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Year : 2018  |  Volume : 14  |  Issue : 11  |  Page : 833-838

Central Nervous System Oncology

Date of Web Publication29-Nov-2018

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How to cite this article:
. Central Nervous System Oncology. J Can Res Ther 2018;14, Suppl S4:833-8

How to cite this URL:
. Central Nervous System Oncology. J Can Res Ther [serial online] 2018 [cited 2019 Sep 21];14:833-8. Available from: http://www.cancerjournal.net/text.asp?2018/14/11/833/246375

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Re-irradiation in diffuse intrinsic pontine glioma: An institutional experience

Rahul Krishnatry, Rahul Krishnatry, Jifmi Jose Manjali, Tejpal Gupta, Jayant Goda Sastri, Girish Chinnaswamy, Vijay Patil

Aims/Objectives: Diffuse Intrinsic Pontine Glioma (DIPG) is one of the most aggressive tumours of children. Two multi-institutional collaborative registries around the world have shown post-primary radiotherapy median progression-free survival (PFS) and overall survival (OS) of 6 and eight months respectively. All studies investigating various additional therapies have shown no significant improvement. Recently some groups have demonstrated a benefit with the use of re-irradiation (reRT) in selected patients. We present our institutional experience in reRT for this rare and fatal pediatric tumours since April 2016. Materials and Methods: Retrospective review of patients who underwent re-irradiation for their baseline and at reRT features (demographic, clinical, and treatment) using descriptive statistics. The outcomes (PFS and OS) are presented using Kaplan Meier and Log-rank test. Results: A total of 17 patients with mean age-at-initial diagnosis of 7 (range: 3-18; < 10: 70%) years, eleven males (64%), mean initial Lansky play-performance scale (LPS) of 65 (range: 20-90, <50: 30%) and diagnosed with at least 2/3 clinical criteria with all radiological criteria (100%). All received initial radiotherapy (54Gy/30#) using 3DCRT, resulting in at least 50% clinical improvement (>75% in four). The median PFS post radiotherapy was nine months, and PFS at 6, 12 and 18 months was 82.3+9.2, 17.6+9.2 and 5.9+5.7% respectively. The progression was defined with clinical and radiological criteria of diagnosis, where all patient had at least 2/3 clinical criteria and five (29.4%%) satisfied all three with mean LPS of 60 (41%:≤50). The mean post-RT time was 8.7 (range: 4-20) months. Re-irradiation was done using 3DCRT in all but one patient (IMRT) to a dose of 30-45 (mean+SD:39.4+6) Gy where four patients received <30Gy and 45Gy each while rest between 39-43.2Gy. Clinical improvement was noted in 14 (82.4%) ranging from complete recovery to stable clinical signs. Three patients progressed clinically on reRT, where two were confirmed radiologically. Two patients with good improvement post-reRT developed intra-tumoral bleed on day 15 and 45 and succumbed to it. The post reRT progression pattern was known in 10/13 patients (local: 7, disseminated: 3). The median overall survival of the whole group was 15 months with OS at 12, 18 and 24 months was 81.6+9.6, 31.6+12.6 and 21+12% respectively, of which the median survival addition due to re-irradiation was 4.5 months, where three patients are still alive at 1-5 months, and three patients survived 6-9 months. Conclusion: Re-irradiation is an effective and safe option for a selected group of patients of DIPG leading to improvement in neurological function, symptoms. Prospective studies can help to refine the doses, patient selection criteria and impact on quality of life.

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Observational analysis of clinical profile and treatment outcomes of patients with newly diagnosed glioblastoma multiforme treated at regional cancer centre, Thiruvananthapuram

Gouri Somanath, Asha Arjunan

Regional Cancer Centre, Trivandrum, Kerala, India

Aim of the Study: To assess the clinical profile and treatment outcomes of patients with newly diagnosed Glioblastoma Multiforme, treated at RCC, Thiruvananthapuram. The end points of the study were Disease Free Survival, Overall Survival, Prognostic factors. Methods and Materials: 53 patients with newly diagnosed GBM had registered in RCC during the time period of the study, of which, 33 patients who met the inclusion criteria were followed up. Data regarding patient demographics, tumour characteristics, treatment schedules and follow up were collected using a structured proforma. The clinical outcome in terms of Disease Free Survival (DFS), Overall Survival (OS) and Prognostic factors were analysed. Results: The median follow up period was 20 months. 23 (69.7 %) of the patients were males. 7 (21.2%) patients underwent gross total excision, 23 (69.7%) patients had significant residual disease and 3 (9.1%) patients underwent biopsy only. 26 (78.8%) patients received conventional radiation doses ranging from 59.4 to 60 Gy in 30 to 33 fractions and 7 (21.2%) patients received hypofractionated regimens, either 40 Gy in 15 fractions or 30 Gy in 10 fractions. 27 (81.8 %) patients received concurrent chemotherapy. 25 (75.8 %) patients received adjuvant chemotherapy. At the time of analysis 5 (15.2 %) patients were alive. The 12 months and 24 months disease free survival rates were 48.5 and 15.6 % respectively. The 12 and 24 months overall survival rates were 69.7 and 14.3 % respectively. In univariate analysis, males, performance status poorer than1, subtotal resection/biopsy showed a trend towards poorer disease outcomes. Those patients who received concurrent and adjuvant chemotherapy were seen to have relatively better outcomes. In multivariate analysis, the patients who received adjuvant chemotherapy had a significantly better outcome (p-0.0001, 95% CI 0.064-.412). Conclusion: Despite maximal initial resection and multimodality therapy, 36 % of patients had disease progression within 1 year. The median survival period of patients treated at our centre was 13 months. Our survival outcomes for patients in this study were comparable to published literature.

