gupta, M. Rastogi, R. Khurana, R. Hadi, S. P. Mishra
Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Background: Intracavitary brachytherapy (ICBT) is an integral part of treatment for carcinoma cervix and is increasingly being delivered by High Dose Rate (HDR) technique. This allows aggressive vaginal retraction and packing to reduce doses to the bladder and rectum. While some workers have found a retractor to be superior to gauze packing for reducing rectal dose, there are no Indian studies documenting the same. Aim: We look to compare the efficacy of the two most commonly used methods for rectal dose reduction during HDR-ICBT of the cervix, i.e., gauze packing (GP) and rectal retractor (RR) in a retrospective analysis. Materials and Methods: Rectal doses of 15 patients of CA cervix who underwent two applications of HDR ICBT (9 Gy to bilateral point A) over the past 1 year were analysed. The application was performed after following a rectal protocol using gauze packing when (a) a retractor was not available or (b) when one could not be applied; otherwise a retractor was used to reduce rectal dose. The doses to the ICRU rectal point, Dmax and Dmean were recorded for the two groups - applications with gauze packing alone and those with a retractor. Results: A total 30 applications were analysed, 15 with gauze packing only and 15 with a rectal retractor in addition to gauze packing. The average doses to the rectal point, Dmean and Dmax were 5.27 Gy (SD 0.76), 5.09 Gy (SD 0.68) and 5.52 Gy (SD 1.08) respectively in the GP group vs 5.83 Gy (SD 1.0), 5.09 Gy (SD 0.73) and 5.83 Gy (SD 1.11) respectively in the RR group; p = 0.09, 1.0 and 0.45 for each comparison by the students t-test. Conclusion: We found that on an average, applications with a rectal retractor delivered a higher dose to the rectum than gauze packing alone. A prospective study with a larger sample size may be warranted to compare these two techniques.
A comparative evaluation of radiotherapy with concurrent weekly cisplatin versus concurrent weekly paclitaxel in patients with locally advanced carcinoma cervix
thN. Maurya , L. Singotia, A. K. Saxena, M. K. Advait
Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India, E-mail: email@example.com
Aim: A prospective study to compare weekly cisplatin versus weekly paclitaxel as concurrent chemotherapy with standard radiotherapy in locally advanced carcinoma cervix. Materials and Methods: The study was carried out between November 2013 and August 2104. 60 women with histopathologically proven squamous cell carcinoma cervix (FIGO stage IB2 to IVA) and preoperative/pre chemotherapy were enrolled into this study and randomized to receive on weekly basis either 40 mg/m2 cisplatin (control group: 30 patients) or 50 mg/m2 paclitaxel (study group: 30 patients) concurrently with radiotherapy total dose for radiotherapy 80 Gy for both the group (50 Gy from EBRT and 30 Gy from HDR brachytherapy) follow up time was 6 month. Results: The mean number of chemotherapy cycles was comparable with 86.7% and 80% of patients receiving 5 doses in control and study group respectively. At the completion of treatment 20 patients (66.7%) in control group and 15 patients (50%) in study group had complete response, 10 patients (33.3%) in control group and 15 patient (50%) in study group had partial response. After 6 month of follow up 23 patients (76.7%) in control group and 19 (63.3%) patients of study group had complete response and 7 (23.4%) patients of control group and 10 (33.4%) patients of study group had partial response respectively. One patients of study group developed progressive disease during follow up period. Conclusion: This small prospective study shows that weekly paclitaxel does not provide any clinical advantage over weekly cisplatin for concurrent chemoradiation for locally advance carcinoma cervix and associated with more gastrointestinal and hematological toxicities.
Cervical cancer: Outcome of treatment and patterns of failure a retrospective study
thN. Sharma , A. K. Arya, I. Yadav, T. Samani
Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Background: Cervical cancer is the fourth most common cancer affecting women worldwide. Radiation is one of the most effective treatment in managing cervical cancer. Approximately 30% of cervical cancer patients ultimately fail after definitive treatment. The prognosis of Ca cervix depends on initial stage, histologic type, tumour volume, presence of involved lymph nodes, stage, delivered radiation dose, treatment duration, Hb level, and the optimal use of intracavitary brachytherapy. Management of recurrence depends on the extent of disease, primary treatment, and performance status/comorbidity. Aim: This study summarises the various treatments offered to cervical cancer patients at S.N. Medical College, Agra, taking into consideration the clinicopathological factors like age, stage, histopathology and treatment. We intend to find out some of the common risk factors, patterns of failure and recurrence prevalent in our patient population, to highlight most likely causes of treatment failure patterns. Materials and Methods: In this retrospective study, case files of 100 patients presenting with invasive carcinoma of cervix during 2008-2018 were studied in respect to personal profile, disease related risk factors, pathological characteristics, treatment administered and outcome in the form of tumour response and failure patterns. Results: Our study had 67 patients in FIGO Stage II, 23 in Stage III, 6 in Stage IV and 4 in Stage I. The mean age of presentation was 45 yrs. The mean age of coitarche was 17.5 yrs. 44% patients used contraceptive for birth spacing and 43% patients had Hb less than 10 g/dl. Number of patients who underwent post-operative radiotherapy was 44 as compared to 56 patients receiving radiotherapy as definitive treatment. 32.5% patients showed recurrence in postoperative radiotherapy group and 35.7% patients showed recurrence in radiotherapy only group. The most common cause of failure was stump recurrence (69.23%) in post op radiotherapy group and local recurrence (60%) in radiotherapy only group. Para-aortic nodes (21%), bone metastasis (9%) and lung metastasis (3%) were subsequent causes of failure. Conclusion: Advanced stage at diagnosis, lack of follow-up, early onset of sexual activity, anaemia, poor nutrition and ignorance about self-hygiene were main causes of treatment failure. The rates of failure were comparable in both radiotherapy only and post-op radiotherapy group as treatment largely depended upon the FIGO Staging of the patient.
