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Year : 2018  |  Volume : 14  |  Issue : 11  |  Page : 909-911


Date of Web Publication29-Nov-2018

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How to cite this article:
. Uro-oncology. J Can Res Ther 2018;14, Suppl S4:909-11

How to cite this URL:
. Uro-oncology. J Can Res Ther [serial online] 2018 [cited 2019 Nov 15];14:909-11. Available from: http://www.cancerjournal.net/text.asp?2018/14/11/909/246383

 > Urology: 01 Top

Second cancer incidence and completing causes of death in patients with early stage seminoma: A population based mortality analysis comparing radiation therapy versus chemotherapy

Gaurav Bahl, Rima Pathak, Jenny Ko, Micheal Sia, Scott Tyldesley, Christian Kollmannsberger

Purpose/Objective(s): The purpose of this study is to examine the incidence of Second Cancers (SC) and evaluate the causes of death in patients with Stage I or II Seminoma treated in British Columbia (BC), Canada, and compare outcomes between patients managed with Radiation Therapy, Chemotherapy, or Active Surveillance. Materials and Methods: Consecutive patients with Stage I or II Seminoma (n = 1549) diagnosed in British Columbia between 1984 and 2013 were identified from the BC Cancer Registry and included in this study. Patients were managed with Radiation Therapy (RT; n = 663), Chemotherapy (CT; n = 259) or Active Surveillance (AS; n = 624). Data was extracted from the registry and verified by individual patient chart review. Cumulative incidence rates and mortality rates were computed using competing risk analysis, and compared using the Fine and Gray model. The 10yr testicular-cancer mortality (TCM), second cancer related mortality (SCM), cardiovascular mortality (CVM), treatment related mortality (TRM), and all-cause mortality (ACM) were calculated, from diagnosis date. Results: After a median follow-up of 14 years (RT group: 21.5yrs, CT group: 10yrs, AS group: 8yrs), the 15 year Overall Survival was 91.4%. Only 9 patients died due to Seminoma, while 6 died from treatment related toxicity, 46 from second cancers, 52 from cardio-pulmonary causes, and 30 from other reasons. The 10yr ACM rate was 5.67% (4.72% RT group vs. 8.06% CT group vs. 5.75% AS group, p=ns), TCM was 0.62% (0.60% RT vs. 1.83% CT vs. 0.22% AS, p=ns), SCM was 1.66% (1.53% RT vs. 2.52% CT vs. 1.29% AS, p=ns), CVM was 1.43% (1.37% RT vs. 0.84% CT vs. 1.87% AS, p=ns), TRM was 0.45% and the difference between treatment groups was statistically significant: 0.15% RT vs. 1.55% CT vs. 0.32% AS, p=0.014. All 6 of the treatment related death were due to chemotherapy associated toxicity (some events occurred during salvage therapy, groups for analysis were based on initial treatment). A total of 115 patients developed SCs, and the cumulative incidence (CI) of SC, at 15 years, was: 5.9% for patients who received RT, 8.6% for those who had CT, and 4.9% for patients managed with AS. The higher CI for patients treated with CT, versus RT, was not statistically significant (p = 0.08). Conclusion: Patients with early stage Seminoma have excellent outcomes and very low cancer related mortality rates (0.62% at 10yr). We report significantly higher treatment related mortality rates with the use of chemotherapy (1.55%), as compared to RT or AS. We found no statistically significant difference in the Cumulative Incidence of Second Cancers for patients treated with Radiation Therapy versus Chemotherapy in our patient population. Longer follow-up for the CT group is required to confirm trends evident in our analysis.

 > Urology: 02 Top

Adaptive radiotherapy for carcinoma of the urinary bladder: Long term outcomes with dose escalation

Priyamvada Gupta, Vedang Murthy, Kasturi Baruah, Rahul Krishnatry, Ganesh Bakshi, Gagan Prakash, Mahendra Pal, Amit Joshi, Kumar Prabhash