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Volumetric modulated arc therapy versus conventional intensity modulated radiotherapy for progressive benign, high risk low grade and recurrent high grade gliomas

V. Hemalatha, A. S. Uday Krishna, C. Varatharaj, T. Naveen, V. Lokesh

Objective: To compare dosimetric, radiological and clinical outcomes of tumours with small target volumes by VMAT vs. IMRT. Materials and Methods: CT data set of 15 patients (5 in each cohort) was utilized to generate VMAT and IMRT plans. Target volume and OAR's were contoured after co registration with Gadolinium enhanced MRI as per guidelines and plans optimized to achieve 100% dose to 95% of volume. Dosimetry was compared using homogeneity index (HI), conformity index (CI) and V50. KPS, NPS and T2 FLAIR MRI at 1st follow up were compared at first follow up. Results: The mean PTV of 3 cohorts [Benign (2: Craniopharyngioma>3 OPHG), Low grade glioma (all IDH mutant) and 5 recurrent Glioblastoma] was 203cc, 486cc and 383cc respectively. HI in each cohort was 0.39 vs. 0.04, 0.22 vs. 0.06 and 0.29 vs. 0.08. CI was 0.99 vs. 0.99, 0.98 vs. 1, and 0.99 vs. 1. Brain V50 was 24 vs. 25, 33 vs. 32 and 14 vs. 16. Total MU was 537 vs. 503, 559 vs. 594 and 771 vs. 510. Improvement in KPS and NPS in the 2 groups was seen in the same proportion. Hyper intensity of normal brain on the T2 FLAIR was larger in patients treated by IMRT. Conclusion: VMATis dosimetricallycomparable to conventional step and shoot IMRT in these patient groups with superior preservation of normal brain beyond the target volume.

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A prospective study evaluating the recurrence pattern, recurrence probability, re-stereotactic radiosurgery rate and toxicity in Indian oligo-brain metastatic patients treated with robotic radiosurgery alone

Athira Krishnan, Rupa Das, O. C. Clinto, Debnarayan Dutta

Background: Evaluation of recurrence pattern, recurrence probability, re-SRS rate and toxicity in Indian oligo-brain metastatic patients treated with robotic radiosurgery alone. Materials and Methods: Thirty consecutive oligo-brain metastasis patients treated with CyberKnife radiosurgery without whole brain radiation therapy. Inclusion criteria was three or less brain metastasis, good performance status (KPS>80) and stable primary disease. MRI scan based (T1 contrast and T2 flair) planning done, treated with Cyberknife (M6) after optimization with Monte Carlo algorithm. PTV margin was 2-3 mm and dosage of 20-30 Gy/1-5 fractions depending upon the volume. Results: Among 30 patients treated, 22 (74%) patients had controlled primary at 6 month evaluation. 8/30 (27%) had progression of intra-cranial lesions. 5/30 (17%) patients had new lesions in other region and 3/30 (10%) patient had recurrence in primary site within high dose region. Among the eight patients with recurrent disease, 4 (50%) received re-SRS with CyberKnife. Rest patients receive whole brain RT. Dose for re-SRS was similar as primary treatment (20-25Gy/1-5fr). 12Gy normal brain volume was kept less than 5% to prevent late toxicity. Probability of recurrence as per published literature was evaluated in Indian patient population. Conclusions: SRS is a standard option in Indian brain metastasis patients. Recurrence rate after SRS is 26% at 6 month follow up and 50% of patients with recurrence are re-treated with SRS.

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Primary intracranial germ cell tumours: 10-year experience from a tertiary care centre