Prospective study to compare conventional chemoradiotherapy with hypofractionated chemoradiotherapy in carcinoma cervix
thS. Agarwal , S. N. Prasad, S. Singh
J.K. Cancer Institute, Kanpur, Uttar Pradesh, India, E-mail: email@example.com
Background: Cervical cancer is the leading cancer in Indian women and the 2 nd most common cancer in women worldwide. Treatment for advanced stage carcinoma cervix is a combination of EBRT & brachytherapy. Conventional external beam radiation delivers a dose of 2 Gy per fraction with standard pelvic portals with AP or box field technique. Overall treatment time has considerable effect on local control and survival. In hypofractionated treatment the overall treatment time is reduced. In our institute, we focused on hypofractionated radiotherapy, which is a modality without additional burden to the patients. We conducted a clinical study to evaluate the effect of fraction size of 3 Gy on local control in advanced stage cervical cancer. Aim: To evaluate the efficacy in terms of locoregional response & toxicity of a hypofractionated chemoradiation regimen of Carcinoma Cervix vs. Conventional fractionated chemoradiation Materials and Methods: 52 eligible patients with FIGO stage IIB-IVA non metastatic squamous cell carcinoma Cervix reporting to JKCI OPD were randomly divided into two groups of 26 patients each: GROUP I EBRT/60 Co/46 Gy/23 #/4 week/to pelvis With concurrent cisplatin 40 mg/m2 weekly followed by ICRT 6 Gy weekly x 3 weeks GROUP II EBRT/60 Co/39 Gy/13 #/2 week/to pelvis With concurrent cisplatin 40 mg/m2 weekly followed by ICRT 6 Gy weekly x 3 weeks Results: Between January 2014 to July 2015 a total of 52 patients were enrolled, 26 in each group. The median total treatment time in group I was 8 weeks and 6 weeks in group II. Response rate was comparable between two groups, with complete response in group I and group II 73.07% vs. 69.23% respectively. On comparing the incidence of acute toxicity (grade III) nausea and vomiting was 15.38% in group I vs. 23.07% in group II; GI toxicity (grade II/III) was 50% in group I vs. 57.6% in group II. Skin and mucosal toxicities (grade III) were 11.5% in the former group vs. 23.07% in the latter whereas haematological toxicity 20% vs. 23% in group I and group II respectively. Conclusion: In locally advanced carcinoma cervix hypofractionated radiotherapy with concurrent cisplatin weekly followed by Brachytherapy is a reasonable alternative to the standard fractionated regimen with concurrent cisplatin weekly followed by Brachytherapy offers advantages of decreased overall treatment time with comparable response rate and toxicity profile. Decreased treatment time seems an upper edge in view of work load.
Interdigitated versus sequential high dose rate intracavitary brachytherapy with external beam radiotherapy in locally advanced carcinoma cervix
thM. Alam , S. Siddiqul, M. Hussain, M. Akram, I. Bano, M. Karimi,
Jawahar Lal Nehru Medical College and Hospital, Aligarh, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Aim: To decrease overall treatment time and compare clinical outcome of external beam radiotherapy (EBRT) and interdigitated high dose rate intracavitary brachytherapy (HDRICBT) versus sequential EBRT and HDRICBT in treatment of locally advanced carcinoma cervix. Methods: 82 patient with histologically confirmed carcinoma of the cervix, untreated FIGO stage Ib to IVA were included and randomised in two arms. ARM1 (study arm) received EBRT 50 Gy/25 fraction with HDRICBT 8 Gy/fraction weekly total 3 fraction starting after 15 fraction of EBRT. Patient in ARM2 (control arm) received EBRT 50 Gy/25 fraction with sequential HDRICBT 8 Gy/fraction weekly total 3 fraction. External Beam Radiotherapy delivered using telecobalt ICBT delivered using MicroSelectron HDR machine with Fletcher-Williamson applicators. After completion of 15 fraction in Arm 1 next day 1st fraction of brachytherapy of 8 Gy HDR given to point A and Further EBRT and ICBT given according to study design. Patient in Arm2 EBRT and sequential ICBT given according to the study design. Toxicity during treatment managed with best supportive care. At the end of the study, results of both arms compared in terms of acute and late toxicities and response to therapy clinically. Radiation induced acute and late toxicities were assessed and compared in both arms according to the RTOG toxicity criteria. Results: Total 82 patients were enrolled 41 in each arm.72 patient completed treatment and analysed. ≥Grade3 acute skin toxicities in arm1 & arm2 were 11% & 8.1% respectively. ≥Grade3 acute mucosal toxicities in arm1 & arm2 were 17.1% & 13.5% respectively. ≥Grade3 late skin toxicities were not seen in arm1 & arm2. ≥Grade3 late mucosal toxicities in arm1 & arm2 were 5.7% & 5.4% respectively. ≥Grade3 acute GI toxicities in arm1 & arm2 were 2.8% & 0% respectively. ≥Grade3 late GI toxicities in arm1 & arm2 were 5.7% & 2.7% respectively. No ≥Grade3 acute and late genitourinary toxicities in both arm. 33 patients (94.2%) had CR in arm1 and 34 (91.8%) in arm2. 2 patient (5.7%) had PR in arm1 and 3 patients (8.1%) in arm2. The median follow-up duration was 10 months (2-18). Conclusion: Acute and late toxicities in interdigitated ICBT arm were slightly higher than sequential arm but were manageable with best supportive care. Response rate is comparable. So is a good alternative to conventional schedule as it shortens total treatment time, Reduces hospital stay, enhances patient compliances, and it is cost effective.
