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ABSTRACT
Year : 2018  |  Volume : 14  |  Issue : 11  |  Page : 839-852

Gastro-Intestinal Oncology


Date of Web Publication29-Nov-2018

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How to cite this article:
. Gastro-Intestinal Oncology. J Can Res Ther 2018;14, Suppl S4:839-52

How to cite this URL:
. Gastro-Intestinal Oncology. J Can Res Ther [serial online] 2018 [cited 2019 Nov 18];14:839-52. Available from: http://www.cancerjournal.net/text.asp?2018/14/11/839/246376




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Prospective assessment of migration, quality of fiducial placement, complications and acceptability of fiducial placement in liver tumours for robotic radiosurgery based SBRT treatment

Kaushik J. Kataki, Ajinkya Gupte, Ram Madhavan, Haridas Nair, P. G. Shalet, J. Jishan, Raghavendra Holla, Debnarayan Dutta

Background: Assessment of migration, ‘quality’ of fiducial placement, complications and acceptability of fiducial placement in liver tumours for robotic radiosurgery based SBRT treatment. Materials and Methods: Prospective evaluation of fiducial placement related parameters in liver tumours treated with SBRT. Efficacy of fiducial placement under image guidance for cyberKnife treatment as measured by appropriateness in placement of fiducials. I) Fiducial placement actual and planned position variation, II) Any episodes during fiducial placement. Fiducial related events on patients. During CyberKnife treatment execution, impact of fiducial placement will be evaluated. ‘Correlation factor’ need to be at least 40% for al patients. ‘Ease’ of matching of the fiducials, treatment time, and interruptions during treatment because of fiducial mis-match, and required proportion of additional (unplanned) images for fiducial matching will be analyzed. Results: Thirty-three patients with primary liver tumour (HCC) accrued after informed consent and were evaluated. All the patients had at least three fiducial placed under USG/ CT scan guidance. CT scan imaging for migration assessment done at day of fiducial placement (D0), day-3 and on Day-8. Majority of the patients had minimal pain score after fiducial placement, and subsided with medication. One patient (2.6%) required admission and supportive care. Gross migration / displacement was observed in two patients immediately after placement (Day-0). Migration on day 3 & 8 from day-0 were minimal. Migration range at follow up assessment (Day-3 & 8) was 1.93-3.08 mm (Mean migration 2.33 mm). Duration of fiducial placement was 20 min (range 10-38 min). ‘Quality of fiducial placement’ were assessed and scored by radiologist & radiation oncologist. Fiducial migation did not impact the treatment delivery. Inter-fractional migrations were ranging from 0.01 to 0.4 mm. Conclusions: Fiducial migration after proper placement has minimal impact on treatment delivery. Migration occurs mostly during first three days of placement. There was minimal migration in intra-fraction assessment. Post-fiducial placement, treatment may be started within 2-3 days. Role of ‘wait’ for settlement of fiducial migration beyond three days has no clinical justification.


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Dosimetric comparison of hybrid intensity modulated radiotherapy versus hybrid volumetric modulated arc therapy in carcinoma middle 1/3 esophagus as preoperative radiotherapy with or without chemotherapy – A single institution prospective study

Chaitanya Medichelme, Charu Garg, Kartikeswar Patro, Anil Kumar Anand, Naveen Kumawat

Department of Radiation Oncology, Max Cancer Center, Max Super Speciality Hospital, New Delhi, India

Introduction: Radiotherapy has a major role to play in treatment of esophageal carcinoma. However, it presents a particular challenge in treatment planning, especially for the middle third esophagus. The tumor is centralized and surrounded by several organs at risk(OARs): the lungs, heart and spinal cord. Innovative technologies in radiation delivery such as IMRT) and VMAT have successfully achieved good tumor dose while sparing OARs. But these approaches generally produce widely distributed low dose levels thus necessitating need of hybrid approaches. Purpose: To dosimetrically compare Hybrid VMAT vs Hybrid IMRT planning in carcinoma middle third esophagus to tumor and surrounding OARs with pre operative radiotherapy with or without chemotherapy. Materials and Methods: 25 patients of carcinoma mid esophagus in various stages [I-III] were treated with preoperative radiotherapy with or without chemotherapy from June 2015 to September 2016. The prescribed dose was 4500 cGy in 25 fractions and planning was done on Eclipse Planning system. Hybrid plan included 9Gy in 5fractions by AP-PA fields and 36Gy in 20fractions by either IMRT or VMAT technique. Both Hybrid plans were generated in all cases and Dose Volume Histogram (DVH) comparative analysis was performed for PTV and OAR. Paired t test was used for statistical analysis. Results: The PTV D95 was 43.48±0.3Gy and 43.37±0.45 in Hybrid IMRT and Hybrid VMAT [p= 0.219].PTV V95% was better in Hybrid VMAT plans i.e, 93.94±19.41% as compared to Hybrid IMRT plans i.e, 92.58±19.13% [p=0.003]. Hybrid VMAT plans had significantly better HI with value of p=0.003 with values of 0.0759±0.131 with Hybrid VMAT and 0.0852±0.097 in Hybrid IMRT. However, CI was comparable in two plans, Lung V5Gy% was 84.92±11.41% with hybrid IMRT and 88.16±10.12% with Hybrid VMAT [p=0.03]. Whereas MLD and V20 were 16.39±1.77Gy and 28.64±4.92% in Hybrid IMRT as compared to 15.95±1.68Gy and 26.13±4.61% with Hybrid VMAT [p=0.0001 and.004 for V20% and MLD respectively]. There was 8.76% in V20 and 22.2% reduction in MLD respectively with Hybrid VMAT. Doses to heart were also reduced with Hybrid VMAT but not statistically significant and spinal cord doses were comparable. Treatment time was significantly reduced with Hybrid VMAT [2min] than Hybrid IMRT [3.6min] p=0.0001. Conclusion: Hybrid VMAT can be a better option in treating mid esophageal carcinoma as compared to Hybrid IMRT. The VMAT plans result in equivalent or superior dose distribution to target volumes with a reduction in MLD, V20 lung and V36 heart. It has less treatment time thus improving patient comfort and reducing intrafraction errors. These advantages of VMAT comes at the cost of increased low lung doses [V5].


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Dosimetric evaluation of tumor cytoreduction during radiotherapy for esophageal carcinoma to identify optimal criteria for adaptation

Kurian J. Puthur, Bindhu Joseph, Vinay Desai, C. R. Vijay, V. Lokesh

Objectives: Primary objectives: To evaluate the comparative potential reduction in cardiac and lung dose when introducing elective replanning at 20 Gy and 40 Gy. Secondary objective: To identify potential predictive parameters for adaptation. Materials and Methods: All the patients were planned to receive 50.4Gy/ 28 fractions of preoperative radiotherapy with concurrent weekly Paclitaxel and Carboplatin. Each patient was individually planned for 3DCRT and IMRT plans at baseline after 20Gy and after 40Gy. Dosimetric comparison of the primary plan was done with the adapted plan at 20Gy and 40Gy. The target volume parameters of GTV reduction, PTV coverage and normal tissue parameters of V30 and mean dose for heart, V20 and mean dose for individual lungs, V5 for both lungs were compared. The predictive parameters of primary tumor volume and histopathological grade were compared. Results: In total, 20 interval adaptive plans were evaluated. The most significant reduction in primary tumor volume and PTV was observed at the end of 2 weeks of treatment(20Gy). The mean percentage reduction of size of primary tumor was 28.6% at 20Gy(13.86+/-7.5505) compared to only 15.8% at 40Gy(7.84+/-10.3995) (p=0.001). The reduction in radial diameter of primary tumor[14.6%(0.639+/-0.36) vs 11.1%(0.429+/-0.374), p= 0.001] and PTV(17.6% vs 14.3%, p=0.001) was correspondingly significant. There was no significant observed difference for mean dose to the heart for adaptation at 20Gy(p=0.229) and 40Gy(p=0.142). However, we did observe a significant reduction of individual lung volumes receiving 20Gy(V20) at adaptive replanning at the second week of treatment(p=0.03) compared to adaptation at 4th week of treatment. The IMRT plans showed identical patterns of dosimetric correlation of heart and lung toxicities. IMRT plans showed a reduction in V30 (48.9%) and mean dose (25.2%) to heart compared to 3DCRT plans. However, doses to lungs were not significantly different. Conclusion: There is a significant reduction in primary tumor that is maximum at 2nd week of treatment. Adaptive replanning at 20Gy will give us the benefit of reduced toxicity to lungs and even though may not significantly reduce heart dose, will give a more realistic estimate of the actual dose received by the heart. This would help us to anticipate and correlate cardiac toxicity with the actual plan delivered. With image guidance, IMRT will be the preferred treatment of radiotherapy delivery in carcinoma esophagus for optimal cardiac and pulmonary sparing.


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Dosimetric comparison of three-dimensional conformal radiotherapy, intensity modulated radiotherapy and RapidArc (Volumetric Modulated Arc Therapy) in patients with rectal carcinoma receiving postoperative Chemoradiotherapy

Teena Nelson1, Judith Aaron1, Jenny Joseph1, Jose Tom1, Johny K. Joseph1, Biju P. Thomas2, Ajitha Sasi3

1 Department of Radiation Oncology,2 Medical Physics, Department of Radiation Oncology, Caritas Cancer Institute,3 Statistician, Caritas Hospital, Kottayam, Kerala, India

Aims and Objectives: A major outcome of treatment in rectal cancers has been the achievement of local control. It significantly increased with the advent of total mesorectal excision and pelvic radiotherapy. The present concern is to reduce toxicities while maintaining or improving local control rates. Unlike in neoadjuvant chemoradiotherapy, larger volumeof tissue (postoperative bed) and more of small bowel loops get irradiated in postoperative setting. The chance of bone marrow suppression is also higher as patients have already undergone 6-8 courses of adjuvant chemotherapy. Hence, the aim of this dosimetric study is to assess the technique of radiation (3DCRT/ IMRT/ RapidArc) that can efficiently deliver increased dose to target while reducing dose to organs at risk in rectal cancer when treated with postoperative chemoradiotherapy. Materials and Methods: 10 postoperative patients with locally advanced rectal cancer were selected retrospectively. Dose prescription to planning target volume was 50.4 Gy in 28 fractions. Three-field/ four-field 3DCRT, seven-field IMRT and Double Arc-RapidArc plans were generated and optimised (PTV V95>95% and bowel bag V45<195 cc) on Varian Eclipse Version 13.6. Data regarding dose to target volume and organs at risk for all the three plans were obtained from dose-volume histograms and compared. Conformity index was calculated and monitor units were also recorded. Comparison between the groups was done using the one-way ANOVA test and a p value <0.05 was considered significant. Results: The target coverage assessed by CTV D98 and conformity index were higher with RapidArc when compared to 3DCRT (p=0.001 and p=0.008 respectively) and IMRT (p=0.298 and p=0.021 respectively) for phase 1 CTV. The same was observed for CTV D98 of boost volume (p=0.042 and p=0.794 respectively). However, the comparison between the techniques for phase 2 conformity index was not statistically significant. For organs at risk doses with IMRT and RapidArc were lower than 3DCRT plans. Mean V45 of bowel was 13.2±28.6, 0.995±4.0, 1.6±6.6 in 3DCRT, IMRT and RapidArc respectively. Significant reduction in V40 of bladder (p=0.021 and p=0.104 respectively), dose maximum of bladder (p=0.016 and p=0.011 respectively), V20 0f bone marrow (p=0.008 and p=0.002 respectively), V30 0f bone marrow (p<0.001 for both), V40 of bone marrow (p<0.001 for both) were seen with IMRT and RapidArc plans. The maximum and mean doses to right and left femoral heads were also significantly lower with IMRT and RapidArc. Monitor units was lower in RapidArc technique. Conclusions: This study shows that RapidArc provides the maximum target coverage with better conformity index. Organs at risk are spared effectively by both IMRT and RapidArc when compared to 3DCRT, especially at doses that have already been proven to be associated with toxicity (V40 of bladder, V20 of bone marrow and V45 of bowel). RapidArc plans had lesser monitor units when compared to IMRT. It can be concluded that, with shorter treatment time, RapidArc can be considered to be a better radiation technique for postoperative rectal cancer patients.