P. V. Jeyaanth, Rajkrishna, Sunitha Susan Varghese, S. Patricia, B. Rajesh, B. Selvamani

Department of Radiation oncology, CMC, Vellore, Tamil Nadu, India

Background: Intracranial germ cell tumours (IC-GCTs) are a heterogeneous group of lesions which occur in children and young adults accounting for approximately 3% of paediatric brain tumours. Extragonadal germ cell tumors should always be included in the differential diagnosis of pineal and suprasellar intracranial tumors. The diagnosis of an intracranial germ cell tumor is usually clinico-radiological along with serum and cerebrospinal fluid (CSF) tumor markers, like α-fetoprotein (AFP) and β-human chorionic gonadotropin (β-HCG), which may obviate the need for tissue diagnosis. Germ cell tumours are classified as germinomas constituting>80% of ICGCTs) and non-geminomatous germ cell tumors (NGGCTs). As pure germinomas are highly sensitive to chemotherapy and radiotherapy, they have very good prognosis whereas non-germinomatous germ cell tumours have poorer prognosis. Aims and Objectives: To retrospectively analyse theclinical pattern and outcomes of patients treated with radiation therapy and chemotherapyfor intracranial germ cell tumour from January 2006 to June 2016 in our Institute. Materials and Methods: Retrospectively data was collected from electronic medical records of 51 patients who received treatment for primary IC-GCT from January 2006 to June 2016at Christian Medical College, Vellore. The patient's demographic information, clinical, biochemical and radiological information at presentation was collected. Information on pituitary hormone levels were collected at baseline and on follow up. Details of radiation therapy and chemotherapy and toxicity data were analysed. Progression free survival (PFS), time to progression (TTP) and overall survival (OS) were analysed using Kaplan Meier curves. Results: Of the 51 patients diagnosed with primary IC-GCT, 32 (63%) were males and 19 (37%) were females. Their age ranged from 6 to 38 years (median–16 years). Headache and vomiting were the most common presentation followed by visual symptoms and neurological deficits. The location of the tumour was pineal/posterior third ventricular origin in 28 (55%) patients, suprasellar in 13 (25%), and the rest were corpus callosum (2%), thalamic region (6%), brainstem (4%) and multifocal (8%). Seventeenpatients (34%) including all suprasellar GCTs presented with endocrine abnormalities and diabetes insipidus was the commonest endocrine abnormality. Histopathological diagnosis was possible in 49% of patients only. 25 patients were diagnosed as Pure Germinoma, 15 as germinoma with elevated markers and 11 were diagnosed as non-germinomatous germ cell tumours. Cisplatin/Etoposide regimen was most commonly used in adults and Carboplatin/Ifosfamide/Etoposide (Carbo PIE) was used in children. Whole ventricular radiation therapy (Median dose–30.6Gy) followed by focal boost (median–19.8Gy) was delivered to 76% of patients and cranio-spinal irradiation (Median dose–36Gy) followed by focal boost (Median dose–18Gy) in 24% of patients. All patients tolerated RT well and there were no grade 3 or 4 toxicities. Median follow up was 29 months (3–139 months) and median PFS was 34months (6–139 months). On follow up, 7 patients (14%) had disease recurrence/progression. Median OS was 60 months. Conclusion: IC-GCTs are rare intracranial tumours seen commonly in childrenand young adults. With multi-modality treatment, excellent local control and overall survival can be achieved.

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Treatment outcomes of patients with Hemangiopericytoma/Solitary Fibrous tumour arising in Brain and Head and Neck regions: A retrospective analysis from a tertiary care referral centre in South India

Sobin V. Jacob, Sunitha Susan Varghese, S. Patricia, B. Rajesh, B. Selvamani

Department of Radiation Oncology, IDA B Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, India

Background: Hemangiopericytoma (HPC) and Solitary Fibrous Tumours (SFTs) arise from Zimmerman's pericytes that line capillaries, post capillary venules and sinusoidal spaces. The WHO classification of CNS tumours in 2016 update has reclassified HPC, combining it with SFT. HPC-SFT occurs at various sites; most commonly in the thigh (25.5%), pelvic retroperitoneum (24.5%) and head and neck (16.0%). Intracranial HPC-SFT are rare (0.4% of all primary CNS tumours and 2.5% of meningeal tumours), slow growing, extra-axial tumours. HPC-SFTs have an aggressive behaviour which tends to recur locally and metastasize. Because of the rarity of the tumour, there are no large studies defining the natural history of the disease, management and guidelines for follow up. Complete resection followed by adjuvant radiation offers good local control. Role of adjuvant chemotherapy with anthracycline based regimens have not proven any benefit till date. Aims and Objectives: To retrospectively analyse the treatment outcomes in patients with HPC-SFT who received treatment from January 2006 to June 2016. Materials and Methods: Hospital database was searched and 44 patients with HPC – SFT were treated in our institution from 2006 to 2016. The data on clinical presentation, treatment, histopathology and disease outcome was collected. Survival outcome was evaluated with median overall survival and progression free survival using Kaplan Meier curves. Univariate analysis was done with variables like age, gender, tumour location, extent of surgery, adjuvant radiotherapy and radiation dose to independently predict treatment outcome. Results: Of the 44 eligible patients, 70% were males and 30% were females. Intracranial HPC-SFT was diagnosed in 91% of the patients and 9% patients had head and neck region involved. Gross resection was done in 45% patients, subtotal resection in 50% and one patient has received radiotherapy based on radiological evidence. Grade 3 histology was noted in 54% patients and grade 2 in 29% and was not reported in others. The median RT dose received was 5580cGy. Of the 39 patients who received RT, 41% were treated with conformal techniques. Two patients received adjuvant chemotherapy with Adriamycin based regimen. The median follow-up was 22 months (range 2 to 226 months) and 6 patients were lost to follow up. Six patients developed local recurrence and 3 had distant metastases. The median progression free survival was 55 months (range 3-120 months). The median overall survival was 67 months (Range 18-226 months). Median time to first recurrence was 20 months in patients who did not receive RT and 60 months in patients who received adjuvant RT. Conclusion: HPC-SFT is a rare entity which is locally aggressive with a tendency to relapse locally or distally. Mainstay of treatment is complete resection. Adjuvant radiotherapy improves local control and survival. Role of chemotherapy is inconclusive. However, there is a need to establish a systemic chemotherapy or targeted therapy to control distant metastases.