Epitheloid sarcoma of the vulva: A case report
thT. R. Choudhary , J. Poddar, A. Parikh, S. P. Shah, U. K. Suryanarayan, S. Gupta, K. Patel, A. D. Sharma
GCRI, Ahmedabad, Gujarat, India, E-mail: email@example.com
Background: (1) Epitheloid sarcoma is a rare and aggressive malignant soft tissue tumour. (2) Epitheloid sarcoma of vulva is even rarer and only 22 cases have been reported. Case Report: A 46 year old female, presented with a palpable, firm, non-tender mass of right labia majora. USG of the abdomen and pelvis revealed multiple submucosal (2.9 cm), subserosal (2.1 cm) and cervical fibroids. Right ovary was normal and left ovary had multiple simple cysts, largest measuring 2.3 cm. She underwent Trans-abdominal hysterectomy and bilateral Salpingo-oophorectomy with wide local excision of the labial mass. Histopathological report suggested high grade malignant epithelial tumour of the labia. Immuno-histochemistry showed AE1 positive, Vimentin Positive, AFP -ve, Desmin negative, CK7 negative and was concluded to be Epitheloid sarcoma, Proximal type. A thorough metastatatic work up was done and was found to be normal. The patient was delivered postoperative radiotherapy 50 Gy in 25 fractions over five weeks. Results: Patient is currently on follow up and is asymptomatic.
Evaluation of concurrent chemoradiation with neoadjuvant and adjuvant chemotherapy vs concurrent chemoradiation alone in locally advanced carcinoma cervix
thR. Singh , M. L. B. Bhatt, K. Srivastava
King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Background: Concurrent chemoradiation is a standard treatment for locally advanced carcinoma cervix and has improved survival outcomes compared to radiation alone. Despite an improved survival rate with concurrent chemoradiation against radiation therapy alone, local and distant failures (17% and 18%, respectively) of locally advanced carcinoma cervix are encountered with overall survival rates ranging from 60 to 65%. One method of improving treatment outcomes among these patients is to give additional chemotherapy along with the main treatment of concurrent chemoradiation therapy. Aim: Aim of the study was to compare concurrent chemoradiation with neoadjuvant and adjuvant chemotherapy versus concurrent chemoradiation alone in locally advanced carcinoma cervix in terms of treatment response and toxicities. Materials and Methods: A randomized control study was done on 116 patients of locally advanced carcinoma cervix (stage IIB to IIIB) registered in Department of Radiotherapy, King George's Medical University, Lucknow, Uttar Pradesh between January 2014 to February 2015. Patients were randomly divided to receive either one cycle of cisplatin and 5-FU based neoadjuvant chemotherapy and two cycles of same adjuvant chemotherapy with concurrent chemoradiation (Arm A) or only concurrent chemoradiation (Arm B). All patients received three fractions of HDR intracavitary brachytherapy. Results: A higher proportion of patients of chemotherapy arm achieved complete local control as compared to the non-chemotherapy arm, and this was statistically significant. There was a trend toward more treatment related acute toxicity with chemotherapy. Conclusion: These results have corroborated the view that if neoadjuvant and adjuvant chemotherapy are added to concurrent chemoradiation, it could further the effects of concurrent chemoradiation for patients with locally advanced cancer of uterine cervix.
Dosimetric analysis of target volume coverage in point based intracavitary brachytherapy in carcinoma cervix: A single institute study
thP. Gupta , R. Hadi, M. Azam, S. Rath, M. Ali, R. Khurana, M. Rastogi, A. Srivastava
Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow,
Uttar Pradesh, India, E-mail: email@example.com
Introduction: Cervical cancer has a low incidence in developed countries but still a high incidence in developing countries including India. Brachytherapy (BT) is an important component in the curative management of carcinoma of the cervix, and significantly improves survival. High-dose-rate and low dose-rate BT appear to be relatively equivalent in terms of survival outcomes. In gynaecologic BT, correlation between the radiation dose and the normal tissue effects have been assessed using point doses. Since 1985, these points have been defined in the international commission of radiation units and measurements (ICRU- 38) report. However GEC-ESTRO recommended volume based treatment planning in their respective series (I-IV). For Cervical cancer BT, the correlation of ICRU point doses and volume based treatment planning is investigational till date. Analysis become feasible when cross sectional image-based treatment planning for BT using computerized tomography or magnetic resonance imaging is utilised as per GEC-ESTRO recommendation. Materials and Methods: It is a retrospective pilot study includes patients (pts.) of carcinoma cervix treated with HDR BT 9 Gy in 2 fractions 1 week apart. All volume based dosimeteric parameters regarding high risk clinical target volume (HRCTV), intermediate risk clinical target volume (IRCTV) like D90, D100 and for organ at risk (OAR) D 0.1 cc, D 1.0 cc and D 2.0 cc were delineated and dose coverage was analysed in point dose based planning. Results: We have analysed eleven pts. of squamous cell carcinoma cervix. The median age was 48 yrs. (41-62 yrs), stage II B 6 pts. & III B 5 pts. The median value of D90 & D100 in HRCTV during I and II session were 8.27, 4.73 and 6.56, 4.18 Gy respectively. Same values for IRCTV were 6.38, 3.64 and 4.78, 3.13 Gy respectively. Analysis of OARs demonstrated that median dose received by 0.1, volume of bladder during I and II session received 10.4, 9.74, by 1cc volume 7.8, 7.86 and by 2 cc volume 6.13, 6.33 Gy respectively. The median dose received by 0.1 cc of rectum were 11.19, 8.66, by 1 cc volume 8.98, 7.21 and by 2 cc volume 7.7, 6.13 Gy respectively. In point based analysis median dose delivered to bladder point during I and II session were 6.23, 6.14 and to rectum point were 5.9, 5.60 Gy respectively. Conclusion: The dose in I session ICRT and to the volume parameters are higher in comparison to point dose. We need more number of pts in prospective randomized trial for more consistent result.