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Tolerance and toxicity of paclitaxel and carboplatin in definitive chemoradiation in carcinoma oesophagus

Joneetha Jones, N. V. Vinin, M. Geetha, E. K. Nabeel Yahiya

Department of Radiation Oncology, Malabar Cancer Centre, Talassery, Kerala, India

Introduction: Oesophageal cancer accounts for eighth most common cause of cancer worldwide. Trials have shown that the 3-year survivalrate for patients with localized oesophageal cancer after chemoradiotherapy was typically in the range of 15% to 30%. Cisplatin-based chemoradiotherapy (CRT) has always been utilized in the definitive treatment of patients with locally advanced oesophageal cancer. Based on the results of the landmark study conducted by the Radiation Therapy Oncology Group (RTOG 85-01) concurrent chemoradiation has become the standard of care for patients with locally advanced diseaseIn all these trials, cisplatin-based regimens were employed. However, cisplatin is cumbersome to use as prolonged intravenous hydration is required. In addition, cisplatin is a relatively toxic drug with a high incidence of nausea/emesis and renal dysfunction. Paclitaxel has demonstrated significant activity in oesophageal carcinoma, with a 32%response rate in patients with metastatic or locally advanced disease. Carboplatin an analog of cisplatin has activity similar to cisplatin in a number of tumour types and it provides several practical advantages over cisplatin. Carboplatin, given together with paclitaxel, appears to have anticancer activity in esophageal cancer. Aim: To find out the tolerance and toxicity of paclitaxel and carboplatin used in concurrent chemo radiation in carcinoma oesophagus. Materials and Methods: This was a retrospective study of patients who underwent definitive concurrent chemoradiation for carcinoma oesophagus from January 2013 to January 2018 at our centre. Case records and radiation charts were reviewed and data was collected. All patients who underwent radical chemoradiation with paclitaxel at a dose of 50mg/m2 and carboplatin AUC 2 weekly was included in the study. Results: A total of 32 patients underwent radical chemoradiation with paclitaxel and carboplatin during the study period. The median age of the study group was 64 years. 27 were males and 5 were females. All had squamous cell carcinoma histology. Median length of the lesion was 5 cm. The most common site was mid oesophageal lesions which was about 62 % of total cases followed by lower oesophageal lesions. All patients were treated with 50.4Gy in 28 fractions.6% of patients completed 6 cycles of chemotherapy as planned and 46% completed 5 cycles. Two patients had grade 3 neutropenia. No other grade 3 or 4 toxicity was recorded. Conclusions: The combination of carboplatin and paclitaxel is a feasible treatment option for patients with oesophageal cancer in concurrent chemoradiation with close monitoring for toxicities.


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Role of diffusion weighted magnetic resonance imaging for predicting response to neoadjuvant chemoradiotherapy in esophageal cancer

Neenu Oliver John, I. Aparna, Vijay Abraham, Subhashini John, Simon Pradeep Pavamani

Department of Radiation Oncology, Christian Medical College, Vellore, Tamil Nadu, India

Aim and Objectives: To study the role of diffusion weighted magnetic resonance imaging (DW-MRI) for predicting clinical and pathologic response to neoadjuvant chemoradiotherapy in patients with locally advanced esophageal cancer. Materials and Methods: This is a prospective cohort study conducted in our institution comprising24 patients with biopsy proven, locally advanced esophageal cancer, planned for neoadjuvant chemoirradiation between 2015 and 2017. All the recruited patients underwent a baseline DW-MRI before initiation of chemoirradiation, interim scan at 10 to 14 days and the third scan at the end of radiation. DWMRI is a novel imaging technique which studies the movement of water molecules across cellular membranes. We hypothesized that response to NACRT could be assessed by the changes in the diffusion restriction of the tumor tissue. The Apparent Diffusion Coefficient (ADC) values and the ΔADC values were calculated and were correlated with the treatment response. During assessment for surgery, the patients who were deemed surgically inoperable were called as non-responders. Among those who were operated, patients with complete pathological response (pCR) or near complete response were called responders and those with a poor response non-responders. Pathological poor response was defined as Tumour Regression Grade 2 or 3 according to the American College of Pathologists grading system for tumor regression. Results: Twenty-seven patients were screened and twenty-four were included in the study. Two patients defaulted treatment during the course of chemoirradiation. About 6 weeks after completing neoadjuvant chemoirradiation, all the remaining 22 patients were assessed for operability. Three patients were deemed inoperable. Among the 19 patients who were operated 11 patients were found to be responders whereas 8 patients were found to be non-responders. Most of the patients(14 patients (58.33%)) were treated with 3DCRT technique whereas 5 patients (20.83%) were treated with IMRT and other 5 patients (20.83%) were treated with 2D (Linac / Cobalt-60) technique. Out of 24 patients, 16 of them (66.6%) were planned for 45 Gy in 25 fractions whereas 8 patients (33.35) were planned for 41.4 Gy in 23 fractions. The mean v95 to the PTV was 95.6% (87.25 - 97.35%). The ADC values measured in the interim scan was significantly higher among patients with pathological responders compared to the non-responders (mean ADC 2675.57 vs 1868.5; p=0.013). Conclusions: These results show that serial DW-MRIs performed in patients undergoing chemoradiotherapy is feasible and may be used to predict treatment response at surgery. Also, a significant rise in ADC values in the interim scan obtained at 10-14 days, may predict a pathological complete response at surgery.


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Impact of dose escalation with endorectal brachytherapy boost in achieving complete clinical response in rectal cancer managed by the “wait and watch” approach

Prashant Nayak, Reena Engineer, A. Dheera

Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Aims/Objectives: Observation after chemoradiotherapy in rectal cancer following complete clinical response has emerged as a management option with excellent oncological outcomes. Few studies have shown that giving additional radiotherapy boost leads to increased local tumour response. In this study, we aimed to use brachytherapy boost post neoadjuvant chemoradiation (NACTRT, in an attempt to increase the number of patients amenable for ‘wait and watch’ without significantly increasing late toxicities. Materials and Methods: Consecutive patients with T2-4 N0-2 M0 rectal cancer who started radical intent NACTRT between October 2017 and May 2018 were analyzed retrospectively. External beam radiotherapy consisted of 3D-CRT or IMRT to a dose of 45 to 55.8 Gy (1.8 to 2 Gy per fractions), to the primary and nodal regions along with daily capecitabine (825mg/sqm). Treatment response was evaluated by digital per rectal examination (DRE) and those with only a residual ulcerative lesion, no greater than three-fourth circumferential involvement and palpable cranial extent, considered reliable for follow up were given the option of further boost. A planning MRI scan with a multiple channel vaginal applicator in place was taken within 2 to 6 weeks of NACTRT completion. The residual tumour / fibrotic regions were contoured (CTV), dose prescribed at 8 to 10 mm from applicator surface and isodose distribution generated for 2 to 3 channels in closest proximity to the CTV. Coverage of the CTV by the 95% isodose cloud was ensured while limiting the doses received by the opposing rectal wall to less than 50%. High dose rate brachytherapy was delivered with iridium-192 source in 2 fractions of 4 to 6 Gy each, one week apart. Patients with an incomplete clinical response at 6 to 12 weeks as evaluated on DRE, rectal MRI and direct endoscopy were sent for immediate surgery, while those with a complete (CR) or near complete clinical response (NCR) were observed. Results: In all, 66 patients underwent NACTRT in the given period. 21 patients received brachytherapy boost with a median follow up of 27 weeks. 1 patient defaulted immediately after brachytherapy completion. Of the remaining 20 patients, 5 (20%) had residual disease at 12 weeks and were advised surgery while 15 (75%) had CR or NCR. Subsequently, 1 patient with NCR underwent transanal local excision in view of persistent ulcer at 18 weeks. 14 patients (70%) are currently on observation for non-operative management. There were no regional or systemic relapses. No late toxicities were observed, granting short duration of follow up. Conclusion: Dose escalation by endorectal brachytherapy boost is feasible and can increase the rate of complete response in a select group of patients, subsequently allowing organ preservation. Longer follow up and a larger sample size would be required to evaluate the progression free interval, relapse rate and long-term toxicities.


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Esophageal cancer: Experience with trimodality treatment approach

P. V. Arunmohan, kirthi Koushik, Arul Ponni, Mohan Kumar

Objective: To analyse the treatment response and outcomes of esophageal cancer treated with neoadjuvant chemoradiation followed by surgery. Materials and Methods: Retrospective analyses of patients treated with neoadjuvant chemoradiation followed by surgery for carcinoma esophagus at our institution between 2014 to 2018 were carried out. Patients received either weekly administration of paclitaxel and carboplatin with RT to a dose 41.4 Gy in 23 fractions or 3 weekly cisplatin and 5FU with 45 Gy in 25 fractions followed by surgery (either transthoracic or transhiatal approach). Tumor location, duration between neoadjuvant treatment and surgery, histopathology response were collected in a structured format. The outcome and cause of death were analysed till the date of analysis. Results: A total of thirteen patients underwent treatment(7:female; 6:male). The median age was 56 years (45-66years). Tumor was located in middle one third in 4 patients and lower one third in 8 patients and middle onethird to lower one third junction in 1 patient. 38.46% patients had complete response, 46.15% partial response and 15.38% had progressive disease. 69.23% patients were alive at the time of analysis. Conclusion: Neoadjuvantchemoradiotherapy followed by surgery in locally advanced oesophageal /GEJ cancer patients is a well tolerated approach. More stringent following of inclusion criteria may further improve the outcome & compliance.


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“How long is too long” The ideal gross tumor volume length for delivery of radical radiation therapy in carcinoma esophagus

Goutham Sunny, Solly Thomas, Manu Mathew, Rajesh Isiah, Subhashini John, Simon Pavamani

Department of Radiation Oncology Unit II, Christian Medical College, Vellore, Tamil Nadu, India

Background: The role of radiation therapy in the management of carcinoma esophagus is no longer debated. The long-term results of the CROSS trial from the Dutch group published in 2015 had established the role of neoadjuvant chemoirradiation in survival benefit. Previous trials like the Intergroup 0123 and RTOG 8501 had established the role of radical chemoirradiation and its benefit while delivering a much higher dose than in the neoadjuvant setting. While CROSS trial mentions a length of tumor greater than 8 cm as an exclusion criteria while delivering 41.4 Gy; the published literature does not mention the ideal length that could be treated while meeting the OAR constraints. This prompts us to ask the question “What is the ideal gross tumor volume (GTV) length to be considered for Radical Radiation in inoperable carcinoma esophagus?” We try to answer this question by analyzing our retrospective patients, dose delivered and constraints met. Materials and Methods: All Patients who received radiation with radical intent between January 2015 and August 2018 was analyzed. The demography, tumour characteristics, baseline imaging characteristics, radiation technique, dose delivered, chemotherapy details, organ at risk constraints and progression free survival were collected. An ROC curve analysis was done to identify the ideal GTV and PTV length where full dose of RT was delivered. For Bayesian analysis, the GTV length of 8 cm was taken as standard and predictive modelling was done to identify probability of full dose delivery with varying GTV lengths. Results: A total of 31 patients underwent radical irradiation for inoperable disease. There were 20 males and 11 females in the cohort with an average age of 59.2 years. The histology for 30 patients were squamous cell carcinoma and one was Poorly differentiated adenocarcinoma. The mean GTV length was 8.048 cms and mean PTV length was 17.91 cms. The mean lung volume was 2455.15 cc and mean Lung – PTV volume was 2414.25 cc. The dose delivered varied from 45 Gy to 63 Gy. Assuming 59.4 to 60 Gy as full dose, 19 patients received full dose and 12 patients did not. 26 patients received neoadjuvant or concurrent chemotherapy. ROC curve analysis revealed that 8.575 cm was the ideal length at which full dose could be delivered with a sensitivity of 70% and specificity of 62%. 2110 cc was the critical lung volume which permitted delivery of full dose of RT with a sensitivity and specificity of 70%. Applying Bayesian theorem, a formula was devised to identify the sensitivity and specificity with which it could be predicted whether delivery of full dose was possible with each 0.5 cm increment in GTV length. Conclusions: The length of GTV and Lung volume were the critical determinants to the dose delivered to esophagus while delivery of radical dose was attempted. It would be beneficial to identify patients early for whom radical RT is not feasible to prevent wastage of manpower and resources. A predictive algorithm for same would contribute in this regard.