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Observational study of medulloblastoma, barnard institute of radiation oncology, Madras Medical College, Chennai: 2001 – 2010

T. Bharathi, R. Giridharan

Aim of the Study: To study the long term outcome of medulloblastoma patients, who were treated in our institution during the period 2000-2010. It is a retrospective study. 1. Age and sex distribution, 2. tumor location, 3. clinical presentation, 4. treatment modalities and 5. the response to treatment. Criteria's of inclusion, 1) biopsy proven medulloblastoma patients.2) registered in department of radiation Oncology, RGGGH, Chennai, 3) The treatment period Jan 2000 – Dec 2010. Gender Distribution: Among the 75 cases reported, 42 males (56%) and 33 females (44%.). Clinical Presentation: Head ache (78%), vomiting (73%), Seizures (9.3%), of treatment completed patients < % of patients with incomplete treatment. Defaulters: Surgery is the arm-13 % In radiotherapy arm-37.4% The chemotherapy arm-33. %Reason of Treatment Default: 1. Lack of awareness about different modalities (42%) that should be incorporated. 2. False belief of poor outcome of patient in the treatment (28%) 3. Fear of toxicity4. Lack of adequate follow up facility. Recurrence: Out of total 75 patients, 7 had recurrence (3 loco regional and 4 distant recurrence). Quality of Life Assessment: (QLQ – C30 version of EORTC). Ideas about life partner-80%, Difficulty in learning-69%, Interpersonal relationship-62%, Cosmetic disfigurement-33%, Aggressive nature, irritable –33%, Visual impairment-25%, Sports activities-0%. Conclusion: Althoughmedulloblastoma is a tumor of high mortality, correct treatment with surgery, chemotherapy and radiotherapy can save the life of the patient to certain extent. Medulloblastoma special clinics must be created so that the patients are enrolled in the clinic and adequate treatment follow up is ensured.
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Prognostic significance of magnetic resonance spectroscopy metabolic parameters post adjuvant radiation in Grade III Gliomas: A retrospective study

Kushal Goswami, Amitabha Manna, Anish Bandyopadhay

Aims and Objective: The primary objective was to assess the prognostic significance of MRspectroscopy parameters (choline/NAA and choline/creatine ratio) both at Baseline (Pre operative MRS) and post adjuvant radiation regarding survival and its comparison with traditional anatomic MRI based grading parameters (enhancement quality, enhancementproportion, enhancement margin, T1 Flair Ratio). A secondary objective was to corelate any association between the MRS metabolic baseline and response values (cho/NAA and cho/creatine) with Histopathologically proved recurrence. Materials and Methods: 25 histopathologically proved Grade III gliomas (astrocytomas and mixed oligoastrocytomas), registered in our institution between 2013-2016who had both preoperative and post radiation MRI and MRS done were included in the study. MRS metabolic parameters were graded at baseline (Pre op) into cho/Naa ratio (>3.5,<3.5) and cho/creatine ratio (>2,<2) and at response (post adjuvant radiation) into cho/Naa change (>25%,<25% of baseline) and Cho/creatine (>10%,<10% of baseline). Baseline Anatomic MRI characteristics of the tumor (pre op) was also graded into enhancement quality (mild/avid), proportional enhancement (>50%,<50%), Margin of enhancement (well defined/poorly defined) and T1/Flair Size ratio (expansive/infiltrative) based on the VASARI/REMBRANDT MR feature set. PFS was estimated from time of completion of adjuvant treatment to clinical or radiological progression or last clinical follow up. Univariate analysis using Kaplan maier survival method and Log Rank value test was done for both the metabolic MRS value groups (baseline and Response) and the anatomic MRI parameters. Univariate survival analysis was also done to assesssignificance of Radiation dose (>50 Gy,<50 Gy) and extent of surgery (total vs subtotal/biopsy). Any parameter with log rank p value<0.08 was deemed to be significant and was entered into multivariate cox regression analysis. Histopathologically confirmed cases of recurrence (positive HPE/negative HPE) was correlated with baseline and response MRS value groups using Paired t test to corelate any significance. Results: Median follow up period was 38 months and median pfs was 13.2 months. On univariate analysis of the baseline and response value groups of MRS, the most significant factor associated with better survival was cho/cr change greater than 10%(PFS of 22.1 months vs 9.3 months, log rank p value=0.002) followed by baseline cho/naa less than 3.5 (PFS of 21.7 months vs 12.7 months, p=0.021). Among the Anatomic MRI parameters well defined enhancement margin was associated with survival advantage (PFS 20.5 vs 12.3 months, p=0.045). Full RT dose and total excision both were individually associated with better survival (p=0.073 and p=0.002). On multivariate analysis only cho/cr change >10% was significant at p=0.144 among MRS parameters. Among the 7 patient who underwent rexcision following clinical/radiological progression, 6 were HPE confirmed recurrence. On paired t test Cho/naa change>25% of baseline (post RT response value) was identified as the best predictor of HPE confirmed recurrence (p=0.008) better than radiological progression during Follow up (p=0.350). Conclusion: MRS metabolic parameters (Lower baseline cho/naa and greater cho/cr change after treatment) are of significant survival advantage whereas lesser cho/Naa response has better specificity for HPE proved recurrence than its anatomic counterpart. Prospective studies evaluating voxel based MRS data incorporated into treatment planning systems can be an interesting way forward.