Imaging in gynecologic brachytherapy: Lessons learned
thS. Mathews , V. R. Anjali, S. Mohandas, K. Sreelish, B. Sarin,
S. Menon, P. G. Jayaprakash
Regional Cancer Center, Trivandrum, Kerala, India, E-mail: firstname.lastname@example.org
Background: Over the last ten years Image Guided Brachytherapy has emerged as the standard in Gynecologic brachytherapy (BT) practice and data suggest increased survival and reduced toxicity with IGABT. Traditional BT methods continue to be practiced in India and many countries due to financial and technical constraints. At RCC Trivandrum we treat an average of 5 patients every day. BT treatment planning is largely 2D X-ray based. CT based conformal BT treatment planning was initiated in 2011. Aim: In this analysis we have compiled the measurements of uterus and cervix relevant for BT, from CT images taken with applicators, to see how imaging would influence conventional BT practice. Materials and Methods: 65 patients with locally advanced Cervix cancer treated between Jan- Aug 2015, at RCC Trivandrum were eligible for analysis. All patients received EBRT 40-45 Gy along with concurrent CDDP followed by 3sittings of CT based HDR BT. The CT based BT planning goal was to cover the entire cervix and part of the uterus, with the prescription isodose of 8 Gy limiting the dose to rectum, bladder and adjacent bowel. Observations Intrauterine applicator was seen perforating the uterus in 4 patients and in 11patients the IU tip was seen stretching out the fundal myometrium. Standard loading pattern had to be altered in 15 patients. The length of uterus as measured from top of the fundus to the flange of IU tandem was <6 cm in 39 patients (60%) and >8 cm in 6 patients (9%) Cervix length- From Internal OS to Flange In all but 3 patients the entire cervix was within 2 cm of the flange. In 32% patients the height of Cervix was less than 1.5cm. Width at 2 cm. The width at 2 cm from flange was <4 cm in 58 patients. Point A dose after optimization. The average resultant Point A dose after optimizing 8 Gy to the target was 622 cGy. Conclusion: BT target volumes are often small in our patient population and Point A prescriptions represent overtreatment. Unguided applicator placements would result in perforations in nearly 10% patients and excess bowel dose from IU tip loading in 20-25% patients. Even when constrained in adopting sophisticated technologies for day to day treatments, the potential benefits of incorporating some form of soft tissue imaging into standard BT practice, needs to be acknowledged. Ultrasound scanning is a commonly available, easily accessible and economical imaging modality that can be incorporated into our BT practice.
Clinical comparision of toxicity pattern of two linear quadratic model-based fractionation schemes of high-dose-rate intracavitary brachytherapy for cervical cancer
thA. Batra , M. L. B. Bhatt, K. Srivastava, P. Katepogu, S. Kumar,
C. Awasthi, S. Gupta, M. Suhel
King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: email@example.com
Introduction: Carcinoma cervix is the fourth* most common cancer among women worldwide. In India, approximately 1,23,000* new cases of carcinoma cervix are diagnosed each year. Brachytherapy is an integral part of treatment of cancer cervix. In the context of a developing country like us where maximum utilization of the resource is of prime importance to provide treatment to the large patient cohort, shortening the treatment duration and number of fractions always increases efficiency. In order to maximize the logistic benefits of HDR-BT while improving patient compliance and resource sparing, various fractionation regimens are used. Aim: To compare patient outcomes and complications using two linear-quadratic model-based fractionation schemes of high-dose-rate intracavitary brachytherapy (HDR-IC) used to treat cervical cancer. Materials and Methods: A prospective randomized study on 318 patients, with histologically proven advanced carcinoma cervix (stages IIB-IIIB) was enrolled in the study. All patients received External Beam Radio Therapy (EBRT) 50 Gy in 25 fractions with concurrent chemotherapy (cisplatin 35 mg/m2) followed by IntraCavitary brachytherapy using high dose rate equipment. Patients were randomised after completion of EBRT into two arms: Arm 1: HDR ICRT 6.5 Gy per fraction for 3 fractions, 1 week apart. Arm 2: HDR ICRT, 9 Gy per fraction for 2 fractions, 1 week apart. On completion of treatment, patients were assessed monthly for 3 months followed by 3 monthly thereafter. Treatment response was assessed according to WHO criteria after one month of completion of radiotherapy. The RTOG criteria were used for radiation induced toxicities We analyzed late toxicities in terms of Rectal, Bladder, Small Bowel toxicity and Vaginal Stenosis. Results: Acute reactions in both the groups were comparable. None of the patient developed Grade 4 toxicity in our study and no toxicity related mortality was encountered. A slightly high frequency of late toxicity was observed in 9 Gy Arm patients but was not statistically significant. Conclusion: Based on the results of our study we can conclude that HDR brachytherapy using 9 Gy per fraction in two fractions one week apart is safe, effective and resource saving method with good local control and manageable normal tissue toxicity as compared to 6 Gy in 3 fractions weekly.