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Imapact of Histology on Recurrence and Survival after Neoadjuvant Chemoradiotherapy of Esophageal Cancer: A Retrospective Single Institution Study

Manjinder Singh Sidhu

Objective: To determine the impact of histology on survival outcomes and recurrence patterns in patients with esophageal cancer (EC) who received neoadjuvant chemoradiotherapy (CRT). Methods: Between 2011 to 2016, 36 patients who underwent neoadjuvant CRT followed by esophagectomy were retrospectively reviewed, including 26 patients with SCC (72.22%) and 10 patients with adenocarcinoma (27.77%). Pathologic response, survival, recurrence pattern were compared. Results: Pathologic complete response (pCR) rate was significantly higher for SCC compared with adenocarcinoma (19.2% vs 10%). After a median follow-up of 25 months, we observed 10 patients (38.5%) with SCC versus 5 patients (50%) with adenocarcinoma had recurrent disease. We further analysed difference in recurrence pattern, sites of recurrence and survival end-points between the 2 histology subtypes of two groups for patients who achieved pCR Vs non-pCR. Conclusions: SCC was associated with a significantly higher pCR rate than adenocarcinoma. Recurrence pattern and survival outcomes were significantly different between the 2 histology subtypes in non-pCR patients.


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Definitive concurrent chemo radiation with a dose escalated regimen of radiation treatment for Stage I-III squamous cell carcinoma of oesophagus: A prospective observational study

J.S Lakshmi, Aswini Lakshmaiah, Beena Kunheri, Ram Madhavan, Haridas M. Nair

Department of Radiation Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Background: Treatment outcomes of carcinoma oesophagus continue to be poorer. In an attempt to improve results, various techniques have been tried, including the increasing dose of radiation, performing curative intent surgery after chemo-radiation therapy, and addition of intra luminal brachytherapy. Aim: In this prospective study, we evaluated the local response, toxicity survival and quality of life (QOL), following dose escalated radiation therapy with concurrent chemotherapy, in patients diagnosed with stage I-III, squamous cell oesophageal carcinoma, who were either unfit or refused surgical intervention. Materials and Methods: This is a prospective observation study of patients diagnosed with SCC of oesophageal who were treated with radical intent dose escalated radiation (total radiation dose of 6000cGy in 30 fractions) and concurrent chemotherapy during the period august 2015 to august 2017. A total number of 20 patients of age group 18-75yrs, KPS >80, pathologically proven carcinoma of thoracic oesophagus of Stage I-III were included. Local response, toxicity, survival following dose escalation were studied. QOL was assessed using FACT E questionnaire. For all the patients, Radiation Treatment planning with 3DCRT using 6MV and 15 MV photon combination were carried out. The radiation fields were AP, PA with posterior obliques. Three phase treatment with volume reduction was done. All patients received cisplatin with or without 5 Fu on week 1,5,8 and 11. Results: Patients median age was 64yrs [24 yrs to 74 yrs]. KPS score of most of the patients was above 80 and majority had grade 2 dysphagia according to oral intake scale. Two thirds of population in the study had tumor in middle thoracic oesophagus. Eighty five percent had complete response at 3 months, following completion of radiation. The acute radiation reactions oesophagitis or stenosis (10%), resolved by initial 3 months. QOL comparison pre and post treatment showed improvement in 85 % of patients. A longer followup may predict the long term effects of radiation. Conclusion: High radiation dose was relatively safe, well tolerated and is effective in achieving good local control. The implementation of external beam radiation therapy, with reduced treatment volume reduces the sequalae of radiation.


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Changing trend in the age of presentation for colorectal cancer

Shashank Joshi, Paramjeet Kaur, Ashok K. Chauhan

Department of Radiation Oncology-II, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Introduction: Colorectal cancer is the third most common cancer worldwide and fourth most common cause of cancer related deaths in the world. It is the third most common cancer in men (10 % of all) and second most common in women (9.4 % of all). In India, the incidence is lower and is ninth common in men (4.1 per 100000) and does not fit in top 10 cancers (3.9 per 100000). Colorectal cancer is a cancer of old age, mostly occurring after fifth decade of life. But recently the incidence is increasing in young age, especially in developing countries and is associated with poor prognosis. Aim and Objective: The aim was to assess the demographic and clinical details of patients with colorectal cancers and compare in terms of age at presentation. Materials and Methods: A retrospective analysis was done in the Department of Radiation Oncology -II, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana from January 2016 till December 2017. Sixty three patients were diagnosed of colorectal cancer out of total patients registered. The age ranged from 16 - 82 years. Male: female ratio was 32: 31. Eight patients were of early stage colorectal cancer (I and II) while the rest (55) were of locally advanced and metastatic type. Results: The age wise stratification of the data showed:three patients (<20years), five patients (20-30 years), five patients(30-40 years), twelve patients (40-50 years) and thirtyeight patients (>50 years). The mean age of presentation was 49 years. Twentyfive patients (40 %) were having age <50 years, while thirty eight patients (60 %)were of age >50 years. Sixteen patients had metastasis at the time of presentation among which six patients had age 30-50 years, and rest ten patients had age >50 years. Among age <50 years, only three patients had early stage disease while sixteen had locally advanced and six had distant metastasis at the time of presentation. Male: female ratio for age < 50 years was 15: 10. Among age > 50 years, five patients had early stage disease, twenty three patients had locally advanced disease and ten had distant metastasis at the time of presentation. Male: female ratio for age > 50 years was 17: 21. Conclusion: Incidence observed was higher in younger age group in patients of colorectal carcinoma which usually presented as aggressive and metastatic disease. Therefore, screening program should be considered in patient with high risk at early age.


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IMRT reduces acute toxicity, improves compliance and outcomes in anal canal cancer: A pilot study

Ramesh Kumar, Neeraj Rastogi, Shagun Misra, Shaleen Kumar

Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Purpose: To compare acute toxicity, compliance and outcome of anal canal cancer patients treated with 3DCRT vs IMRT. Methods: We audited data of anal canal cancer patients who were treated in our institute over 6-year period with 3DCRT technique (Cohort I) and compared with patients treated with IMRT (Cohort II) in a prospective protocol over a one year period. Those treated with 3DCRT (received RT alone or concurrent chemotherapy using 5FU+Cisplatin or 5FU+Mitomycin while all patients with IMRT received concurrent Capecitabine with Mitomycin. All toxicity graded by CTCAE version 4.0. Differences in mean and proportions were calculated using independent t-test and chi square test respectively. Kaplan Meier method was used to estimate probability of survival. The patient who lost to follow up with or without disease were considered as event, assuming the worst case scenario. Results: From 2009-2015, 58 anal canal cancer patients were registered and, 48/58 patients were treated with radical intent in Cohort I[n=48] while in 2016-2017, 11 patients were registered and 8/11 were treated with radical intent in Cohort II[n=8]. Patient characteristics were different in cohort I and cohort II respectively such as mean age (58 ± 12 vs 50 ± 11.8, p=0.088), T3/T4 (50% vs 62%, p=0.457), N+ status(45.8% vs 12.5%, p=0.058) and stage III disease (45.8% vs 12.5%, p=0.059). In Cohort I 43/48 (89.5%) received chemoradiotherapy (CTRT) while all patients (100%) in Cohort II received CTRT. Planned treatment was incomplete in higher proportion in cohort I (Cohort I vs II: 25% vs 0%, p=0.040). Overall treatment time should be less than 42 days but were more in Cohort I(Mean 51.8 days + 10.4 days) and Cohort II(Mean 50.1 days + 4.6 days). In patients who completed treatment, 42% had treatment gaps >5 days in Cohort I[n=48] vs 75% in Cohort II[n=8]. Most common toxicity responsible for incomplete treatment was GI toxicity(all grades) seen in 22/48 patients (45.8%), all these patients had received concurrent 5FU+MMC in Cohort I. Skin reaction >grade3 (Cohort I vs II: 70% vs 12.5%, p=0.096), gastrointestinal toxicity >grade3 (Cohort I vs II: 34% vs 12.5%, p=0.09) and haematological toxicity >3 (Cohort I vs II: 20.8% vs 12.5%, p=0.58) were lower in IMRT arm. Treatment deaths were higher in cohort II(25% vs 12.8%, p=0.41). Clinically complete response after 12 weeks of treatment was higher in Cohort II(52.3% vs 87.5%, p=0.038). Median OS was 17 months (95% CI: 6-28) in cohort I while it was not reached in cohort II. The overall survival at 2yrs in Cohort I vs II: 30.8% vs 87.5%(p=0.072). Conclusion: IMRT with oral capecitabine and mitomycin is safe and tolerable with improved compliance and outcomes.


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Defining a new standard of preoperative chemoradiation in operable stomach cancers

Y. Susheel Kumar, Rajneesh Singh, Shagun Misra, K. J. Maria Das, Shalini Singh, Senthil Kumar, Shaleen Kumar

Purpose: In the context of clinically operable gastric adenocarcinomas (AC), the perioperative strategy of epirubicin-cisplatin-capecitabine (ECX) chemotherapy (CT) (MAGIC protocol) is one accepted and doable strategy. Motivated by the improved pathologic complete responses seen in esophageal and junctionaltumors with the addition of pre-operative chemo-radiotherapy (CRT), a similar strategy incorporated into the MAGIC protocol is currently under investigation for gastric cancers (TOPGEAR protocol). The safety and feasibility of a phase II study undertaken in an unselected, consecutive patient population is reported. Methods: Prospectively registered patients, age >18yrs with potentially resectable AC of the stomach/Siewert type II/III, stage IB-IIIC on radiology (CECT abdomen) and deemed operable after discussion in multidisciplinary joint clinic were accrued in the study. Staging laparoscopy and FDG-PET study were not performed for reasons of cost containment. Patients were planned to receive 2 cycles of CT, Cisplatin 60mg/m2 Day1 and Capecitabine 625mg/m2 bid Day 1-21 (CX) at three-weekly intervals pre-operatively, and after a 2-4 week break following CT, CRT (capecitabine 825mg/m2 bid on RT days) was commenced along with IMRT 45Gy/25 fractions delivered to a target identified with 4D-CT imaging. After 6 weeks of the last fraction of RT all patients (with no overt metastatic disease on CECT scan)were to proceed to surgery (Sx). Patients were to receive a further 3 additional courses of CX) within 4-10 weeks after Sx. All patients gave a written informed consent; ethics clearance and approval from institute research committee was taken. Results: Between 01.06.2017 and 31.08.2018, total of 21 patients met inclusion and were accrued in the study. Median age was 60yrs (20-73), median KPS 80, median wt 52 kg (IQR: 45-62), wt loss >10%=7/21 (33%). Most common presenting symptoms were loss of appetite 14/21 (62%), loss of wt 16/21 (72%) and abdominal pain 10/21 (48%). Proximal gastric and Junctionaltumors were 11/21 (52%). The disease was staged either T2 or T3 in all and 17/21 (81%) were node positive as on CECT scan. All completed the first cycle of CT and 18/21 (85%) patients received 2 cycles of NACT, two with dose reduction 2/21 (9.5%). Grade 3 or higher toxicity was seen in 5/21 (23.8%); commonest was vomiting 2/21 (9.5%). Six of 21 (28.5%) patients have completed RT till date. Median duration from NACT end to RT start was 5.5 (2-22) weeks, major deviation (> 6 weeks) was seen in 3/6 (50%), Grade 3 and 4 toxicity was not observed during RT, one patient died 1 week after RT completion. Median duration of RT was 5.3 weeks (5-6 weeks) with no deviation. Four patients have undergone Sx, median duration of 6.8 weeks (6-7 weeks) from end of CRT to Sx. Pathological complete response (pCR)was seen in 1 /4 (25% patients); 2/4 patients (50%) had ypN0. None had evidence of peroperative dissemination. Postoperative complications were seen in 1/4 (25%) patient -delayed wound healing and anastomotic leakage. Adjuvant chemotherapy, 3 cycles was completed by 1 patient. The first 11 patients had poor compliance with 4/11(36%) lost to follow up due to finances/poor motivation and 3/11 (27%) patients had progressive disease while only 4/11 (36%) patients proceeded to Sx. 1 patient died following RT- sudden collapse, cause unclear. The accrual rate was 1 patient /month. The latter 10 patents had quicker accrual - 4patients / month and better compliance (none lost to follow up), and nonehad disease progression during CT and all 10 are awaiting/undergoing RT. Conclusion: Accrual and complianceof patients to this protocol improved over time- a learning curve was seen. Toxicity was acceptable with a pCR in1 out of 4. The protocol is doable and safe, but poor financial support, motivation and disease progression (chemo-selection) in a relatively unselected group of patients inform real world scenarios in a public sector hospital.