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Medulloblastoma in adults: A retrospective single institution analysis

Souransu Sen

Aims/Objectives: Adult medulloblastoma is a rare disease treated according to the current pediatric treatment guidelines. This retrospective analysis investigated the clinical outcomes and prognostic factors of adult medulloblastoma patients, who received multimodality treatment at our institution. Materials and Methods: Data of all patients above the age of 15 years with de novo Medulloblastoma, treated in our institution between 2008 and 2017, were retrospectively analysed. Patients' demographic parameters, initial symptoms, treatment modalities, toxicities, and survival outcomes were investigated. Results: In total, 9 patients with de novo adult medulloblastoma were treated in our institution between 2008 and 2017. Median age was 29.3 years. After tumour resection, all patients received Craniospinal irradiation followed by posterior fossa boost. 2 patients received concurrent chemotherapy while 2 patients received sequential chemotherapy. Most common side effects were haematological toxicities. Median overall survival (OS) has not been reached after a median follow-up of 90 months. The 5-yr OS and PFS were estimated to be 70% and 65% respectively. In univariate analysis, gross total resection and shorter interval between resection and completion of radiation were associated with better outcomes. Conclusion: The combined modality treatment showed a good outcome in adults with medulloblastoma. Treatment times should be kept as short as possible.

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Volumetric analysis for follow up in patients with vestibular schwannoma, poststereotactic radiotherapy/stereotactic radiosurgery in our institution

Theertha M. Asokan, I. Bhargavi, P. Mahadev

Apollo Cancer Institute, Chennai, Tamil Nadu, India

Aim: To assess the response of patients with vestibular schwannoma post Stereotactic Radiosurgery/Stereotactic Radiotherapy with slice by slice volume data. To emphasise the existence of pseudoprogression in benign diseases. Introduction: Vestibular Schwannomas represent 5% to 8% of primary CNS brain tumors, which are derived from Schwann cells of the neurilemma of the vestibulocochlear nerve. Most common symptoms are sensorineural hearing loss, tinnitus, facial nerve symptoms and vertigo. Management options are Surgery, Stereotactic Radiosurgery or Stereotactic Radiotherapy. Radiotherapy in the form of Stereotactic Radiotherapy or Stereotactic Radiosurgery has higher rates of hearing preservation and facial nerve preservation compared to surgery. Materials and Methods: We have retrospectively analysed the pattern of response with slice by slice volume data in 50 patients who have undergone Stereotactic Radiosurgery/Stereotactic Radiotherapy in our department. The initial volume was documented and the volumetric analysis was done at the first follow up after six months. Based on the radiological parameters and volumetric data, the pattern of response was documented as stable, regression or increase in size. Results: When compared with the radiological parameters, the volumetric analysis seemed to provide an accurate depiction of the response post radiosurgery. The response assessment showed that 7% showed an increase in volume, 65% showed stable disease and 28% showed regression in size. The 7% of the cases which showed progression were followed up and 3% showed stable disease and 4% showed regression. None of them required surgical intervention. Conclusion: Response of Schwannoma being a benign disease is different from response in malignant diseases. A Stable schwannoma, post treatment indicates disease control and this is the commonest pattern of response in schwannoma post Radiation. However, a few cases might show an increase in size suggesting pseudoprogression. Despite the increase in volume, patients are asymptomatic. On follow up, they are found to have stable disease or regression which is also a pattern of disease. This might be attributable to a transient increase in central necrosis post treatment.

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Clival chordoma treated with cyberknife radiosurgery: A case series

Jakka Mohan Krishna, Sham Sundar, B. Subathira, Rathna Devi, Janos Stumpf, Mahadev Potharaju

Aims/Objectives: To analyse the clinical characteristics and outcomes of patients diagnosed with clival chordoma treated by Cyberknife radiosurgery (CKRS) at our institute. Materials and Methods: We retrospectively analysed all patients diagnosed with clival chordoma treated by CKRS at our institute between August 2009 and December 2017. Details of the patients such as age, sex, presenting symptoms, diagnostic procedure, details of surgery and radiation therapy were collected from Medical records. Details of clinical evaluation and MR imaging were collected for the patients who had come for follow-up. Others were contacted by telephone and email to know about the disease status. Results: 11 patients diagnosed with clival chordoma were treated with Cyberknife radiosurgery. Of the patients 6 were female and 5 were male, median age was 49 years (range 22-73). Nine patients had histo-pathological diagnosis and two had radiological diagnosis. 8 patients had subtotal excision and 1 had biopsy alone. 10 patients received SRS postoperatively or after radiological diagnosis. One patient was on follow-up after surgery and was treated with radiosurgery at disease progression. Eight patients were treated with five fractions with a median dose of 25Gy; one was treated with four fractions, one patient received 10 fractions and one was treated with conventional fractionation. Our median follow-up was 2.5 years (range 1-6 years). Two patients had disease progression. One patient developed marginal recurrence 5 years post radiation and other developed a new lesion 2 years post radiation on contra lateral side. Conclusions: Patients receiving CKRS have a favourable outcome in terms of neurological symptoms and radiological response. Radiosurgery has an important role in the management of clival chordoma.

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Comparison of imaging modalities for the accurate delineation of arteriovenous malformations and evaluation of set up accuracy with reference to non-invasive mask based stereotactic radiosurgery