Role of radiation therapy in vaginal carcinoma: AIIMS experience
thP. Kumar , A. Gandhi, S. Kumar, G. K. Rath,
All India Institute of Medical Sciences, New Delhi, India, E-mail: firstname.lastname@example.org
Introduction: Vaginal carcinoma is relatively a rare gynaecological malignancy. Radiation therapy plays a key role in the management of VC. There are limited series in the literature especially from India regarding the role of RT in VC. The present study is a retrospective analysis of all the patients of VC treated at our centre to evaluate the role of RT. Materials and Methods: From the year 2007 to 2014, case records of the all the VC patients were analysed. From each case record, we extracted the information regarding the patient's demography, clinical details, diagnosis, treatment given and survival. Staging was done according to FIGO 2009 system. The clinical outcome was determined with respect to loco-regional control and distal failures. Results: A total of 38 case records were retrieved for this retrospective analysis. Age ranged from 27 to 87 years with a median of 54 years. Eleven patients presented in early stage (stage I-II) and 18 presented in advanced stage (stage III-IVA). In 9 patients, exact stage could not be ascertained. Six patients underwent surgery and 3 of them received PORT. Patients receiving definitive concurrent CT+RT, RT alone and palliative RT were 10, 12 and 5 patients respectively. Five patients received supportive care only. Median dose of pelvic EBRT was 45-60 Gy. Twenty two patients received HDR intra-cavitary/interstitial brachytherapy with a median dose of 21 Gy in 3 fractions (weekly). Mean follow period up was 12 months (range 1-82 months). Thirteen patients failed at loco-regional (8) or distant site (2) or both (3). Thus loco-regional control rate was 71%. Stage was found to be the only significant prognostic factor. Conclusion: Despite majority of patients presenting in advanced stages at our center, RT provides an effective loco-regional control rate (71%). Stage of the disease continues to be significant prognostic factor for patients with vaginal carcinoma.
A service evaluation of carcinoma of cervix in a tertiary care hospital in northern India
thJ. C. Alepes Lamin , S. Singh, D. Kapoor, N. Rastogi, P. Lal, S. Kumar
Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: email@example.com
Background and Aim: To assess the patterns of referral, demography, staging work up, management practices and follow-up policies of cancer cervix in a tertiary care hospital in a northern part of India. Materials and Methods: Between January 2008-December 2011, 300 cervical cancer patients were registered, medical records were retrieved to abstract the various host and treatment related parameters and outcomes. Local disease free survival (LDFS) and overall survival (OS) was calculated from time of registration and computed by Kaplan-Meier method. Death due to any cause or loss to follow-up was considered as an event for survival analysis i.e., assuming the worst case scenario and alternate analysis done assuming the best case scenario. Results: More than half of the patients were referred by community doctors. The median distance to the hospital was120 km. Of the 300 patients, 72 (24%) patients did not report after first consultation while 64 (21%) were referred for brachytherapy only. For present analysis, 164 (55%) patients who received treatment with either radical or palliative intent in our department were studied. Of 164 cases, 76%, 15% and 9% presented as de novo cervical cancer, post-operative and stump carcinoma respectively. The median age (range) at presentation was 52 years (26-90), 75% were postmenopausal. MRI was the preferred pre staging imaging modality in about half followed by ultrasound. FIGO stage I-IV was 17%, 34%, 29% and 20% respectively with more than half having bulky disease and one third presenting with regional lymphnodes. 93% patients were treated with radical while 7% with palliative intent. Two thirds received concurrent platin based chemoradiotherapy, 80% patients received brachytherapy. Patients were kept on clinical follow up and imaging was done as and when required. At the time of analysis 38% were disease free and alive, 21% dead while 40% were lost to follow-up with or without disease. At median follow up of 23 months (0-90), the median LDFS for stage I, II, III and IV was NR (not reached), NR, 17 and 0 months, p = 0.000 while median OS was NR, NR, 17 and 8, p = 0.000 (worst case scenario) and for best case scenario, median OS was NR, NR, 23 and 8 months respectively for stage I, II, III and IV (p = 0.000). Conclusions: Cervical cancer present as bulky advanced stages with regional and metastatic spread at time of presentation. The outcome is dismal in advanced stages. It is a challenging task to ensure compliance to follow-up.