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A prospective phase II study to assess the pathological complete response rate with preoperative short course radiotherapy followed by chemotherapy in locally advance rectal cancer

Shashank Bansal, Mouchumee Bhattacharyya, Apurba K. Kalita, Partha P. Medhi, Ghritashee Bora

Aims and Objective: The primary aim of the study was to evaluate the pathological complete response rates in locally advance rectal cancer patients receiving preoperative short course radiotherapy followed by chemotherapy. Materials and Methods: From January 2018 to March 2018, ten patients diagnosed with locally advance rectal cancer, scheduled for neoadjuvant chemo-radiotherapy were selected. Radiotherapy planning was done using 3DCRT technique for a dose of 25Gy/5# followed by four cycles of FOLFOX-4 after 1 week gap post radiotherapy and which was followed by surgery (TME) after a gap of 4 to 5 weeks form the last cycle of chemotherapy. After the completion of surgery post-operative histopathological report was evaluated for the response. Results: Ten patients were enrolled in the study, six were female and four were male, median age of patient was 45.5 years. Nine patients completed the schedule treatment and one patient denied surgery after completion of radiotherapy and chemotherapy. Eight patients have stage III disease and 2 patients have stage II disease at presentation. On preoperative evaluation, nine (90%) had radiological partial response, one (10%) had radiological stable disease, down staging was noted in 4 (40%) patients. one(10%) patient has grade 3 diarrhoea, five patients (50%) have Grade 2 diarrhoea, four patients (40%)have Grade 2 nausea and vomiting, three (30%) patients have grade 2 proctitis, four (40%) patients have grade 2 neutropenia. No post-operative deaths was recorded, low anterior resection with total mesorectal excision was done in 9 patients out of which one (11%) had a complete pathological response and 7 (77%) had partial pathological response, one (11%) has stable disease, R1 resection was done in one patient (11%). Conclusion: Patient compliance with short course radiotherapy is good and no treatment delays were seen, owing to lower Grade 3 acute toxicity rates. This regimen can be an effective alternative to long course chemo-radiotherapy. It's difficult to draw final conclusion from the study as the numbers of patients were less and a large number of patients are required for final validation of results.


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Clinical audit of carcinoma esophagus cases treated in radiotherapy Department of HCG Vadodara

Rahul Misra, Rakesh Jadhav, Pritesh Lohar, Priyanka Das, Pinaki Mahto, Rajeev Bhatt, Sishir Shah, Srikanth

Department of Radiotherapy, HCG Vadodara, Gujarat, India

Objective: To evaluate the response of esophageal cancer patients treated in our department. Materials and Methods: The response of 36 Patients of esophageal cancer treated at HCG VADODARA from 2nd april 2016 2016 to 2nd july, 2018 were analyzed retrospectively. All patients were first seen by a group of surgical, radiation and medical oncologists. The disease was confirmed with a upper GI Scopy and biopsy and were appropriately staged with a CT Thorax and abdomen or a PET CT. After complete staging these cases were discussed in the tumor board and were treated according to the following protocol.

  • Those who were borderline operable or node positive were offered neoadjuvant chemo radiation with 41.4 Gy in 23 fractions @ 1.8 GY per fraction along with concurrent weekly paclitaxel(50mg/m2) and Carboplatin(AUC 2) as per the CROSS PROTOCOL. They were then evaluated for surgery after a month with CT Thorax/PET CT and were then operated. Their Histopathology reports were later analysed
  • Those who had locally advanced disease were considered for Radical CCRT upfront or after Neo adjuvant Chemotherapy. In Radical CCRT they were treated with 50.4Gy radiation in 28 fraction with concurrent chemotherapy in the form of weekly Paclitaxel(50mg/m2) and Carboplatin(AUC 2)
  • Those patients with metastatic disease were offered palliative chemotherapy and palliative radiotherapy if they had significant dysphagia.


Conclusion: Preop chemoradiation followed by surgery is an effective approach as it results in reduced incidence of positive margins, better loco-regional control as shown by the CROSS TRIAL. The same has been replicated in our results with increased negative margins following surgery and no major morbidities. Also in patients with locally advanced disease Radical CCRT with two drug chemotherapy (viz: paclitaxel and carboplatin) is an effective option and results in better response rates. Also the treatment can be tolerated by our patients as well contrary to the practice of giving single agent chemotherapy with radiation. Hence this disease should be treated aggressively as per guidelines to achieve better results.


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To study the factors contributing to testicular dose in rectal cancer patients – Comparison with different treatment delivery techniques and clinical correlation to quality of life

Poorna Chandra Tejaswi, Vinay Desai, S. D. Shamsundar, B. Thejaswini, R. Nanda, K. Aradhana

Background: Radiotherapy is an important part of multimodality treatment in Rectal cancer, either as pre-operative, definitive or as adjuvant therapy. Due to close approximation of testis to treatment field in male patients, it receives either scattered or direct radiation. Hence we studied the factors contributing to testicular dose in comparison with different treatment delivery techniques and its correlation to Quality of life questionnaire pertaining to their sexual activity. Aim: Is to estimate testicular incidental dose in 3DCRT vs IMRT vs VMAT in rectal cancer patients and its clinical correlation with Quality of Life questionnaire pertaining to sexual activity. Materials and Methods: Forty male rectal cancer patients aged between 25 to 50 years who were planned to receive pelvic radiation in supine position to a dose of 45 Gy in 25 Fractions as Neo adjuvant RT followed by total mesorectal resection were included in the study. Planning of 3DCRT, IMRT and VMAT techniques was done for these patients, but received actual treatment in any one technique. Testicular dose, testicular volume, PTV distance from anal verge and PTV volume in each plan was recorded, boost dose was not taken in account for comparison. And finally clinical correlation with QoL questionnaire pertaining only to sexual activity from EORTC-CR29 and FACT-C was done. Results: Majority of the patients belong to stage 3C. The mean tumor length, thickness and PTV volume was 8.9 cm, 1.77cm and 1352cc respectively. Our study showed that mean dose to Right testis and left testis in 3DCRT was 336.23 & 206.65, in IMRT 165.15 & 140.25, in VMAT 209.2 & 229.2 respectively. PTV volume and Testicular volume had significant correlation with the incidental testicular dose received. The QoL analysis for sexual activity was done, for 31 patients who were alive, of which 4 patients did not respond, 27 patients who responded said they have resumed sexual activity without difficulty (score 4). Majority had resumed their normal sexual life after 3rd month post treatment. All patients reported that the main reason for delay in sexual activity was nervousness about disease recurrence. Conclusions: IMRT showed a significant reduction of testicular dose when compared to 3DCRT & VMAT.PTV volume and testicular volume had a statistical significant impact on testicular dose and most of our patients showed that radiation didn't have any impact on their sexual life.
Table 1

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Table 2: Neoadjuvant concurrent chemoradiotherapy

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Table 3: Radical concurrent chemoradiotherapy

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To compare the dosimetric parameters and acute toxicities in patients receiving definitive chemoradiation for carcinoma esophagus by three-dimentional conformal radiotherapy and Intensity modulated radiotherapy technique

Satyabrata Kanungo, Suresh Rout, Tanushree Mishra, Lucy Pattanaik, Sanjukta Padhi, Niharika Panda, S. N. Senapati

Introduction: Esophageal cancer is the fourth common cause of cancer-related deaths in India. The advanced and highly conformal intensity-modulated radiotherapy technique (IMRT) can decrease doses to critical cardiopulmonary organs. Aims and Objectives: To compare the acute toxicity and dosimetric parameters between Intensity-modulated versus 3-dimensional conformal radiotherapy in the definitive treatment of esophageal cancer. Materials and Methods: 20 patients of carcinoma esophagus presented to our institute during the period from July 2017 to June 2018 with good general condition and medically fit were subjected to chemo-radiation with minimum RT dose is 50.4 Gy in 28 fractions. These patients were randomly divided into 3DCRT and IMRT arms. Chemotherapy was administered concomitantly with RT in all patients, consisted of cisplatin 75 mg/m2 + 5-FU 1000 mg/m2 over 4 days at 21 days interval. During treatment, acute toxicities and basic dosimetric parameters were compared between 3DCRT and IMRT arms on weekly basis and then post treatment 4 weekly. Acute toxicities were measured using RTOG 2016 version. Results: The mean radiation dose to lung was 12.6 Gy and 12.2Gy in 3DCRT and IMRT group; mean heart dose were 18.1Gy and14.2Gy in 3DCRT and IMRT groups. Spinal cord Dmax mean were 36.8Gy and 35.1 Gy respectively in both arms. Acute toxicity such as pneumonitis was low in the IMRT group where as other acute toxicities and dosimetric parameters were comparable in both arms. Conclusion: This study showed that when comparing acute toxicities and dosimetric parameters between 3DCRT and IMRT techniques, IMRT showed lower cardiopulmonary toxicities as compared to 3DCRT.


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Treatment outcome in carcinoma oesophagus with chemoradiotherapy

R. Irfan Ul Huq, N. V. Kalaiyarasi, R. Giridharan, Poonkodi

Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India

Aim: To assess the outcome of locally advanced esophageal carcinoma treated with chemoradiotherapy. Materials and Methods: It is a retrospective study of patients who were treated from January 2010 to December 2012 in our institution. 97 patients were included in the study. Treatment schedule includes chemotherapy with cisplatin 100mg/m2 on day 1 and 5 – fluorouracil 1000mg/m2 per day on day 1- 3 were given for two cycles, with concomitant Radiotherapy of 50.4 GY in 28 fractions at 1.8GY per fraction followed by another two cycles of chemotherapy. Response rate and survival rate were assessed. Results: Out of 97 patients, 13 patients defaulted. 84 patients were taken up for study. 50 patients (60%) achieved complete remission and 34 patients (40%) achieved partial remission. The median survival was 15 months. The overall survival rate was 21% at 5 years. Conclusion: For patients with inoperable disease, chemoradiotherapy provides relatively good outcome.


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Is there a role for radiotherapy in advanced gallbladder cancers?