Aims/Objectives: This study was done to assess the clinical outcomes with dose escalated, image guided adaptive radiation therapy (ART) in patients of muscle invasive bladder cancer (MIBC), as a part of trimodality treatment approach for bladder preservation. Materials and Methods: Patients with non-metastatic MIBC treated with ART were analysed. After maximal resection of bladder tumor, they were treated with radical chemoradiation. For ART, 3 anisotropic planning target volumes were concentrically grown (PTVs small, medium and large) around the bladder. A library of intensity modulated radiotherapy (IMRT) plans was created for each patient. A dose of 64 Gy in 32 fractions to the whole bladder and 55 Gy to the pelvic nodes was planned. In selected patients with solitary tumor or two tumors in close proximity, without any in situ carcinoma component, dose escalation to tumor bed to 68 Gy (equivalent dose for 2-Gy fractions assuming α/β of 10 [EQD2]10= 68.7 Gy) was planned. Simultaneous integrated boost was used for dose escalation and these patients were treated with a comfortably full bladder. On-board daily megavoltage imaging was used every day to choose the most appropriate PTV encompassing the bladder ('Plan-of-the-day' approach) for each fraction. Results: A total of 106 patients were analysed. Most patients had T2 (68%) or T3 (19%) disease. Twenty three patients (22%) received neoadjuvant chemotherapy and 76% received concurrent weekly chemotherapy (platinum-based in 63%, gemcitabine-based in 35%). Ninety two patients (87%) completed the planned dose of 64 Gy to the whole bladder while sixty three patients (59%) received 68 Gy to the tumor bed as boost. With a median followup of 26 months, 3-year locoregional control (LRC), disease-free survival (DFS), and overall survival (OS) were 74.3%, 62.9%, and 67.7% respectively. 82% retained a disease-free bladder, while another 8.5% had non muscle invasive recurrences managed conservatively. Patients receiving dose escalation to 68 Gy showed no difference in OS and DFS compared to those receiving <68 Gy. Acute and late Radiation Therapy Oncology Group (RTOG) grade III/IV genitourinary (GU) toxicity was seen in 7.5% and 9.4% patients respectively. Acute and late RTOG grade 3 gastrointestional (GI) toxicity was seen in 0% and 3.8% patients respectively. The incidence of grade 3 acute or late GU or GI toxicity was not found to be associated with dose escalation. Conclusion: Dose escalation with adaptive plan-of-the-day approach for bladder irradiation is clinically safe and effective. A high bladder preservation rate can be achieved without compromising on survival or toxicities using plan of the day ART.

 > Urology: 03 Top

Dosimetric analysis of 3DCRT versus IMRT in carcinoma bladder

Sarthak Moharir, K. L. Gupta, Virendra Bhandari, Om Prakash Gurjar, Priyusha Bagdare

Aims and Objectives: The current study aims to compare the dosimetry in 3DCRT vs. IMRT plans in the treatment of Urinary Bladder Cancer. Materials and Methods: 10 patients of Muscle invasive and locally advanced Ca Bladder were selected for study. After complete emptying of the bladder, four clamp orfit was used for immobilization of patients. Contouring of disease and relevant volumes was done on CECT images with 3 mm slice thickness were taken.3DCRT and IMRT plans were generated for each of the patients on the Eclipse Ver. 13.7 Treatment planning software. Total prescription dose to the PTV was taken to be 50 Gy in 25 Fx. @ 2Gy/# 5 days a week. Clinical Target volume (CTV) consisted of the grossly visible tumor (GTV) plus the whole bladder, as outlined in the RTOG consensus guidelines.PTV margins were taken at 0.5 cms from the CTV. Rectum and Both femoral heads were contoured as normal OARs. Plan was normalised to ensure that at least the 95% isodose adequately covered the full PTV. Initial optimization parameters were set according to institute protocol, and then adjusted to the required dose constraints. Conformity Index (CI) and Homogeneity index (HI) were calculated for each of the IMRT and 3DCRT plans generated. Dose delivered to the rectum and bilateral femoral heads were recorded and analyzedand comparison was done between IMRT and 3DCRT plansas per QUANTEC/ RTOG guidelines. Results: Mean V50 to Rectum in 3DCRT 42.034 Gy whereas in IMRT it was 21.976 Gy (p-value:<0.0001). Mean V65 (Rectum): 36.76 Gy in 3DCRT whereas 16.205 Gy in IMRT (p-value <0.0001). Mean Dmax to Left Femoral Head was 46.58 Gy in 3DCRT whereas 44.94 Gy in IMRT (p-value>0.05).MEAN Dmax to Right Femoral Head was47.397 Gy in 3DCRT whereas 44.852 Gy in IMRT (p-value>0.05).CI for 3DCRT was 1.2059 while for IMRT 1.6589. (p-value <0.0001)HI for 3DCRT was 1.055582 while for IMRT was 1.059849 (p-value>0.05). Mean dose delivered to rectum was significantly less with IMRT plans. Mean dose delivered to both femoral heads was similar in both planning techniques, with no significant statistical difference. The dose toboth femoral heads were well within constraints in both techniques.CI was superior in IMRT technique w.r.t 3DCRT technique i.e. IMRT planning achieves highly conformal dose distribution as compared to 3DCRT. There was no significant statistical difference between HI in IMRT and 3DCT techniques. Conclusion: With this study we demonstrated that IMRT plans are superior in terms of conformity as compared to 3DCRT.OAR sparing is superior in case of IMRT plans, with much lower doses delivered to the contoured OARs.IMRT plans, however have a disadvantage of higher number of MUs, thus increasing the Integral Body Dose. Bladder is an ideal organ for daily online imaging with corrections based on soft tissue position, and daily image guided adaptive Radiotherapy should be practiced.