K. S. Anju, K. R. Rajeev, Beela Sarah Mathew

Aim: To assess the accuracy of nidus delineation on MRA as compared to that of DSA with respect to volume and maximum diameters of the nidus, and to evaluate set up accuracy during non-invasive mask SRS treatments for AVM with respect to coordinates of isocentre. Materials and Methods: Patients who underwent Stereotactic radiosurgery (SRS) for brain arterio-venous malformations from the period between 1st January 2016 to 30th May 2017 were included in this study. Sixteen patients were included in the study, among which nine patients had undergone previous embolization. Each patient underwent CT simulation and planning Digital Subtraction Angiography (DSA) after immobilization with non-invasive thermoplastic Brainlab mask system, as well as a Magnetic Resonance Angiogram (MRA). The nidus was separately delineated using DSA and MRA after co-registration on to the CT images and were compared with respect to their volume and maximum diameters. For the delivery of SRS, patients were immobilized using non-invasive thermoplastic Brainlab mask system. Three sets of orthogonal kV verification images were obtained with the couch in neutral position: one before start of treatment, one in between couch rotations and one after completion of treatment. These verification images were compared to the Digitally Reconstructed Radiograph of the treatment plan and the set up errors observed in x, y and z directions were recorded. Results: The mean volume of nidus contoured in MRA was 4.16cc compared to 3.11cc in DSA, but this difference was not statistically significant (p=0.297). The mean maximum diameters using MRA and DSA respectively, in antero-posterior, cranio-caudal and transverse diameters were 21.97cc vs 19.46cc (p=0.2380), 6.59cc vs 9.63 cc (p=0.161) and 18.87cc vs 16.81cc (p=0.178). There was no statistically significant difference between nidus delineated using MRA and DSA with respect to their maximum diameters. But, there were discrepancies observed in the niduses delineated using MRA and DSA, especially in patients with previous embolization. Both these modalities can potentially misinterpret the nidus volume, warranting caution for use of either modality alone. The mean translational shift observed in the x, y and z directions were 0.06mm, 0.13mm and 0.13mm respectively after clockwise couch rotation and 0.07, 0 and 0 respectively after counter-clockwise couch rotation. The maximum intra-fraction error observed in any direction was 2 mm. The observed error did not show statistically significant difference from neutral position and is within acceptable range. Conclusion: This study could not demonstrate any statistically significant differences in AVM nidus delineation in terms of volume or size while using MRA or DSA. Set up accuracy achieved with non-invasive Brain Lab thermoplastic mask based immobilization is within acceptable limits for SRS treatment.

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Clinico-pathologic spectrum, treatment characteristics and outcome analyses of IC-GCTs treated at a single institution: A retrospective audit

Sulagna Mohanty, Tejpal Gupta, Mohanty Sulagna, Gupta Tejpal, Epari Sridhar, Krishnatry Rahul, GodaJayant Sastri, ChinnaswamyGirish, Patil Vijay, Moiyadi Ali Sagar

Tata Memorial Centre, Mumbai, Maharashtra, India

Background: Intracranial GCTs accounts for 2-11% of children and young adults. They are heterogenous group of tumours with diverse presentations, histology, ethnic and geographic distribution and have variable outcomes. In the present study, we report outcomes of IC-GCT patients treated at our institution. Aims and Objectives: To study the clinic-demographic patterns of presentation, treatment and outcomes, in terms of event free survival and overall survival. Materials and Methods: A retrospective review was conductedin IC-GCT patients treated in Tata Memorial Hospital, Mumbai between 2006 to 2017. Results: The present cohort consists of 61 patients (41 males and 20 females). Median age at diagnosiswas 15 years. Pineal was most common location (56%) followed by suprasellar (37%) with thalamus accounting for7%. Pineal GCTs were found to be predominant amongst males (83%). Most common histology observed was germinoma (72%) followed by NGGCTs/mixed (28%). Details regarding therapy and outcome were not available for 15 of 61 patients, who were excluded from survival analysis. Germinoma patients were treated with radiotherapy alone (Craniospinal irradiation+ tumour bed boost) or combined modality (chemotherapy+ whole ventricular irradiation+ boost) and NGGCTs/mixed/metastatic germinoma patients were treated with combined modality (chemotherapy+ CSI+TBB). Amongst germinoma seven (23%) had syncytiotrophoblastic differentiation and 93% had localisedand 7% had metastatic. NGGCTs/Mixed histology patients were categorised in to localised (89-100%) and metastatic (0-11%). Amongst them 87% had undergone biopsy and 4 (9%) of them underwent subtotal excision. Rest two (4%) of them underwent ventriculostomy without biopsy and were treated as GCT, in view of raised tumour markers in CSF more than serum and radiological findings consistent with the diagnosis.72% of patients had received chemotherapy post operatively and one succumbed to death on CT. For Six patients, chemotherapy regimen was modified, in view of haematological and neurological toxicities. 94% of patients received radiotherapy according to histology and extent of disease. Three (6%) of them did not receive radiotherapy. Amongst them defaulted and had disease progression and currently on salvage therapy and another had mature teratoma, kept under observation. At Median follow up of 37 months (interquartile range 24-68 months), the 3year overall survival was 60% and 50% and 3year event free survival was 52% and 35% for germinoma and NGGCTs/mixed histology, respectively. On subset analyses in germinoma patients, the 3year OS was 65% and 40% (p=0.02) and 3year EFS was 65% and 29%(p=0.007) for pure germinoma and germinoma with syncytiotrophoblastic differentiation. On surveillance imaging three of them had suspicion of growing teratoma syndrome, one of them underwent surgery and two were under observation. Eight (17%) of them had recurrence and the median time to recurrence was 18 months. They received salvage therapy and following which three of them died due to disease progression. Currently, 39 (84%) of patients are under regular follow up. Conclusion: IC-GCTs are unique group of tumours with variable histopathological spectrum, diverse clinical presentation. Significant toxicities were observed in patients who received chemotherapy. Germinomas have favourable prognosis, while NGGCTs/Mixed GCTs have variable prognosis depending up on extent of disease and histological subtype. On subset analyses, germinoma with syncytiotrophoblastic differentiation had significantly worse OS and EFS compared to pure germinoma patients.