Audit of cancer cervix patients registered in a tertiary care centre
thD. Tiwari , K. Srivastava, M. L. B. Bhatt, D. Kishan, A. Batra, J. Gaur, M. Shah, M. Barthwal
King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Background: Cancer cervix is a major problem especially in developing countries like India. In keeping with the excessive load of cancer cervix and inconsistent results an audit was undertaken for these patients registered in the department of Radiotherapy of a tertiary care hospital. Approximately 500 patients of cancer cervix are registered in our department every year, constituting about 16.6% of all malignancies registered. Aim: The audit was performed to present a comprehensive report of epidemiological parameters, referral pattern, treatment provided, compliance and outcome data and to perform gap analysis. The goal of this audit from the inception was to "know our own data." Materials and Methods: To rule out heterogeneity only one unit of the department was chosen and all the patients registered between 2011-2013 were included. Medical records of all the patients entered in the case sheets was utilized to obtain information regarding various parameters such as patient characteristics, treatment given and its outcome. All the data obtained was entered into the software SPSS- 21 and statistical analysis was performed. Results: Total 452 patients were registered during the year 2011-2013. Most of the cases hailed from various districts of UP and Bihar mostly were of the age group 45-60 years (65%). Squamous cell carcinoma was the most common histopathology (95%). Leading number of the patients presented with locally advanced disease stage IIB-IIIB (74%). Patients presenting after surgery (32) and those presenting with metastasis, VVF or RVF (25) were excluded from the analysis as they did not qualify for treatment by definitive RT. 45 patients did not turn up after initial investigations and 45 patients defaulted during treatment. Total 362 patients took complete treatment under various protocols.46 patients were given neoadjuvant chemotherapy followed by radiotherapy and 224 patients took definitive chemoradiotherapy with concurrent cisplatin. 92 patients took radiotherapy alone. Approximately 20% of the patients only are on regular follow up. Conclusion: The report suggested that approx 56% patients were given standard of care treatment in the form of concurrent chemo-radiotherapy however after completion of treatment very few patients came for regular follow up. Report also suggested that the initiation of treatment after registration was much delayed and needs drastic enhancement of resources.
Clinical value of he4 in response assessment after neoadjuvant chemotherapy in advance stage ovarian carcinoma
thS. Rajan , V. Kumar, S. Gupta, N. Akhtar, R. Kant, S. Singh, S. Misra, W. Ali
King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: Shivrajan.email@example.com
Background: Neoadjuvant chemotherapy is a reasonable approach among patients who present with extensive intra-abdominal disease rendering them not an ideal candidate for primary cytoreduction. CA 125 and imaging studies are currently utilized to assess response after neoadjuvant chemotherapy. This study was undertaken to study the role of serum HE4 in predicting response in these subgroup of patients. Materials and Methods: This prospective study includes 44 patients including 28 (63.6%) stage IIIC and 16 (36.4%) stage IV patients. Standard neoadjuvant chemotherapy (three to four cycles of Paclitexal and Carboplatin) was given after confirming the diagnosis with FNAC or biopsy. Serum CA 125 and HE4 levels along with imaging was done before starting neoadjuvant chemotherapy and before surgery. Response to chemotherapy was assessed and correlated with change in HE4 levels. Results: Mean change in values of HE4 before and after neoadjuvant chemotherapy was 1125.02+/-384.72 (p = 0.0001). Both the sensitivity and negative predictive value was 100%. The specificity and positive predictive value of HE4 was 94.11% and 96.42% respectively. Overall accuracy of HE4 to tell the response was 97.72%. Among patients in whom HE4 levels normalized after neoadjuvant chemotherapy, no nonresponders were identified in this subgroup. Conclusions: Our results shows that HE4 is a useful marker to assess response after neoadjuvant chemotherapy in advanced stage ovarian cancer patients who are not an ideal candidate for surgery upfront. It should be studied further and should be considered in incorporating in guidelines.
Feasibility of fertility preserving surgery after neoadjuvant chemotherapy in germ cell tumor of ovary
thS. Rajan , V. Kumar, S. Gupta, N. Akhtar, J. Vishnoi, P. Dontula, S. Pawar, P. Suryavanshi
King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Introduction: Upfront surgery is recommended for ovarian germ cell tumor presenting in early stage. Even in advanced stage general recommendation is for initial cytoreduction followed by adjuvant treatment. Considering young age of these patients future fertility preservation is an important issue. Sensitivity to platinum based chemotherapy provides a hope for the fertility preservation surgery. We undertook this study to analyze our oncological results with the approach of NACT followed by fertility preserving surgery in patients who otherwise not an ideal candidate for fertility preserving surgery upfront. Material and Methods: We retrospectively analyze our data of patients of germ cell tumor of ovary who underwent NACT followed by fertility preserving surgery. Total 22 such patients were identified from January 2011 to January 2015. The diagnosis was made on the basis of biopsy/cytology or tumor markers levels. Imaging was done initially to map the baseline extent of disease. As an institutional protocol 3-4 cycle of bleomycin, etoposide, & cisplatin regimen were administered. Imaging was done again before contemplating the surgery. Results: The mean age of patients was 22.6 year. Of 22 patients 1 patient had stage IV disease, 2 patients had stage IC, 3 patients had stage II and 16 patients had stage III disease. Of 22 patients, all except 1 patient responded to NACT & underwent successful unilateral salpingo-ophorectomy. Of these 21 patients 16 had complete pathological response. Of these 21 patients, 17 patients are in follow up, and are disease free till last contact without any relapse. Three of these females married and 1 had successful pregnancy. Conclusion: Despite lack of clear consensus in the absence of randomized control trials, NACT followed by surgery seems to be an attractive alternative with good oncological outcomes despite reducing the extent of surgery.