Md. Nawed Alam, S. Agrawal, N. Rastogi, K. J. Maria Das, Punita Lal, V. K. Kapoor, Rajan Saxena

Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India

Purpose: Surgery is the only potentially curative modality for patients with GBC. However, only a minority of patients are eligible for curative-intent surgery because majority present in advanced stage. The standard of care for advanced GBC is Cisplatin and Gemcitabine based chemotherapy. The role of radiotherapy in advanced disease is not defined. Hence we conducted this retrospective study to investigate the role of radiotherapy in advanced GBC. Methods: We retrospectively reviewed data of locally advanced (LA-GBC) and metastatic GBC (M-GBC) registered in Radiotherapy OPD between January 2014 to December 2016. LA-GBC were initially planned for 6 cycles of chemotherapy (CT), either dual agent ([Cisplatin25mg /m2 plus Gemcitabine1000mg/m2, day1and day8, 3weekly] or [cisplatin75mg/m2 (day1) plus capecitabine1250mg/m2 (day1-day21,3 weekly]) or single agent capecitabine (1250 mg/m2 for 21 days, 3 weekly). Radical concurrent chemo-radiotherapy (CTRT) was offered to responders, and good performance status patients (KPS) to a dose of 54 Gy OR palliative RT (20Gy in 5 fractions) to the primary according to physician discretion. Patients with M-GBC were offered single agent chemotherapy or dual agent chemotherapy as above, and some patients received palliative RT (20Gy in 5 fractions) to the primary according to physician discretion. Response to therapy was based on RECIST or WHO criteria according to physician discretion. Overall Survival (OS) and univariate analysis of prognostic factors affecting OS were analyzed by Kaplan Meier analysis. Results: Total 554 patients of GBC were registered, out of which 137 were LA-GBC and 230 were M-GBC. In LA-GBC, median and 2 year survival was 7 months and 8% respectively. On univariate analysis, type of treatment (CT vs CTRT), type of chemotherapy, performance status, nodal status, and response to treatment were statistically significant factors affecting OS. The median OS was 15, 6, 8 and 2 months for patients who received radical CTRT, CT only, palliative CTRT and no treatment respectively (P<.001). It was 8 versus 5 months in those who had KPS more than and less than 80 (P<.001), 11, 7 and 7 months in those who had N0, N1 and N2 nodal status respectively (P=.01), 18, 15, 12 and 6 months in those who had CR, PR, SD and PD respectively (P<.001). In M-GBC, the median and 2 year survival 4 months and 2% respectively. On univariate analysis, factors affecting OS were type of treatment (CT vs palliative CTRT), type of chemotherapy, performance status, number of chemotherapy cycles (< 3 vs more than 3) and response to treatment were significant. The median OS was 7, 4.5, and 3 months for those who received palliative CTRT, CT only, and no treatment respectively (P<.001). It was 4.7 versus 2.8 months in those who had KPS more than and less than 80 (P<.001), 7 months versus 2.9 months for those who received more than or less than 3 cycles CT (p=.001). It was 11.9, 7.8 and 5.4 months in those who had PR, SD and PD respectively (P<.001). Conclusion: The addition of radiotherapy to chemotherapy in responders with good KPS patients is associated with improved survival in advanced GBC. Further studies are needed to determine how best to optimize radiotherapy in these patients.


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Incremental value of esophageal brush cytology in response assessment after chemo-irradiation in esophageal cancer

Shreyasee Karmakar, Naveen Mummudi, Sarbani Ghosh-Laskar, Anil Tibdewal, Prachi Patil1, J. P. Agarwal

Departments of Radiation Oncology and1 Medical Gastroenterology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Background: Locally advanced esophageal cancer are treated with chemo-radiotherapy (CTRT) and have comparable outcomes to that of surgery. Post treatment response assessment includes performing a PET-CT scan, an upper GI endoscopy (UGIE) and histological correlation with biopsy; an esophageal brush cytology may be done in case of stricture post treatment. However, brush cytology has its own limitation and is not the gold standard. This analysis aims to find the incremental value of brush cytology in addition to PET-CT for response assessment. Aim: To determine the correlation between first follow-up PET-CT scan and brush cytology findings in esophageal cancer patients treated with CTRT. Materials and Methods: In this retrospective analysis, 41 patients with Stage II- IV carcinoma esophagus registered in Tata Memorial Hospital between June 2015 and March 2018 treated with radical intent were included. All patients underwent PET-CT and UGIE for initial staging and subsequently for response assessment on follow-ups. Patients with esophageal stricture (disease related or treatment induced) had brush cytology done during UGIE. Patients were treated with either upfront concurrent CTRT or neo-adjuvant chemotherapy followed by concurrent CTRT. Patients with a minimum of 3 follow up visit were analyzed for correlation between PET-CT findings and brush cytology and outcomes. Results: Eighteen female and 23 male patients (median age 59 years; range 31- 79 years) were analyzed. Upper thoracic (19.5%) and middle thoracic (61%) esophagus were more commonly involved than post cricoid (7.3%) or lower thoracic esophagus. Squamous cell carcinoma was the predominant histology (95%); mean RT dose was 60.7 Gy (range 41 to 66 Gy); 2 patients received a combination of intraluminal RT and external RT. Concurrent chemotherapy administered was Paclitaxel and Carboplatin (37 patients), Cisplatin with Etoposide (1 patient); 3 patients received RT alone. On first follow up PETCT, 10 patients (24%) had focal uptake suggestive of residual disease, rest either had a complete metabolic response (12 patients - 29%) or diffuse uptake suggestive of post RT changes (19 patients - 46%). UGIE at first follow up showed stricture in 38 patients and a complete UGIE was possible in 12 patients (29%). A brush cytology was done in 37 patients (90%) and malignant cells were seen in 7 patients (17%). Concordance was seen between PETCT and brush cytology findings: all 10 patients with no uptake on PET and 17/18 patients with diffuse uptake suggestive of post RT changes had a negative cytology; in 9 patients with focal uptake on PET, 6 patients (67%) had malignant cells seen on cytology. Four patients (13%) with discordant findings: findings of cytology were vindicated on further follow up in 3 occasions (75%) and 1 patient had a false negative cytology finding. Conclusion: Within the limitations of a retrospective analysis, we found that brush cytology adds diagnostic value to the findings of PETCT scan, especially in patients with diffuse uptake on PETCT scan, where cytology findings may increase the confidence of the clinician to make a clinical decision.


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Clinical outcomes of definitive chemoradiation in locally advanced oesophageal cancer

J. Parikshith, Dasari Esther Praisy

Aim: Oesophageal cancer is the seventh most common cancer in the world with Age standardised South-Central Asia incidence and mortality of 5.3 and 4.6 respectively per 100,000 population. Definitive Chemoradiation is the treatment of choice in non-surgical candidates with non-metastatic Oesophageal cancer. The two chemotherapy regimens were used, either Cisplatin and 5-fluoruacil (CDDP/5FU) or Carboplatin and Paclitaxel (Carb-Tax). The primary aim was to compare the acute treatment related toxicities such as anaemia, thrombocytopenia, leukopenia and neutrophil counts in both arms as well compare the electrolyte imbalances such as hyponatremia, hypokalaemia and elevated creatinine levels. The secondary aim was to compare Overall Survival (OS), Dysphagia free Survival (DyFS) among both the arms. Methods: 66 patients with biopsy proven Oesophageal carcinoma who were non-surgical candidates and with non-metastatic disease were included in the study who received Definitive Chemoradiation. Patients with Eastern Cooperative Oncology Group (ECOG) Performance Status 0-2 having received a radiation dose of at least 5040cGy by 3 Dimensional Conformal Radiation Therapy (3DCRT), 5 fractions per week were included. Of the 66 patients, 43 received two cycles of three weekly CDDP (70mg/m2 on day 1) - 5FU (750mg/m2 per day from day 1-5) and 23 received at least four cycles of weekly Carb (AUC 2)-Tax (50mg/m2). The primary aim was to evaluate acute treatment haematological toxicities consisting of anaemia, thrombocytopenia, leukopenia and decreased neutrophil counts were observed in both arms with Common Terminology Criteria for Adverse Events (CTCAE) v4.03. Hyponatremia, hypokalaemia and increased serum creatinine levels were also noted as per CTCAE v4.03. The OS was as the time from start of treatment to death in months and DyFS was defined as time to worsening or reoccurrence of dysphagia after completion of treatment. Results: Grade 3 and above Leukopenia was noted in 19 out 43(44.1%) patients receiving Definitive Chemoradiation with CDDP-5FU regimen but 7 out of 23(30.4%) with Carb-Tax regimen. A statistically significant decrease in toxicities was observed (Fischer's exact test value of 7.812, p=0.04). There was no statistical significance with other haematological parameters, electrolyte imbalance and serum creatinine levels. However, there was no significant difference in OS, DyFS among the regimens. Conclusions: Definitive Chemoradiation with Carb-Tax was associated with decreased rates of severe leukopenia and can be safely used as an alternative to CDDP-5FU regimen.


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Preoperative short-course radiotherapy in rectal cancer patients – Experience from tertiary cancer hospital

C. Shamsudheen, Deepak Damodharan, M. Arunlal

Department of Radiation Oncology, MVR Cancer Centre and Research Institute, Kerala, India

Objective: The purpose of this study was to evaluate the clinical outcome after preoperative short-course radiotherapy for rectal cancer patients. Methods: Retrospectively evaluated all patients with pathologically proven resectable rectal cancer, who were treated during August 2017 to September 2018, who underwent preoperative short-course radiotherapy (25 Gy delivered in five fractions), followed by early or delayed total mesorectal excision. Results: A total of 40 patients were treated with preoperative short course radiotherapy, 26 (65%) patients underwent early surgery and 14 patients underwent delayed surgery. 9 out of 14 delayed surgery patients received 3 cycles chemotherapy during the waiting period. Majority of the cases were stage 3B(75%). 35 patients (88%) underwent sphincter preserving surgery. In early surgery group surgery was done within 9 days after RT and in delayed surgery group, time to surgery was 70 days after RT. Grade I/II toxicity was observed in 8 patients(20%) and 2 patients developed grade 3 toxicity after short course RT. Four out of nine patients who received short course radiotherapy followed by chemotherapy attained pathological complete response. Conclusion: Preoperative short-course radiotherapy followed by early or delayed total mesorectal excision is well tolerated with acceptable toxicity.


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Pathological response after neoadjuvant chemoradiation in locally advanced rectal cancer

S. Thamizholi, A. G. Hasib, M. S. Athiyamaan, Sandesh Rao, Sharaschandra, Mohsina, C. H. Sridhar

Father Muller Medical College, Mangalore, Karnataka, India

Background: Locally advanced rectal cancer can be downstaged by neoadjuvant therapy and the resultant tumour response can be quantified histologically. Aim: To assess pathological response in patient with locally advanced rectal cancer treated by neoadjuvant chemoradiation. Materials and Methods: A total of 30 consecutive patient with locally advanced rectal cancer treated in father muller medical college were reviewed. Pre-operative neoadjuvant chemoradiation was delivered with a total dose of 50.4 Gy in 28 fraction concurrent with Tab.capecitabine 825mg/m2. Surgery was planned at 6-8 weeks from completion of neoadjuvant chemoradiation. The pathological response to therapy was assessed by histopathological report of surgical specimen. Results: A total of 30 patient with 17 male and 13 female patient. Initial clinical staging of patient revealed 90% were staged T3/T4 N1-2M0 and 10% were staged T3N0. Patient received neoadjuvant chemoradiation followed by surgery as per protocol. In which 50% underwent Abdominoperineal resection, 23.3% underwent Anterior resection, 20% underwent low Anterior resection, 6.6% underwent Pelvic exentration. Complete pathological response was observed in 23.3% and partial response in 76.7% of patient. Positive lymph node metastasis was confirmed in 40% of cases. Conclusion: Neoadjuvant chemoradiation is a reasonable option for cases of locally advanced rectal cancer to achieve pathological response and sphincter preserving surgery.


