Background: Vertebrae are the second commonest site among skeletal locations affected by hemangioma, but only about one per cent becomes symptomatic throughout the life. Though surgery, intra vertebral injection of various sclerosing agents have been tried in treating this benign process, no general consensus regarding management has been reached. Radiotherapy is emerging as a low cost, simple, non-invasive but very effective modality of treatment of symptomatic vertebral hemangioma. Aim: This study aims to find out the role of external beam radiotherapy in alleviating the symptoms of symptomatic vertebral hemangiomas without compromising the quality of life. Materials and Methods: Seven consecutive patients with symptomatic vertebral hemangioma were treated with a fixed dose of external beam radiotherapy; and muscle power was assessed before, after treatment and during follow-up. Results: All patients showed improvement of muscle power, which increased with the passage of time. Pain relief with improvement of quality of life was obtained in all the patients. Conclusion: Effect of radiotherapy on vertebral hemangioma is dose-dependent and the dose limiting factor is the spinal cord tolerance. In the present era of IMRT, greater dose can be delivered to the parts of vertebra affected by the hemangioma without compromising the spinal cord tolerance and expected to give better results.

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Transbronchial needle aspiration (TBNA) has the potential to allow adequate mediastinal staging of non-small cell lung cancer with enlarged lymph nodes in most patients without the need for mediastinoscopy. Metastasis to the mediastinal lymph nodes is one of the most important factors in determining resectability and prognosis in non-small cell lung cancer. The importance of TBNA as a tool for diagnosing intrathoracic lymphadenopathy as well as in the staging of lung cancer has been reported in various studies. We performed a literature search in PubMed and Journal of Bronchology using the keyword transbronchial needle aspiration. TBNA is a safe and effective procedure to diagnose mediastinal lymphadenopathy. Real-time bronchoscopic ultrasound-guided TBNA is the new kid on the block, which can further enhance the sensitivity of bronchoscopy in the diagnosis of mediastinal lesions.

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Inflammatory myofibroblastic tumor of the abdominal wall is a rare soft-tissue tumor presentation in adults. A 50-year-old woman was referred with abdominal pain and a palpable mass in the left lower quadrant. Computed tomography scan and magnetic resonance investigation revealed an 8-cm heterogeneous abdominal wall mass. Tumor markers were within normal limits. Fine-needle aspiration cytology and tru-cut biopsies yielded necrotic material. A preoperative diagnosis of a resectable rhabdomyosarcoma was suggested. On exploration a tumor measuring 8 x 8 x 6 cm was resected along with the involved structures. Histopathologic examination of specimen revealed an inflammatory myofibroblastic tumor of the abdominal wall. The patient has been followed up for the last 12 months without clinical or radiographic evidence of recurrence. Inflammatory myofibroblastic tumor arising from the anterior abdominal wall in adults is an unusual manifestation of soft-tissue tumors, which can be managed by a multidisciplinary team of surgeons, oncologists, radiologists and pathologists.

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Purpose : To investigate the feasibility of concurrent chemo radiation in locally advanced carcinoma cervix patients in our clinical setting. Materials and Methods : From Sept. 1 ^st 2005 to Aug. 31 ^st 2006, 102 patients of carcinoma cervix belonging to stage IIA to IV A were enrolled in the study. External beam radiation therapy was administered using Cobalt 60 teletherapy machine. Cisplatinum (40 mg/m ² ) and 5 Fluorouracil (500 mg /m ² ) continuous infusions with radiotherapy on D2-D5 in first and last 5 # of radiation therapy were administered. Results : Response to treatment and toxicities were monitored and analyzed in 102 patients (50 study group and 52 control group). All 102 patients completed treatment. Out of 50 patients in the study group, 30, 10 and 4 patients had complete, partial and progressive disease, respectively. While out of 52 patients in the control group, 26 had complete and 12 showed partial response. No difference in overall renal, hematological and cutaneous toxicity was seen between two groups. Conclusion : This study did not show any benefit of concurrent chemo radiation as compared to radiotherapy alone in locally advanced cervical cancer patients. This could be due to more bulk of tumor stage per stage, poor nutritional status, less number of patients in both arms, not enough to pick up statistically significant small difference in outcome.