 > Urology: 04 Top

To evaluate volume changes in prostate cancer on CT-scan and MRI based radiotherapy treatment planning

Shashank N. Singh, V. Bhandari, O. P. Gurjar, P. Bagdare

Aims/Objectives: To evaluate impact of MRI on radiotherapy target volume changes in prostate cancer. Materials and Methods: A total of 10 patients diagnosed with localised prostate cancer (T2, T3; adenocarcinoma) who were advised treatment with radical radiotherapy were included in the study. The patients were simulated on CT simulator with adequate immobilization. All the patients were then subjected to MRI. Both the image sets were transferred to treatment planning system. Target delineation (GTV, CTV) was done on both the image sets separately and their volumes compared. Results: In current study it has been found that the CT images based contouring overestimated the GTV and CTV with 35.4% and 21.7% respectively as compared to that by MRI images. The difference observed was statistically significant in case of GTV, whereas not statistically significant for CTV. Conclusions: It can be concluded that MRI is found to be better modality for GTV delineation, as it gives superior soft tissue contrast. This fact can be used as advantage especially for planning boost and response evaluation. Whereas CT imaging can be efficiently used to cover microscopic tumour spread, also treatment planning systems which are commercially available for dose calculations are all CT based. Hence the fusion of MRI with CT images together should be used as a routine procedure for radiotherapy treatment planning.

 > Urology: 05 Top

Correlating Ga68-prostate specific membrane antigen PET-CT with mpMRI to define dominant intraprostatic lesion for focal radiotherapy boost planning

A. Sasidharan, V. Murthy, A. Natarajan1, P. Popat2, S. Gudi2, S. Singh2, A. Agarwal1, V. Rangarajan1

Departments of Radiation Oncology,1 Bioimaging and2 Radiology, Tata Memorial Centre, Mumbai, Maharashtra, India

Aims and Objectives: Delineation of dominant intraprostatic lesion (DIL) for focal boost radiotherapy planningis done using multiparametric MRI (mpMRI). Image distortions due to MR artefacts, CT-MR fusion uncertainties and inter-observer variability in delineation of lesion are some of the limitations associated with delineation using MRI. Prostate specific membrane antigen (PSMA) PET-CT provides biological in addition to anatomical information in a single scan. This study was done with an aim to evaluate role of PSMA PET-CT in delineation of DIL and correlate with MR delineated volume. The objective was to find a relative cut-off value of SUVmax of the lesion which would autogenerate DIL volume corresponding to the volume delineated in mpMRI. Materials and Methods: Twenty patients with prostatic adenocarcinoma with a DIL visible in both PSMA PET-CT and mpMRI done at baseline before any treatment were included in the study. Volume of DIL was delineated by three radiologists independently in mpMRI blinded to each others' contour. A consensus volume was generated using intersection of two out of the three contours. Multiple relative %SUVmax volumes were autogenerated in PSMA PET-CT and these volumes were numerically matched with mpMRI consensus volumes. Statistical analysis was done with pearson correlation coefficient and linear regression analysis. Results: The median duration between mpMRI and PSMA PET-CT was 1 week (range 0-5). Median consensus volume of DIL in mpMRI was 4 cc (Interquartile range, IQR = 2.5 – 7.6 cc). The IQR for interobserver variability was 0.5 – 2.5 cc. Median SUVmax of the DIL was 14.1 (IQR = 10.2 – 22.3). Median percentage of SUVmax corresponding to MR volume was 41% of SUVmax (IQR = 34-55%). Median absolute SUVmax corresponding to MR volume was 7.2 (IQR = 3.6 - 9.8). There was a strong negative correlation between MRI volume and relative SUVmax (r=-0.829, p<0.001). Linear regression analysis showed an R2 of 0.69. The relationship between percentage of SUVmax (y) and mpMRI volume (x) in our study was y = 67.15+(-4.42*x). There was no correlation between mpMRI volume and absolute SUVmax of the lesion. Conclusions: The median %SUVmax corresponding to MR volume of DIL was 41%. There is a strong inverse relationship between mpMRI defined DIL volume and the percentage of the SUVmax which generates a corresponding numerically matched volume in PSMA PET-CT. This information may help in generating more data to integrate PSMA PET into radiotherapy planning especially focal boost of DIL.