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Clinical profile, management and acute toxicity of patients with anal canal malignancy in a Regional Cancer Centre in South India

K. Bharadhwaj, John M. Mathew, V. Niranjan, Abhilash Menon, E. Thiraviyam, P. Jagadesan

Aims/Objectives: To retrospectively analyse and report the common clinical profile, management and acute toxicities of patients with anal canal malignancies at our centre. Materials and Methods: We retrieved the records of patients who presented with anal canal malignancy at our centre between Jan 2014 and Jul 2018. We analysed data pertaining to patient characteristics, management and acute toxicity of these patients. Results: A total of 33 patients were analysed. The median age at presentation was 60 years. 25(75.8%) were females and 8(24.2%) were males. 25(75.8%) had squamous cell carcinoma, 5(15.2%) had malignant melanoma, 2 had adenocarcinoma and 1 had a poorly differentiated carcinoma. Among carcinomas, 10(35.7%) were moderately differentiated, 12(42.9%) were well differentiated and 6(21.4%) were poorly differentiated. Out of 28 patients with carcinomas, 18(64.3%) presented with Stage III, 9(32.1%) with Stage II and one patient with metastatic disease (Lung). Out of 5 patients with melanoma, 4 had localised disease and 1 had metastatic disease (Lung). Two patients with moderately differentiated squamous cell carcinoma were retropositive. 24(72.7%) were planned for radical treatment and 9(27.3%) for palliative treatment. One patient with Stage IV disease had expired before initiation of treatment. Out of remaining 32 patients, 24(75%) had received treatment as planned and 8(25%) defaulted while on treatment. 4 patients with melanoma and 1 patient with adenocarcinoma underwent APR followed by Adjuvant RT. Out of 32 patients planned for RT, 19(59.4%) were radical, 7(21.9%) were palliative and 5(15.6%) were adjuvant. One patient who was planned for palliative RT was later treated to radical dose in view of good tumor response. Common RT schedules used were 50-60 Gy @ 1.8Gy/# for radical and 20Gy/5# or 30Gy/10# for palliative RT. 14(73.6%) of radical RT patients received concurrent chemotherapy. Common chemotherapy regimen used was concurrent Mitomycin C + 5FU/Capecitabine. There were no Grade 4 toxicities. 3 patients on CT+RT developed Grade 3 skin toxicity. 4 patients developed grade 2 skin toxicity, out of which 2 were on CT+RT. 4 patients developed grade 2 diarrhea, out of which 2 were on CT+RT. Out of 8 defaulters, 4 were on radical CT+RT and 4 on radical RT. Conclusions: The prevalence of primary anal canal malignancies in our centre is low and is more commonly seen in elderly females. Majority of them are squamous cell carcinomas and a significant number of melanomas were diagnosed. Most patients presented with Stage III disease and were fit for curative treatment. Squamous cell carcinomas were treated with Radical RT+CT, while melanomas were treated with APR followed by adjuvant RT. No grade 4 and very few grade 3 toxicities were observed.


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Definitive stereotactic body radiotherapy/stereotactic ablative body radiotherapy in large volume inoperable hepatocellular carcinoma – Dosimetric review and early toxicity

Jeevi Mona Priyadharshni, Bharat Dua, Rajender Kumar, Ritesh Sharma, Anil Kumar Bansal1, Anirudh Urumi Punakkal, A. K. Anand

Department of Radiation Oncology, Max Super Speciality Hospital,1 Division of Medical Physics, Max Super Speciality Hospital, New Delhi, India

Objectives: SABR is a technique that enables accurate delivery of ablative high doses of radiation in a short time with hypo-fractionation as opposed to traditional treatment courses over several weeks while sparing surrounding organs at risk (OAR) through use of accurate tumor localization, patient immobilization and image guidance technique. Treatment of large volume HCC with radiation remains challenging as normal liver sparing may not be adequate. Our objective is to present data on series of patients with large volume HCC who are not suitable for surgical resection and also to evaluate the feasibility and efficacy of SABR for the same. Methods: Patients with inoperable HCC lesions with volume ≥ 100 cc were treated by SABR between 2015 to 2018. Pretreatment Child Turcotte Pugh Class (CTPC) and AFP were recorded. Different methods of tumour tracking viz, Respiratory gating, Tumour tracking, abdominal compression were used and SABR was delivered using 6 MV photons using Novolis-Tx Radiosurgery system. According to lesions size and OAR constraints prescription regimens were adopted: 27–48 Gy in four to eight fractions. SABR was delivered using the volumetric modulated arc therapy technique or Conformal radiotherapy technique or Intensity modulated radiotherapy with photon beams. Dosimetric data was evalauted from Eclipse planning system. Toxicity was evaluated by CTCAE Version 5.0. Results: Ten HCC patients with ≥ 100 cc lesions treated between October 2015 to September 2018 were evaluated. All the patients were CTPC Class A or B. Median tumour volume was 363.54 (479.86 ± 538.68 cc). The median liver volume was 1721.49 (1631.41 ± 831.44 cc). Median normal liver volume (Liver - GTV) was 1133.86 (1183.50 ± 691.59 cc). Median dose delivered was 35 Gy (27 Gy to 48 Gy) with median no. of fractions was 5 (4 to 8). Median BED was 55.5 Gy10 (42.23 Gy10 to 86.4 Gy10). Median dose to Liver –GTV dose was 20.73 Gy (7.93 Gy to 34.23 Gy), 3 patients had underlying cirrhosis. None of the patient had classic radiation induced liver disease. Grade 2 hematological toxicity was observed in 1 patient. 2 patients had gastrointestinal toxicity with 1 patient having grade 2 esophagitis and 1 patient having grade 2 gastritis. One patient had grade 1 ascites at presentation which converted to grade 2 during treatment with development of grade 1 encephalopathy. Nine out of ten patients completed treatment as per protocol and one patient defaulted during treatment. No patient had grade 3 or higher hematological/liver/gastro-intestinal toxicities. Conclusion: Stereotactic ablative body radiation therapy is a feasible and safe therapeutic option for large HCC lesions unsuitable for surgery, with adequate sparing of OARs with minimum acute morbidity. Further follow up will be required to ascertain response, overall survival and late toxicities.


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Retrospective evaluation of the role peri-operative chemotherapy in resectable esophagogastric junction adenocarcinomas treated at a tertiary oncology centre in Kerala

Anindya Mukherjee, Y. Nabeel, P. N. Arun, N. P. Shoaib, J. Joneetha, N. Vinin, R. Nithin, P. Nizamuddeen, A. Manuprasad, K. S. Praveen, M. Geeta

Aims and Objectives: Aim: To evaluate the efficacy of peri-operative chemotherapy in the treatment of EGJ adenocarcinomas (AC). Objectives: (1) To assess whether there was significant tumour downstaging by neoadjuvant chemotherapy. (2) To assess whether survival outcomes differ by location of tumour (according to Siewert types). (3) To evaluate whether completion of planned cycles of chemotherapy (total six) affect survival estimates. Materials and Methods: 21 patients of EGJAC underwent surgery and perioperative chemotherapy with modified ECF regime (Epirubicin 50mg/m2 Day 1, Cisplatin 60mg/m2 Day 1and 5 FU 425mg/m2 Day1-Day3; q 3weeks) at Malabar Cancer Center, Kerala from July 2013 to December 2015. Three cycles of this chemotherapy were planned to be given before and after surgery. Data was collected from retrospective institutional records. SPSS v 23 software was used for statistical analysis. Results: The median age of patients was 59 years (range 40-71; std. deviation 8.76) and most (16 patients, 76.2%) of them were males. 10, 5 and 6 patients belonged to Siewert Type I, II and III EGJ tumours respectively. 19 patients (90.5%) received 3 cycles neoadjuvant chemotherapy while rest 2 received just 2 cycles. 3 cycles of adjuvant chemotherapy was received by 12 patients (57.1%) and 2 cycles by 3 patients. Of the remaining 6 patients, omental metastases were detected in 4 and 1 patient was deemed unresectable by intraoperative findings. So they were given palliative chemotherapy with single agent capecitabine. Only 1 patient had margin positive disease; so concurrent chemoradiation (45 Gy in 25 fractions with weekly 40mg/m2 cisplatin) was given in place of adjuvant chemotherapy. Wilcoxon signed rank test was used to look for differences in cTNM and ypTNM stages of each patient who underwent surgery. The test result was significant with a Z value of -2.886 (p=0.04, by 2 tailed test of significance) based on positive ranks. The median overall survival (OS) and relapse free survivals (RFS) were 13 months (std. error 3.799, 95% confidence interval, CI 5.55-20.44) and 9 months (std. error 4.38, 95% CI 0.407- 17.59) respectively. Survival periods did not vary by location of tumour (Siewert types), p= 0.291 for OS and p= 0.275 for RFS by log rank tests. 13 patients completed 6 cycles of chemotherapy while 8 did not. The median OS was not significantly different (p= 0.359) between the two groups, 19 months (std. error 2.996, 95% CI 13.12 -24.87) vs. 13 months (std. error 3.414, 95% CI 6.30-19.69). Similar was the case with RFS, p= 0.190 (15 months, std. error 4.044, 95% CI 7.07-22.92 for 13 patients vs. 7 months, std. error 1.255, 95% CI 4.54- 9.46 for 8 patients). Conclusion: Perioperative chemotherapy with modified ECF regime significantly downstages EGJAC. There were no significant differences in OS and RFS based on Siewert location or completion/non-completion of 6 cycles of chemotherapy.


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Developing a response assessment criteria for SBRT liver for hepatocellular carcinoma – A new approach

M. Arunlal, Milind, Arun, Vijayagopal, Shamsudheen, Afsal, Jayashankar, Shailage, Dinesh, Niyaz, Renjith, Vysakh

Background: SBRT is currently considered as one of the standard non-surgical treatment options of HCC. There are standard guidelines to assess response to various treatments for malignancy. (RECIST Criteria). Radiologists have other criteria to measure response to interventional modalities like RFA and TARE. Many a time, response assessment scan after SBRT is reported as residual disease causing much heart burn to patients and clinicians. Aims and Objectives: To develop a protocol for reporting response of patients receiving SBRT. Materials and Methods: MRI scan and CT scan of patient's available pre and post treatment were reviewed together with radiologist. Available literature of response assessment was collected and it was used to standardise radiology reporting. Results: 12 patients received SBRT from January 2018 to October 2018. Response assessment images were available for 6 of the patients. All patients were reported initially based on conventional standards of response. A new response assessment criteria was developed with which these patients were re analysed. Conclusions: Current response assessment guidelines are inadequate for assessing the changes in liver due to SBRT. As more and more institutions are undertaking SBRT for liver, a uniform criteria needs to be adopted for reporting.


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Chemoradiotherapy for locally advanced hepatobiliary cancer: A mono-institutional retrospective analysis

Dulal Kiran Mondal, Anu Tiwari

Objectives: To evaluate the role of chemoradiotherapy (CRT) in locally advanced hepatobiliary cancer (HBC), and the toxicity profile in the setting of multidisciplinary approach strategies. Methods: 21 patients with locally advanced and metastatic hepatobiliary cancer (LAHBC & MHBC) receiving Radiotherapy in our institution were retrospectively identified. Information on patient baseline, treatment characteristics and status at last follow up were collected. Data of symptomatic improvement and toxicity were evaluated. Results: 16 patients had locally advanced Gall bladder cancer and 4 patients had locally advanced Pancreatic cancer and 1 patient had metastatic Pancreatic cancer. All patients received 3DCRT with a median dose of 45.0 Gy. All patients received either oral or infusional chemotherapy before, after or during Radiotherapy. Symptomatic improvements were observed in 16 patients after chemoradiotherapy (CRT), particularly in those with severe pain. The mean symptom free period was 6 months (range 0 -19 months). Only 19% cases presented Grade≥3 hematologic toxicities, 14.2% cases developed Grade≥3 liver toxicities while no cases developed Grade≥3 Upper GI toxicities. Conclusions: CRT can give symptomatic improvement in LAHBC with acceptable toxicities, and The mean symptom free period was 6 months (range 0 -19 months).