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Background: There are no data regarding the factors influencing the choice of therapeutic bronchoscopic modality in the management of malignant airway stenoses. Objectives: To assess the choice of therapeutic bronchoscopy modality and analyze factors influencing survival in patients with malignant central airway obstruction. Materials and Methods: We performed 167 procedures in 130 consecutive patients, for malignant central airway obstruction, over six years. Results: Laser was used either alone or in combination with stent insertion in 76% procedures. Laser only was used in 53% procedures for lesions below the main bronchi. Stents alone were used for extrinsic compression or stump insufficiency. Combined laser and stent insertion was most frequently used for lesions involving the trachea plus both main bronchi or only the main bronchi. The Dumon stent was preferred in lesions of the trachea and the right bronchial tree, the Ultraflex stent for lesions on the left side and stenoses below the main bronchi. Survival was better in patients with lung cancer, lesions restricted to one lung and when laser alone was used compared to esophageal cancer, metastases and tracheal involvement. Conclusion: The choice of different airway stents can be made based on the nature and site of the lesion. Dumon stents are suited for lesions in trachea and right main bronchus and the Ultraflex stents on the left side and stenoses beyond the main bronchi. Survival can be estimated based on the diagnosis, site of the lesion and treatment modality used.

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Background: Linear Accelerator-based Intensity Modulated Radiation Therapy (IMRT), either as step-and shoot (SS) or in dynamic mode, is now considered routine in the definitive management of head and neck squamous cell carcinoma (HNSCC). Helical TomoTherapy (HT) is a new platform to deliver IMRT. This study aims to compare step-and-shoot Intensity Modulated Radiation Therapy (SS IMRT) with dynamic Helical TomoTherapy (HT) dosimetrically in patients with head and neck squamous cell carcinoma (HNSCC). Materials and Methods: Twelve patients with HNSCC, previously treated with SS IMRT, were re-planned on HT using the same CT dataset. Plans were compared for target coverage and organs-at-risk (OARs) sparing. Sparing of parotids was assessed after stratifying for side (contralateral vs. ipsilateral) and site of disease (laryngopharynx vs. oropharynx). Normal tissue complication probabilities (NTCP) were also compared for the parotid glands. Results: All HT plans showed improvement in target coverage and homogeneity, and reduction in OAR doses as compared to SS IMRT plans. For PTV 66, the mean V ₉₉ improved by 14.65% ( P = 0.02). Dose Homogeneity (D _10-90 ) was significantly better in the HT plans (mean 2.07Gy as compared to 4.5Gy in the SS IMRT plans, P = 0.02). HT resulted in an average reduction of mean parotid dose of 12.66Gy and 18.28Gy for the contralateral and ipsilateral glands ( P = 0.003) respectively. This translated into a 24.09% and 35.22% reduction in Normal Tissue Complication Probability (NTCP) for the contralateral and ipsilateral parotids respectively ( P < 0.01). Site of disease (laryngopharynx vs. oropharynx) did not have any significant impact on parotid sparing between SS IMRT and HT. The maximum dose to the spinal cord showed a mean reduction of 12.07Gy in HT plans ( P = 0.02). Conclusion: Helical Tomotherapy achieved better target coverage with improved OAR sparing as compared to SS IMRT. The significant reduction in mean parotid doses translated into meaningful reduction in NTCP, with potential clinical implications in terms of reduction in Xerostomia and improved quality of life in patients with HNSCC.

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Aim : Compare the planning target volume (PTV) coverage in three different shielding techniques in cranial irradiation. Settings and Design : Tertiary care center, prospective study. Materials and Methods : The whole brain and meninges were contoured in ten planning CT scans, and expanded by 5 mm for the PTV. Shielding was designed using the French Society of Pediatric Oncology (SFOP) guidelines (SFOP plan), in-house recommendation (with 1 cm margin from the orbital roof and sphenoid wing) on a igitally Reconstructed Radiograph (DRR) and a third plan was generated using a 3D conformal radiation technique (3DCRT). The coverage of the PTV was noted using the isodose covering 95% of the PTV(D95), minimum dose within the PTV(D _min ), and maximum dose within the PTV(D _max ). The location of PTV not covered by the 95% isodose curve was noted. The median dose and maximum dose (D _max ) to both eyes and maximum dose D _max for the lens were noted. Statistical Analysis : General linear model method repeated the measure of analysis of variance test (ANOVA). Results : PTV coverage was significantly poorer in the SFOP and in-house plans as compared to 3DCRT plan (P=0.04). Median volume of PTV not covered by 95% isodose curve was 4.18 cc, 1.01 cc, and 0 cc in SFOP, in-house, and 3DCRT plan, respectively. Conclusions : In the absence of volumetric planning techniques, SFOP guidelines lead to inadequate coverage and the in-house method is recommended.