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Role of radiotherapy in central neurocytoma: A single institutional experience

S. Arun Raj, B. Subathira, I. Bhargavi, Y. V. Lokesh, Prathap K. Reddy

Apollo Cancer Institute, Chennai, Tamil Nadu, India

Aims/Objectives: Neurocytomais a rare benign neuronal tumor which represents about 0.1-0.5% of all primary CNS tumors. Radical excision is the mainstay of treatment. The role of definitive or adjuvant radiation therapy is not well defined in neurocytomas. The aim of this case series is to evaluate the treatment strategy and the role of radiotherapy in Central Neurocytoma based on our institutional experience. Materials and Methods: We have done a retrospective review of 9patients with neurocytoma treated at our centre from 2012 to 2016. All the patients had a histological confirmation of diagnosis by stereotactic biopsy or surgical resection. We present the demographic details, clinical manifestations, treatment strategies and outcome of these patients. Results: There were 9 patients who were diagnosed with aNeurocytoma and who underwent Radiotherapy in our department. The median age of presentation was 26 years (20-56 years). 5 were male (55.5 %) and 4 were female (44.4 %). The commonest presenting symptom was headache associated with gait and visual disturbances (77.7%). All the tumors were intraventricular, with lateral ventricle being the commonest location. Surgery was excision (5/9) or stereotactic biopsy (4/9). The patients who underwent excision, had a post-operative MRI showing residual tumor. All the patients underwent Post-Operative/Definitive Radiotherapy (3DCRT, IMRT, IGRT, SRT). The median dose delivered was 50.6 Gy in conventional fractionation and 25Gy/5 # for the one patient treated with SRT. On follow up at 4 months post Radiotherapy, one patient had 50% regression, one had Progression and the rest were symptomatically better. Conclusions: Neurocytoma is a benign tumor of the Brain, commonly presenting with symptoms of raised ICT owing to its intraventricular location. Surgery forms the mainstay of treatment for these tumors. However in the presence of residual tumor or due to inoperability (comorbidities/eloquent location), Radiotherapy has a major role in the management of these tumors in the post-operative/Definitive setting, based on the type of surgery. Radiotherapy seems to be well tolerated and effective. However, our series requires a longer follow up for response assessment.

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A prospective study of assessment of neurocognitive function in patients with gliomas treated with chemoradiation

Asha Latha Govindu, Monica Malik, Deepthi, Fayaz

Introduction: Gliomas are the most common types of brain tumors among central nervous tumors. Together, they make up about 40% of all primary brain tumors and around 70% of all primary malignant brain tumors. Due to an increase in burden of symptoms, survival has become the major concern in different grades of glioma. Although the role of radiotherapy has been studies extensively, its effects on neurocognitive function (NCF) remain elusive. Assessment of NCF in illiterate patients remains a challenge. The main objective of this present study is to assess the effect of chemoradiation on NCF. Aims and Objectives: The aim of this study was to assess the effect of chemoradiation on NCF in patients of gliomas. Materials and Methods: Patients with histopathologically proven gliomas were recruited following surgery with maximal safe resection. Study period was from October 2015 to October 2018. Target volumes were contoured as per standard guidelines and the subventricular zones (SVZ) and the hippocampus were contoured in all patients. Neuro-cognitive function was assessed using the Addenbrooke's Cognitive Examination (ACE-III) questionnaire prior to the start of radiotherapy and at 3 and 6 months post completion of radiotherapy. Data analysis was done on Microsoft EXCEL 2013 and SPSS version 20.0. Results: 26 patients were recruited. Most of them were illiterate. The mean age was 39.81 years (range 22-65 years). Male to female ratio was 1:1.16. Most of the tumors were grade III (n=19) followed by grade IV (n=6). Most of the patients underwent gross total excision (n=12) followed by near total excision (n=6) and subtotal excision (n=8). All patients received adjuvant radiotherapy to a dose of 54 to 60 Gy with concurrent temozolomide 75mg/m2/day and adjuvant temozolomide 150 to 200 mg/m2/day for 5 days every 28 days for 6 to 12 months. Mean dose to the ipsilateral subventricular zone (SVZ I/L) was 48.6 Gy. Based on the mean dose to subventricular zone patients were divided into two groups: Group I < 50 Gy (n=14), group II ≥ 50 Gy (n=12). In comparison between pre-RT and three months, memory (17.55 vs 21.73, p=0.024) and fluency (10.55 vs 21.73, p=0.031) showed significant improvement in group 1 patients. Compared to pre-RT, at six months post radiotherapy there was significant improvement in memory (17.55 vs 22.82, p=0.03) in group 1 patients and a significant decline in visuospatial function (15.33 vs 13.60, p=0.023) in group 2 patients. Other scores did not show any significant change during the study period. Conclusion: The Addenbrooke's Cognitive Examination (ACE-III) questionnaire can be used to assess NCF in patients with gliomas including illiterate patients. Lower doses to the subventricular zone resulted in improvement/preservation of memory and fluency whereas higher doses were associated with a decline in visuospatial function. Long-term assessment is needed to confirm and validate these results.