Comparison of serum human epididymis protein 4 &, carbohydrate antigen (CA125) as a diagnostic biomarker for epithelial ovarian cancer
thV. Kumar , S. Shivrajan
King George's Medical University, Lucknow, Uttar Pradesh, India, E-mail: email@example.com
Introduction: Human epididymis protein 4 (HE4) is a new promising diagnostic biomarker for epithelial ovarian cancer (EOC). Indian data for this biomarker is lacking. We undertook this study to find out the diagnostic performance of HE4 in comparison to CA125. Materials and Methods: This prospective study includes histopathologically confirmed 30 patients with diagnosis of epithelial ovarian carcinoma & 25 patients with benign ovarian neoplasm. Both HE4 & CA 125 levels were measured in serum by using enzyme linked immunoabsorbent assay (ELISA) as per manufacturer's instruction manual. Results: The median serum HE4 & CA 125 levels were significantly higher in patients with epithelial ovarian cancer than those with benign ovarian neoplasms (HE4 770.50 pM/L vs. 56.0 pM/L; CA 125 701.0 U/mL vs. 31.0 U/mL; p = 0.0001 in both). Compared to CA 125, HE4 had higher sensitivity (100% vs. 95.8%) and specificity (72.7% vs. 63.6%) for the detection of EOC. HE4 had higher positive predictive value (88.9% vs. 85.2%) and negative predictive values (100% vs. 87.5%) than CA 125. Overall accuracy of HE4 for diagnosing EOC was higher than CA 125 (91.4% vs. 88.5%). Conclusion: Both biomarkers (HE4 & CA 125) distinguish malignant epithelial ovarian cancer from benign ovarian neoplasms with high accuracy but HE4 offers clear diagnostic superiority over CA 125 as a biomarker for EOC.
Clinico-pathological and radiological prognostic factors in cancer cervix treated with concurrent chemoradiation
thM. S. Kang , K. Sahani P. Kumar
SRMSIMS, Bareilly, Uttar Pradesh, India, E-mail: firstname.lastname@example.org
Background: Cervical cancer is most common cancer in the rural and second most common in urban areas of our country. It accounts for 16% of all cancers. There are various clinical, pathological and radiological factors which dictate the prognosis of these cancer cervix patients. Aim: To evaluate the prognostic significance of various clinical, pathological and radiological factors in patients of cancer cervix treated with concurrent chemoradiation. Materials and Methods: Thirty two patients between 2012 and 2014 were planned and delivered concurrent chemoradiation. Treatment planned was 3D-CRT (EBRT/50 Gy/25#/5 wks) with 5 cycles of concurrent chemotherapy (CDDP 35 mg/m 2 ) followed by 3 applications of ICRT (6 Gy/fraction). They were evaluated in terms of clinical (age, stage, hemoglobin and HPV infection) -pathological (histopathology, grade, lymph-vascular invasion, mitotic index and necrosis) and radiological (disease dimension, parametrial extension, lymph node, hydronephrosis and vascularity of tumour) prognostic factors. For statistical analysis, univariate analysis using chi-square test was done. Results: In clinical factors age less than 50 (p value = 0.003), higher stage (p value = 0.0005), haemoglobin less than 10 gm% (p value = 0.00001), pathological factors greatest dimension of disease >6 cm (p value = 0.003), radiological factors hydronephrosis (p value = 0.0005) and presence of pelvic lymph nodes (p value = 0.0002) were found to be poor prognostic factors. Conclusion: Age less than 50 yrs, Hb <10%, Higher stage, greatest dimension of disease >6 cm, presence of pelvic nodes and hydronephrosis were concluded as the independent poor prognostic factors.
HDR intra-vaginal intra-uterine brachytherapy using conscious sedation and local anesthesia for locally advanced carcinoma cervix: A pain score and dosimetric analysis
thS. K. Pal , S. Sharma, S. Basu
Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India, E-mail: email@example.com
Introduction: Brachytherapy is an integral part of carcinoma cervix. Presently outpatient procedure for IVIU by HDR technique has gained ground. Though General, epidural and spinal anaesthesia are most commonly used, the procedure can be also done under conscious sedation along with local anaesthesia. This is an attempt to assess the feasibility of the same in terms of pain control. Materials and Methods: 33 patients who had undergone HDR IVIU brachytherapy were included in the study. Pain was assessed with a visual analogue scale of 0 to 10 at the time of insertion of the central tandem, mid-way of packing, at and after removal of applicator and on the next day. Patients were given Tab. Diazepam 5 mg orally the night before the procedure. A vaginal pack with 2% lignocaine jelly was used for local anaesthesia 15 min before staring of the procedure. Patients were put under conscious sedation and analgesia with Injection Paracetamol 1000 mg IV infusion over 15 mins followed by Inj. Pentazocin 30 mg IM after pre-treating with inj. Metoclopramide 10 mg slow IV infusion. During the procedure the patient received Inj. Midazolam IV short push as adjudged by the operating surgeon. The neucleotron HDR brachytherapy applicator with a 15; central tandem and semi-ovoid or ovoid was used for the procedure. Orthogonal X-rays were taken and planning was done using the PLATO system, with the prescribed dose to point-A being 7 Gy. Results: Between May 2014 and August 2014 a total of 33 patients who had undergone 99 procedures were included in the study. The age ranged from 32-74 yrs (median 51 yrs). The total amount of Midazolam required for the procedure ranged from 0 mg to 8 mg (median 4 mg). The Median pain score for the entire duration of procedure was 2.5. The median pain score for tandem insertion was 2 (0-5), mid packing 5 (1-10), at removal of applicator 3 (1-5), and after removal was 0.4 (0-2). The average discharge time was 20 min post completion of procedure. The average pain score was higher in the first procedure than the later ones (3.5 Vs.2). The pain score obtained after 24 hours was 0.2 (range 0-2). The mean difference of distance between the ovoid and the central tandem was 0.5 cm (range 0-0.8 cm). The mean dose to bladder point was 5.1 Gy and rectal point was 4.8 Gy. There were also significant difference in maximum pain score for events where patients were already on NSAIDs compared to those where they were not. Discussion: A meaningful pain control that not only permitted the procedure but also gave the patients an uneventful post procedure period. In most of the patients the obtained geometry as documented by position of the applicators as found in orthogonal X rays and calculated bladder and rectal dose, were found to be satisfactory after optimization. Conclusion: Good pain control with adequate relaxation can be achieved with help of conscious sedation and local anaesthesia at time of orthogonal X-ray based HDR brachytherapy.