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The impact of splenic irradiation during chemoradiation for gastric and gastroesophageal junctional cancers in the development of acute hematologic toxicity

Hepsiba Priyadarshini, A. G. Hasib, M. S. Athiyamaan, Sandesh Rao, Sharaschandra, Dinesh Shet, Rohan Chandra Gatty, C. H. Sridar

Department of Radiotherapy, Father Muller Medical College Hospital, Mangalore, Karnataka, India

Aim: The purpose of this study was to determine the impact of radiation dose and fractional volume of irradiated spleen in the setting of chemoradiation therapy for gastric and gastroesophageal junctional cancers on hematologic toxicity. Methods and Materials: This study was done in Department of Radiation oncology, Father Muller Medical College. We analyzed 40 patients with gastric and gastroesophageal junctional cancers who received concurrent chemoradiation (median 50.4 Gy with concurrent capecitabine) from 2013 to 2018. Splenic dose-volume histogram (DVH) parameters were calculated as mean splenic dose (MSD) and percentage of splenic volume receiving 10 Gy (V10), 20 Gy (V20),30 Gy (V30) and 40 Gy (V40) dose. Results: All the patients experienced hematological toxicities, including 28 patients with leukopenia, 12 with thrombocytopenia and 6 with both leukopenia and lymphopenia. Median Dmean to the spleen was 32 Gy (range 27–37). Higher spleen V10-V40 was correlated with leukopenia, lymphopenia and thrombocytopenia. Median post- chemoradiation Absolute Lymphocyte Count (0.62 K/UL) was significantly lower than pre-chemoradiation Absolute Lymphocyte Count (1.46 K/UL, p<0.0001). Median V10, V20, V30 and V40 were significantly higher in patients with leukopenia and thrombocytopenia compared to those without. Dose volume parameters of the spleen showed the highest correlation with several toxicities like vomiting, anorexia, dehydration, hematologic toxicity, fatigue, combined gastro-intestinal toxicity. In our study correlation with acute hematologic toxicity was assessed. Traditionally the spleen is an ignored organ in RT, it currently raised some interest with the onset of radio-immunotherapy. Conclusion: In chemoradiotherapy for gastric cancer and gastroesophageal junctional cancers, the spleen received a high radiation dose. This resulted in a progressive, radiation dose-dependent hematologic toxicity. Higher splenic doses increase the risk of developing severe post- chemoradiation lymphopenia. When clinically indicated, assessment of splenic DVHs prior to acceptance of treatment plans may minimize the risk of hematologic toxicity.


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Treatment outcome of concurrent chemoradiation in carcinoma anal canal

Blessy Johns, Jayaprakash Madhavan, E. Grace Shirley, T. V. Sandeep, S. Sajeev, Swapna Lilly Cyriac

KIMS Cancer Center, Thiruvananthapuram, Kerala, India

Introduction: Cancers of anal canal account for 1% to 2% of all large bowel cancers. Majority of these patients(75% to 85%)have squamous cell carcinoma. Combination of radiation and chemotherapy is considered the standard of care for squamous cell carcinoma of anal canal, with radical surgery reserved for residual disease. Aims and Objectives: To analyze the clinical profile and treatment outcomes of carcinoma anal canal patients treated with concurrent chemoradiation at KIMS Cancer Center Thiruvananthapuram. Materials and Methods: 4 patients with histology proven carcinoma anal canal treated with concurrent chemoradiation KIMS Cancer Center Thiruvananthapuram were retrospectively analysed. The data was retrieved from electronic medical record and treatment planning system. Results: 4 Patients of carcinoma anal canal treated with concurrent chemoradiation was analysed. All the histology was proven to be basaloid squamous cell carcinoma. Three patients were females and one male. All 4 cases were non -metastatic at presentation. Median follow up time was 18 months. Median age at diagnosis was 67.5 years(65-87 years). All patient had palpable growth in anal region with 3 patients having palpable inguinal node at presentation.3 patients were stage IIIb at presentation and one patient stage II. All patients were treated with 54 Gy in 25# to the gross disease and 45Gy in 25# to pelvic and inguinal nodes.3 Patients were treated with Rapid Arc technique and one patient with IMRT Technique. All 3 patients received concurrent chemoradiation with 5 Fluorouracil and Mitomycin. One patient was not given chemotherapy due to advanced age. All patients treated by Rapid Arc method had PET CT based planning and was treated as simultaneous integrated boost. 2 patients developed grade 3 skin reaction. One patient developed persistent neutropenia during concurrent chemoradiation and needed radiation interruption. Radiation treatment was restarted and completed after 44 days with gap correction. All patients were evaluated at 8-12 weeks by digital rectal examination, inguinal node palpation and CT scan. All 4 patients had no palpable residual anal lesion on digital rectal examination. Follow up CT scan also showed complete remission of lesion in all 4 cases. All the patient are being followed up since 7 years, 3 years,1 year and 2 months. Conclusion: Analysis of 4 carcinoma anal canal patients treated with concurrent chemoradiation showed complete remission of anal canal lesion and palpable inguinal node. No patients required salvage surgey on followup. With advanced radiation technique even patients with advanced age can be treated without any treatment related toxicity with outcome similar to other age groups.


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Dosimetric comparison of intensity modulated radiotherapy and volumetric arc radiotherapy for gastric cancer

S. S. Satpathy, Soren Jatin, Pujari Lincoln, Pattanayak Lucy, Padhi Sanjukta, Panda Niharika, S. N. Senapati

Department of Radiotherapy, AHRCC, Cuttack, Odisha, India

Aim: Dosimetric comparision of intensity modulated radiotherapy and volumetric arc radiotherapy for gastric cancer. Materials and Methods: It is a prospective observational study carried out post graduate dept of radiation oncology, AHRCC cuttack from 2017-2018. A total of 10 post operative gastric cancer patients were enrolled in this study and each patient was scheduled for IMRT and VMAT techniques. Dose volume histograms, conformal index, homogeneity index were analysed to compare treatment plans. The radiotherapy dose 50.4Gy/28# delivered to the PTV along with chemotherapy capecitabine 825mg/m^2/12hr 1hr before RT including weekends. Results: For the PTV coverage the mean Conformal index of VMAT plans (0.89+/-0.02)were higher than the IMRT plans and the mean Homogenity index of the VMAT plans(0.12+/-0.01) were significantly improved incomparision to IMRT plans. In addition for the kidneys the dose sparing(V3, v18, mean kidney dose) was better in VMAT plans. Conclusion: Considering the shorter delivery time and reduced low dose exposure to OARs the use of VMAT in post operative radiotherapy remains suitable for gastric carcinoma.


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Dosimetric comparison of using conformalradiotherapy versus intensity modulated radiotherapy in the treatment of mid esophageal carcinoma

S. Thamizholi, A. G. Hasib, Athiyamaan, Sandesh Rao, Sharaschandra, Mohsina

Father Muller Medical College Hospital, Mangalore, Karnataka, India

Background: Esophageal carcinoma accounts for 6% of all GI malignancies in the world. The treatment of cancer of the esophagus has evolved from 2 dimensional conformal radiotherapy to the present day image guided radiotherapy. Due to the presence of many vitals organs like the spinal cord, heart, lung which lie in close proximity to the esophagus, the treatment of this cancer has been challenging. In our setting most of the cases usually present with tumors in the mid and distal esophagus. Over the past few years, studies based on dosimetric parameters have revealed the efficacy of IMRT in the treatment of these cancers owing to its superior target volume coverage and conformality with decreased dose to the normal structures. Objectives: To compare the 3D conformal and IMRT technique with respect to conformality of target coverage and to analyze the dose received by various structures around the esophagus. Methods: A prospective comparative study with purposive sampling of 25 patients of esophageal cancer being treated with radical chemo radiation or radiation alone were included in the study. Three plans were created for all patients, one 3DCRT and two IMRT plans using 5 beam and 7 beams were made and dosimetric parameters were compared in each of these plans to analyse the structures around the esophagus will benefit from using more advanced planning techniques. Results: Patients in our study had performance scores ranging from 70 to 90 with the mean GTV length being 8.74 cms and the mean PTV length 18.34 cms. The percentage of PTV receiving 95% of the dose was 84.23% in 3DCRT, 93.67% in 5 beam IMRT and was 94.73% in 7 beam IMRT plans thus showing statistically significant improvement in the IMRT plans as compared to 3DCRT plans (p<0.001). The volume of the heart that received 40Gy in the 3DCRT plans was 67.23% whereas in the 5 beam IMRT plans was 30.77% and 30.36% in the 7 beam IMRT plans, all of which was found to be statistically significant.(p<.001). The V20 of whole lung was 23.64% in the 3DCRT plans and 39.68 in the 5 beam IMRT plans and 36.69 in the 7 beam IMRT plan. Conclusion: In this study it was found that IMRT plans had significantly better PTV coverage as compared to 3DCRT plans. However the lung doses were higher in the IMRT plans as compared to 3DCRT. When the 5 beam and 7 beam IMRT plans were compared it was found that the 7 beam IMRT plans had a lower lung dose as compared to the 5 beam IMRT plans. The heart doses were significantly lower in the IMRT plans as compared to 3DCRT plans.


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Neoadjuvant chemo-radiation regimen for treatment of carcinoma oesophagus – Experience from tertiary cancer centre

P. Greshma, Deleep Kumar Gudipudi, B. Amani, Heena, A. Krishnam Raju

Introduction: Neoadjuvant chemo-radiotherapy (NACRT) using the CROSS protocol is efficient, safe and well tolerated regimen; It has become a standard of care for both squamous cell carcinoma as well as adenocarcinoma of the esophagus and esophago-gastric junction. CROSS study showed more than 90 % of patients were able to complete the protocol of NACRT followed by surgery with grade 1 and grade 2 tumour regression in 29% and 32% respectively. Unfortunately in our scenario, for many nonspecific reasons, the patients who are not turning for the surgery after NACRT is higher. Thus we modified the CROSS regimen, where our patient received Simultaneous Integrated Boost (SIB) to gross tumour volume (GTV) with a maximum curative intent though the treatment is part of the neoadjuvant regimen. Simultaneous Integrated boost - SIB was considered in patients who were in dilemma for surgery. In this study we have reported the early experience of our novel neoadjuvant radiation regimen by assessing the pathological response of the tumour and the compliance to the treatment. Aim and Objectives: The primary objective is to study the pathological response to the treatment and the secondary objective is to know the compliance to the treatment by assessing acute side effects, completion of the planned treatment, and factors responsible for deferring or avoiding surgery. Materials and Methods: We have retrospectively reviewed the patients between June 2017 to May 2018 with histologically proven, resectable esophageal and gastro esophageal junction carcinoma who received radiotherapy(SIB) with concurrent weekly Paclitaxel (50 mg/m2) and carboplatin (doses titrated to achieve an area under the curve of 2 mg per milliliter per minute) for 5 weeks. SIB was planned to a dose of 50.6Gy in 23 fractions to GTV at 2.2Gy per fraction and 41.4Gy in 23 fractions, 1.8Gy per fraction to PTV, 5 days per week. Fischer's exact test was used for analysis. Results: During June 2017 to May 2018, 18 of 181 treated patients with mean age of 52 years have received the SIB treatment. All 18 patients were able to complete the prescribed NACRT. 12(66.66%) had grade 1 and 1(5.5%) had grade 2 skin reaction; 3(16.6%) had grade 1 and 6(33.3 %) had grade 2 dysphagia. Of 18 patients, 8 (44.4%) underwent surgery and of the remaining 10 patients, 3 patients expired due to non cancer cause during the workup period for surgery, surgery was deferred in 2 patient in view of cardiac co-morbidity, 3 patient did not turn for surgery as they were doing well and 2 patient are considering surgery at a later date. Among 8 patients who underwent surgery all (100%) had R0 resection with no tumor within 1 mm of the resection margins. Pathological complete response (grade 1) was achieved in 4 patients(50 %), grade 2 response in 2 patients (25 %)and grade 3 response in 2 patients (25%). There was no grade 4 response. Postoperative mortality was nil in our study. Conclusion: Our retrospective study in carcinoma esophagus was associated with better pCR rates and R0 resection in view of SIB radiation, with similar adverse effect profile and compliance to CROSS protocol. However, larger study population with long term follow up is warranted.


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Feasibility of using concurrent chemoradiotherapy followed by intra luminal brachytherapy in carcinoma oesophagus – A single institutional study

R. Suman, Nafisa Begum, S. D. Shamsundar, K. Aradhana, R. Nanda, B. Thejaswini

Department of Radiation Oncology, Kidwai Cancer Institute, Bengaluru, Karnataka, India

Aim: This study was taken up to evaluate the outcomes of node negative locally advanced carcinoma oesophagus patients treated with Concurrent Chemoradiation followed by Intra luminal brachytherapy in terms of response, survival and toxicity. Materials and Methods: A total of 45 eligible patients treated between December 2014 to December 2017 were included in this prospective study. Patients were treated with 50.4Gy in 28 fractions via 3DCRT along with weekly cisplatin based concurrent chemotherapy followed by single channel Intra luminal Brachytherapy of 5.6 GY x 2 fractions 1 week apart. The patients were followed up with Upper GI endoscopy and CECT thorax at 6 monthly intervals. Results: Out of the 45 patients, 23 were males and 22 were females in the age group of 40- 70 years. At last follow up 22(48.8%) patients are alive and 23 (51.1%) patients were dead, of which 4 patients died due to other reasons. Local recurrence was seen in 19 (42.2%) patients and distant metastases seen in 1 (2.2%)patient. The overall survival at median follow up of 18 months was 67%. The treatment related grade 3- 4 toxicities were ranging from 10-15%. Conclusions: Our study shows feasibility of using concurrent Chemoradiotherapy followed by Intra luminal brachytherapy in Carcinoma Oesophagus patients with comparable outcomes and acceptable toxicity.