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Comparison analysis following reirradiation of recurrent gliomas with different fractionation schedules

Haridas M. Nair, Durgapoorna2, SathiyaKrishna Moorthy3, Debnarayan Dutta

Amrita Institute of Medical Sciences,1 Aster MedCity, Kochi, Kerala,2 Apollo Hospital, Chennai, Tamil Nadu, India

Background: The natural history of gliomas follows a very high tendency for local recurrence. Despite a multimodality approach with surgery, radiation therapy and chemotherapy, the relapse rates are high. Salvage surgery in most cases are difficult and appears to be feasible only for selected cases. Reirradiation is a viable option but it is associated with concerns of radiation toxicity especially in case of gliomas, where initial radiation dose would be in range of about 54-60Gy. Aim of this analysis was to review the patients reirradiated for recurrent gliomas and determine their outcomes and impact of dose fractionation. Material and Methods: We retrospectively reviewed total of 44 patients, treated at 2 centres with infield recurrent or progressive gliomas who received reirradiation between Jan 2008 and July 2018. All patient, disease and treatment related factors were analysed. Survival analysis was done by Kaplan-Meier method and univariate analysis performed. Results: Mean age of patients who received reirradiation was 37 years. 50% patients could undergo repeat maximal safe resection. Among the recurrent gliomas, 29 patients(66%) were GBM, 9 patients Grade 3 and 6 patients grade 2. 20 patients received chemotherapy. Median time interval between initial RT and ReRT was 1015 days (33.8 months). A trend for improving survival was seen in patients with increasing time interval when grouped as <350days, 350-700 days and >700days. The mean target volume reirradiated was 178cc. The median initial RT dose was 60Gy (50-65Gy). Mean Cumulative BED following ReRT was 172 Gy. Mean followup period was 409 days. The overall Mean OS was 689 days (95% CI-403.8-975.9). The outcome of these patients were compared based on various factors and the most significant factors were KPS and chemotherapy status. Patient with KPS 80-100 had a significant OS advantage when compared with KPS 60-70(Median OS 22 vs 5.3 months; p = <0.001). Significant OS improvement was also noted in patient who received some form of systemic treatment.(Median OS 22 vs 7 months; p =<0.001). Patients were stratified into 3 groups based on dose fractionation-Conventional RT (1.8-2Gy/#)-16 patients; Hypofractionated RT (2.25-3.5Gy/#)-8 patients; Ultra-hypofractionated RT (>/= 4Gy/#)-20 patients. Patients who received conventional RT appeared to have a trend for better survival compared to the hypofractionated schedules. The mean cumulative BED achieved was higher in the Conventional RT group (188 vs 158 vs 160Gy). Only 6 patients had symptomatic Grade 3-4 toxicity following ReRT. Conclusion: Re-irradiation can be considered as a feasible salvage option in recurrent gliomas with acceptable toxicities especially for patients with good performance status and reasonably good time gap for ReRT. Extreme hypofractionated RT schedules appear to have a trend for inferior survival than conventional RT schedule.

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Hypofractionated radiotherapy in elderly glioblastoma patients with poor KPS: An institutional experience

Preety Jain

Govt Cancer Hospital, M.G.M.M.C, Indore, Madhya Pradesh, India

Introduction: Elderly glioblastoma (GBM) patients with low KPS have been shown to have limited benefit from radiotherapy (RT) compared to fitter younger patients. 60 Gy conventionally fractionated over 6 weeks with concomitant temozolamide (TMZ) continues to be the standard dose and schedule for GBM patients. It has been argued in the literature that patients with a poor prognosis should receive a shorter course of palliative RT. We at our institute Govt cancer hospital, M.G.M.M.C, Indore give a 2-week schedule of hypofractionated RT (Hypo RT) consisting of 30 Gy in 10 fractions for patients with GBM who are elderly with poor performance status. This retrospective review was undertaken to determine whether Hypo RT can be used to reduce the overall treatment time of conventional RT without increasing the toxicity or compromising survival. Material and Methods: A retrospective review of medical records was done of of 26 patients with GBM who were older than 60 and had poor performance score KPS ≤ 70 and received Hypo RT between January 2004 and December 2012. Hypo RT was initiated within 3 weeks of the surgical procedure. Patients were prescribed a total dose of 30 Gy given at 3 Gy once daily for 10 treatments in two weeks. Patients treated were prescribed whole brain RT with parallel opposing fields. Results: The median follow-up for the entire cohort was 7.4 months (range 1.2–9.9 months). At time of analysis, 22 of the 26 patients had died of disease. All except one of the patients completed their hypofractionated course of radiation. The median duration of symptoms prior to diagnosis was 2 months (range 1–9 months). Most patients presented with a combination of symptoms including seizures (31%), focal neurological deficits (58%), cognitive changes (52%), headaches (43%), or vision changes (7%). Median overall survival (OS) was 6.9 months (95% CI, 4.5–8.6). Univariate analysis based on the overall survival experience limited to the first 12 months reveals concurrent chemotherapy (P = 0.003) and surgery less than a gross total resection (i.e. biopsy or STR) (P\0.001) were unfavourable prognostic indicators. In multivariable analysis limited extent of surgery (P = 0.001) remaining as independent unfavourable prognostic indicators of overall survival. Conclusion: We conclude that short course partial brain irradiation offers reasonable palliation in patients with adverse prognostic factors of poor performance status and older age, with comparable survival benefit than that would be obtained with radical radiotherapy. The choice of treatment for an individual patient should not only include considerations of the effect of treatment on life expectancy, but also on quality of life and good quality survival embodied in the concept of quality adjusted survival.


  [Table 1], [Table 2]


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