Late toxicity of the organs at risk after dose escalated image based brachytherapy in cervical cancer: Clinical audit from a tertiary center
thV. Simha , F. D. Patel, B. Rai, S. C. Sharma, Veenu Singla, A. S. Oinam
Post Graduate Institute of Medical Education and Research, Chandigarh, India, E-mail: firstname.lastname@example.org
Aim: To correlate the long term radiation associated morbidity after radical treatment of cervical cancer treated with MRI based dose escalation protocol. Materials and Methods: Sixty patients of cervical cancer treated with MRI based brachytherapy from November 2010- December 2014, with a minimum follow-up of 6 months were considered for the study. Patients were treated with a minimum HRCTV dose of 85.7 Gy (EQD2). Dose volume data for both the target and the organs at risk were obtained from the dose volume histogram at the time of brachytherapy and the total dose was calculated in terms of EQD2 taking the α/β ratio to be 10 for the clinical target volumes and 3 for the organs at risk. Patients were followed up clinically every 3 monthly for the first 2 years and 6 monthly thereafter. A follow up MRI was done at 1 year follow up. Toxicity scoring for urinary symptoms and bowel and bladder symptoms was done according to CTCAE version 3.0. Results: The total dose prescribed to High Risk Clinical Target volume was 85.7 Gy EQD2. The mean 2cc EQD2 of the bladder was 90.6 Gy EQD2. The mean 2cc EQD2 to the rectum was 70.2 Gy and the mean 2cc EQD2 to the sigmoid was 74.2 Gy. A total of 10 (16.6%) patients developed grade 1-2 gastrointestinal toxicity and a total of 6 (10%) patients developed grade 3 gastro-intestinal toxicity. A total of eight patients (13.33%) developed grade 1-2 cystitis and only one patient developed grade 3 bladder toxicity. The incidence of bladder toxicity significantly increased with doses >85 Gy EQD2; incidence of rectal toxicity increased significantly above 65 Gy and >75 Gy for the sigmoid D2cc. higher doses to the HRCTV and IRCTV were correlated with increased bladder and gastrointestinal toxicity. Conclusion: The threshold for development of grade 1-2 bladder and rectal toxicity was lower than the doses recommended by the GEC-ESTRO group which may require modification based on the clinical judgment in our set of patients. This study also shows that there is increased incidence of OAR toxicity by overtreating the HRCTV and IRCTV even though the OAR doses are within the recommended constraints.
The enigma in treatment of early stage carcinoma of uterine cervix
thK. Jayasree , J. Swapna, G. Kesari, H. Narendra, B. V. Subramaniam, P. Das
Sri Venkateswara Institute of Medical Sciences, Tirupati,
Andra Pradesh, E-mail: email@example.com
Background: Uterine cervical cancer is one of the major health problems among women in our country. The global annual incidence in 2012 was 528,000, the annual death rate being 266,000. The prognosis of cervical carcinoma has been strongly related to lymph node involvement by tumor. The sensitivity of magnetic resonance imaging (MRI) scan in evaluating parametrial invasion ranges from 40% to 57%, and the specificity from 77% to 80%, which is superior to computed tomography (CT) scan. In evaluating nodal disease, both CT and MRI have equal sensitivity and specificity. However the adequate delineation of lymphnodes as well of parametrial involvement in cervical cancer remains a matter of concern in oncology practice. Previous studies showed that RT and surgery has equal local response and survival rates in early stage cervical cancer. But majority of the patients with primary surgery required adjuvant RT. With this back ground, we did a retrospective analysis, the subset of patients that require adjuvant RT after radical hysterectomy as part of management of early stage non-bulky uterine cervical cancer. Materials and Methods: A retrospective observational study was conducted in Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhrapradesh from 2009-2014 in histopathologically proven carcinoma cervix patients of clinical stages IB1 and IIA1, who underwent radical hysterectomy and bilateral pelvic lymphadenectomy and received adjuvant RT with or without chemotherapy. Results: Out of total 57 patients, 50 patients are stage IB1 and 7 patients are stage IIA1. Among them 25 patients required adjuvant RT after radical hysterectomy. Acute and chronic complication developed in only surgery arm in 5 patients; and in RT+surgery arm in 12 patients. Conclusion: In early stage cervix carcinoma patients, radical radiotherapy can be considered as the primary modality of treatment over radical surgery with or without adjuvant radiotherapy, which in turn helps in preventing morbidity and mortality related to the combined modality approach, and increases the compliance.
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