 > Urology: 06 Top

Evaluation of intrafraction prostate motion, associated factors and acute toxicity profile during image guided radiation therapy of carcinoma prostate

A. I. Lodi, V. Bhandari, O. P. Gurjar, P. Bagdare, A. Khan, P. Handa

Aims: To evaluate the internal organ motion of prostate and volume changes of bladder and rectum by comparison of before-and-after treatment kV CBCT (cone beam computed tomography) images during radiotherapy treatment delivery to the prostate. Also, to understand the pattern of acute toxicities during image guided radiation therapy (IGRT) of prostate cancer. Materials and Methods: Ten patients of localized prostate cancer were planned for definitive treatment by IGRT to a maximum dose of 76 Gray (Gy) abiding by a strict bladder and bowel protocol, combining a pair of before-and-after treatment kV CBCT imaging with 16 fractions out of the possible 38 fractions. A total of 320 kV CBCT image sets were generated corresponding to 160 sessions for 10 patients. Patients were set on the linear accelerator couch using immobilizing devices. Online geometrical verification was done by taking kV CBCT images before the plan delivery and pre-treatment couch shifts were corrected to nullify the interfraction motion. Immediately after the plan delivery, repeat kV CBCT were acquired to analyse the intrafraction motion. The intrafraction prostate shifts were assessed across the lateral, longitudinal and vertical axes and corresponding changes in the bladder and rectum volumes were determined by comparing the before-and-after treatment CBCT image sets. The patients were followed up in view of acute treatment-related toxicities and graded according to common terminology criteria for adverse events (CTCAE) version 5.0 and Radiation Therapy Oncology Group/ European Organisation for the Research and Treatment of Cancer (RTOG/EORTC) toxicity scale. Results: The mean and median intrafraction prostate shifts across 160 treatment sessions was found out to be 0.10 cm (±0.04), 0.09 cm (±0.04), 0.15 cm (± 0.06) and 0.09 cm, 0.09 cm and 0.15 cm along the lateral (X), longitudinal (Y) and vertical (Z) axes, respectively. The mean IDV (isodisplacement vector) of intrafraction shifts was 0.24 cm (± 0.05). The mean change in bladder and rectum volumes was 79.79 ml (± 41.48) and 5.83 ml (± 1.60), respectively. Grade 1 and grade 2 fatigue was seen in 1 patient each. Grade 1 and 2 cystitis was present in 2 and 1 patient, respectively. Grade 1 frequency, incontinence, diarrheoa and proctitis were observed in 3, 2, 1 and 2 patients, respectively. Overall, grade 1 and 2 genitourinary (GU) toxicities developed in 4 and 1 patient, respectively. Grade 1 and 2 gastrointestinal (GI) toxicities were seen in 3 and 1 patient, respectively. Conclusions: Based on these observations, daily CBCT is recommended necessarily with a strict bladder and bowel protocol during radiotherapy of carcinoma prostate for precise dose delivery with least possible dose to the organs at risk (OARs) to ensure accurate treatment and minimal toxicities.

 > Urology: 07 Top

Systemic therapy in metastatic kidney cancer


Department of Radiotherapy, Medical College Kozhikode, Kozhikode, Kerala, India

Aims: To evaluate the role of systemic therapy in Metastatic Renal Cell Carcinoma Kidney cancer is the 6th most common malignancy among men and 10th among women, 25–30% of patients present with metastases at the time of diagnosis. Historically, Kidney cancer accounts for about 2–3 % of all cancers in the world each year and is the third-most common urological tumor. The most common type of renal malignant tumour in adults is renal cell carcinoma (RCC), which represents approximately 90–95 % of all cases. Renal Cell Carcinoma consists of different types of tumors, with the most common histological subtype being clear cell (ccRCC) of about 75–80 %. All other subtypes are classified as non-clear cell RCC, which include papillary (papRCC), chromophobe RCC (chRCC) and various other entities. During the last decade of the millennium metastatic RCC (mRCC) was treated using cytokine therapies (interleukin-2 and interferon alfa). The new millennium promised many opportunities like the development of tyrosine kinase inhibitors (TKIs), which target vascular endothelial growth factors, and mammalian target of rapamycin (mTOR) nhibitors superseding the cytokine-based therapies, which have greater toxicity and relatively lower efficacy. More recently, checkpoint inhibitors have introduced a further therapeutic option. Currently, there are eight first-line therapies approved for patients with mRCC, including the recent Food and Drug Administration (FDA) approval of cabozantinib, a multikinase inhibitor. Recently completed phase III studies have brought into light immunotherapy options into the first-line therapy like nivolumab plus ipilimumab. Conclusions: Lot of research needs to be done in the field of metastatic Renal cell carcinoma for obtaining a meaningful symptom free life for these patients. The new drugs especially the immunotherapy drugs has made large difference in this aspect.


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