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A prospective assessment of quality of life in patients of esophageal cancer undergoing definitive chemo-radiation

Ajay Kumar Shukla

Department of Radiation Oncology, Assam Medical College, Dibrugarh, Assam, India

Background: Definitive chemo-radiation (dCRT) is considered the standard care for locally advanced esophageal cancer but there is dearth of extensive randomised prospective studies from Indian sub-continent on the efficacy, compliance and treatment outcomes in form of patient satisfaction and quality of life (QOL) post dCRT. Aims and Objectives: This study aims at assessing the patients' QOL pre and post dCRT and during follow-up using Functional Assessment of Cancer Therapy-Esophageal scoring (FACT-E, version4.0). Materials and Methods: This is a hospital based prospective study conducted at the Department of Radiation oncology, Assam Medical College, for which all the histopathologically proven cases of esophageal cancer were approached. Initially 78 patients were approached for the study out which 3 patients refused to be a part of the study, seven did not comply with the treatment plan due to their personal reasons and one of them died during the initial week of treatment. Hence, I proceeded with the remaining 67 patients. External beam radiotherapy was delivered through Cobalt-60 Bhabatron-II teletherapy unit where a total dose of 50 Gy was delivered in 25 fractions using three field technique over 5 days a week for 5 weeks along with concurrent chemotherapy with Paclitaxel 50mg/m2 intravenously starting on day1 with Carboplatin AUC 2 IV on day1 was given weekly for five weeks. Complete baseline assessment of dysphagia, performance status and QOL was carried out and recorded at the beginning of the management, at the completion of dCRT and at 3 months follow-up. The patients were assessed using Karnofsky Performance Scale (KPS) for overall performance, the Functional Assessment of Cancer Therapy-Esophageal scoring (FACT-E) version 4.0 for QOL. Results: COMPARISION OF BASELINE QOL WITH QOL AT COMPLETION OF CHEMO-RADIATION: The comparative data showed a decline in most domains of FACT-E scale but the physical domain(PWB), the emotional domain(EWB) and the FACT-General scores declined significantly(i.e. Pvalue<0.05). Interestingly the ECS subscale revealed a significant rise (P value=0.0342) when the means were compared using paired t test. COMPARISION OF BASELINE QOL WITH QOL AT 3 MONTHS FOLLOW-UP: The data revealed significant rise in ECS and TOI scores (p value<0.05) though there was an increment observed in the means of FWB and FACT-E total scores(p value>0.05). There was a decrease in the mean scores of PWB, SWB, EWB domains and the FACT-General scores though not significant (p value>0.05). An important finding in the results was the increase in the mean scores of all the parameters of FACT-E scale when the data at completion of dCRT and post dCRT completion 3 months follow-up was compared. Conclusions: The QOL score deteriorates from before treatment due to acute complications of chemo-radiotherapy, but recovers at 2 to 3 months post dCRT in most patients. The study requires further evaluation due to its limitations of small sample size and a short follow-up period.


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High dose rate intraluminal brachytherapy postchemoradiotherapy in carcinoma esophagus

Abhishek Krishna, A. G. Hasib, M. S. Athiyamaan, Sandesh Rao, Sharaschandra Shankar, Mohsina Ali

Department of Radiation Oncology, Father Muller Medical College Hospital, Mangalore, Karnataka, India

Aims and Objective: To access response and toxicities in patient treated with high dose rate intraluminal brachytherapy post chemoradiotherapy in carcinoma of the esophagus. Materials and Methods: 24 patients with biopsy proven carcinoma of the esophagus received concurrent chemoradiotherapy with the dose of 50Gy in 25 fractions with weekly cycle of Cisplatin 35mg/m2 followed a week later by Intraluminal brachytherapy of 8Gy in 2 weekly fractions of 4Gy each. Evaluation of response and toxicities was done at 1st and 4th month after completion of treatment. Results: 33% of patients were able to tolerate normal solid diet one month after treatment. At the end of 1 month, there was complete clinical response of 70.8%. None of the patients in had persistent disease. Grade 2 esophagitis was seen in 7 of 24 patients (29.2%). None of the patients developed fistula. Grade 2 ulceration was 41.7%. At 4 months patients showed an improvement of 12.5% in dysphagia with tolerance to normal solid diet seen in 45.8%. At the end of 4 months, on endoscopic evaluation 83.3% had complete clinical response and 16.7% had partial response. None of the patients had persistent disease. Grade 2 strictures was seen in 33% (8 patients). Grade 3 stricture was 10% (2 patients). Grade 2 esophagitis was seen in 4 of 24 patients (16.7%). Grade 2 ulcerations was seen in 29%. At the end of 4 months, none of the cases developed fistula. Conclusion: Intraluminal brachytherapy appears to be effective in terms of local control of esophageal cancer with acceptable toxicities.


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Dosimetric comparison of Radiation dose to Testes and Penile bulb with 3DCRT versus VMAT during Preoperative radiotherapy for rectal cancer

Tarun Jose, S. Arvind, Kaalindhi Singh, Neenu O. John, Sharief K. Sidhique, Abel Juhan Thomas, Henry Finlay Godson, Jeba Karunya, Thomas S. Ram

Aims/Objectives: To compare and analyse the dose received by the testes and the penile bulb during preoperative radiotherapy for rectal cancer using different radiation techniques. Materials and Methods: The VMAT plans of ten patients who underwent preoperative long course radiation therapy for locally advanced rectal cancer were included in this study. Testes and penile bulb were contoured on the planning CT scans of these patients. A PRV of 5mm was given for testes. Dose constraint of Dmax less than 2Gy to PRV testes and 50Gy for the penile bulb was given. The dose to testis and Penile bulb with the existing VMAT plan without any dose constraints for PRV testes and penile bulb were noted. Using the same dataset and the structures delineated, VMAT plan was generated with the dose constraints for PRV testes and penile bulb. Simultaneously 3D CRT plan was also generated. The maximum doses to PRV testes and penile bulb were recorded for each plan. Results: The mean PTV D95 was 50.9 Gy in VMAT(without constraint), 50.16 Gy in VMAT (with constraint) and 49.83 Gy in 3DCRT. The mean Dmax to PRV testes in VMAT(without constraint) was 3 Gy [Range: 1.57 to 7.89 Gy], VMAT (with constraint) was 2.57 Gy [Range: 1.57 to3.90 Gy] and in 3D CRT it was 3.05 Gy [Range: 0.93 to 11.25 Gy]. The mean of maximum doses to penile bulb in VMAT(without constraint) was 48.37 Gy [Range: 35.16 to 56.03 Gy] and VMAT (with constraint) was 45.79 Gy [Range: 35.16 to 53.67 Gy] and in 3D CRT was 45.49 Gy [Range: 29.63 to 53.51Gy]. Mean distance between PTV and PRV Testes was 3.5 cm(Range: 0.5 cm to 6.5 cm). There was a inverse relationship between the distance and the testicular dose. Conclusion: It is feasible and possible to reduce the dose to the testes and penile bulb with the dose constraint of Dmax less than 2Gy and penile bulb less than 50 Gy without compromising the PTV dose.


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Predictive factors of esophageal stricture after definitive chemoradiation therapy for esophageal carcinoma: A retrospective single institute study

Manraj Singh Kang, Deepak Kumar Uppal, Pardeep Garg, Raja P.S. Banipal, Sapna Bhatty, Romi Kant Grover, Gagandeep

Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India

Background and Introduction: Esophageal cancer is the eighth most common cause of cancer. Chemoradiation is the well established approachfor treatment of esophageal carcinoma. Radiation-induced esophageal stricture is one of the most common late complications of RT usually occurs 3–8 months after completion of RT. Esophageal stricture is often observed after radiation therapy despite good tumor response and hence the quality of life (QOL) suffered. The purpose of this to identify patient, tumor, and treatment factors that have a significant impact on the likelihood of developing esophageal stricture following definitive chemoradiation therapy (CRT) for esophageal/ gastroesophageal junction (GEJ) carcinoma. Methods: Retro one year audit of 40 patients with biopsy proven esophageal cancer who underwent definitive concurrent chemoradiation in Department of radiation oncology at Guru Gobindsingh medical college and hospital. Barium swallow was performed for all patients within 3 months after completion of the radiation therapy and the esophageal stricture was evaluated. We then tried to establish the correlation between the stricture levels after radiation therapy. Time to stricture was defined as elapsed time from completion of RT to first dilatation. Prophylactic dilatations were not performed. Multiple patient, treatment, and tumor characteristics were evaluated in terms of risk for stenosis and was statistically evaluated. Results: Tumor location was significantly associated with stricture risk, with more superior tumors having higher rates of stricture. Patient age, sex, current or previous smoking history, alcohol use, stage group, RT technique, and the use of a dose above 54 Gy were not associated with stricture risk. Conclusions: Patients with more inferior esophageal tumors and treated with concurrent chemotherapy decreased risk of stricture relative to those who did not, and EBRT dose did not appear to affect the estimated incidence of stricture. Dose escalation may be feasible in the inferior esophagus without affecting the rate of stricture. For predicting the possibility of esophageal stricture, the tumor site, length of disease, T stage might be useful.


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Comparison of Dosimetric Parameters in Different Radiotherapy Techniques of 3D-CRT, IMRT and VMAT in patients of cancer Esophagus

Gehlaut K1, Kumar P2, Kumar P3, Nigam J3, Chauhan AK4

1 Junior Resident,2 Professor and Head,3 Assistant Professor,4 Associate Professor, Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

Aims and Objectives: Concurrent Chemo-Radiotherapy (CCRT) is the standard of care for locally advanced or unresectable Esophageal Carcinoma. The present study was conducted to evaluate and compare the Dosimetric parameters in different radiotherapy techniques of 3-Dimensional Conformal Radiotherapy, Intensity Modulated Radiotherapy and Volumetric Modulated Arc Therapy in patients of cancer Esophagus. Materials and Methods: Twenty-five patients were included between December 2016 to March 2018. All patients were treated with External Beam Radiotherapy dose 50.4 Gy in 28 fractions. The patients were treated with 3D-CRT or IMRT techniques but for evaluation and comparison of Dosimetric parameters treatment plans were generated for all the three (3D-CRT, IMRT, VMAT) radiotherapy techniques. The Dosimetric parameters were calculated in terms of PTV Coverage (D95), Organ at Risk: Heart (Mean dose, V5, V10, V20, V30) Lung (Mean Dose & V5, V10, V20, V30) and Monitor units (MU), Conformity Index & Homogeneity Index. Results: Planning dosimetry of the patients receiving 3D-CRT, VMAT and IMRT was analyzed regardless of the tumor location. PTV coverage & maximum spinal cord dose was similar for 3D-CRT, IMRT & VMAT. IMRT & VMAT had lower Heart Mean Dose compared to 3D-CRT (p 0.036 with IMRT & p 0.004 with VMAT) & lower V30 (p 0.001 for IMRT & p 0.0001 for VMAT). IMRT & VMAT had lower Lung mean dose, lower V5 (p 0.005 with IMRT & p 0.0054 with VMAT) lower V10 (p 0.0004 with VMAT) & lower V30 (p 0.0001 with VMAT). Conclusions: The present study reveals the treatment plans of IMRT & VMAT had significant lower mean doses for Lung & Heart in comparison to 3D-CRT plans. These Dosimetric evaluations needs clinical validation by treatment delivery and long term follow up.





 
 
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