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Angiogenesis plays a key role in the initiation of growth and metastatic process in cancers. The angiogenic switch may be one of the earliest events in conferring a metastatic potential to the tumor. Further evolution in this multi-step cascade is controlled by the positive and negative regulators of angiogenesis. Recent advances in molecular biology have given a better insight into the mechanisms governing head neck cancer with promising data elaborating the role of angiogenesis. Metastasis to neck nodes is a very important determinant of prognosis, and is more frequently encountered than distant metastasis in head and neck cancers. Systematic PUBMED search of English-language literature of studies involving humans between 1990 and 2008 using the Mesh terms 'pathologic neovascularization', 'head and neck neoplasms', 'lymphatic metastasis' was performed. Quality assessment of selected studies included clinical pertinence, publication in peer reviewed journals, adequate number of enrolled patients. The present article reviews the utility value of various angiogenic parameters and markers that have been utilized to predict regional metastasis including micro vessel density, positive and negative regulators of angiogenesis, and genetic markers for angiogenesis. Although there seems promising preclinical and clinical evidence paving way for novel diagnostic and therapeutic interventions, the implicit role of angiogenesis in metastatic head and neck cancers needs further substantiation.

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Background : Aim of the study was to assess prostate motion on daily basis with respect to setup and to compare the shifts based on bony anatomy and gold fiducial markers. Materials and Methods : Gold fiducial markers were inserted in prostate under U/S guidance and daily portal images were taken and compared with digitally reconstructed images, both using bony landmarks and fiducial markers as reference. A dose of 2 MU was given for two orthogonal images daily. The mean and standard deviation of displacement using gold seeds and bone were calculated. Systematic and random errors were generated. The planning target volume (PTV) was calculated using the Van Herk formula. Results : A total of 180 portal images from 10 patients were studied. The mean displacement along x, y and z axes was 1.67 mm, 3.58 mm, and 1.76 mm using fiducial markers and 2.12 mm, 3.47 mm, and 2.09 mm using bony landmarks, respectively. The mean internal organ motion was 1.23 mm (+1.45), 3.11 mm (+2.69 mm); and 1.87 mm (+1.67 mm) along x, y and z axes, respectively. The PTV to account for prostate motion if daily matching was not done was 4.64 mm, 10.41 mm and 4.40 mm along lateral, superoinferior, and anteroposterior directions, respectively. If bony landmarks were used for daily matching, margins of 3.61 mm, 7.31 mm, and 4.72 mm in lateral, superoinferior, and anteroposterior directions should be added to the clinical target volume. Conclusion : Daily alignment using gold fiducial markers is an effective method of localizing prostate displacement. It provides the option of reducing margins, thus limiting normal tissue toxicity and allowing the possibility of dose escalation for better long-term control.

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Background : Cell regulatory G2/M phase proteins are the key regulators of mitosis and have been reported with abnormal expressions in various malignancies. Aim : To determine the expressions of these proteins in neoplastic uterine cervix tissue. Materials and Methods : This study evaluates the G2/M phase regulatory protein expression of Cyclin B1, Aurora-B, Pololike kinase 1 (PLK1) and LIM kinase1 (LIMK1) in tissues of 25 normal (control), 16 dysplastic (dysplasia) and 34 neoplastic (cancer) patients of uterine cervix. The expressions of different proteins were obtained by using Western Blot technique. Statistical Analysis : One way analysis of variance (ANOVA), Pearson correlation, Kaplan-Meier and other tests are used for analysis. Results and Conclusion : The level of expression of LIMK1 in cervical cancer patients was found to be significantly higher (P <0.01) than both the controls and dysplasia. The expression of Aurora B and PLK1 in cervical cancer patients was also found to be significantly higher ( P <0.05) than controls but it did not differ with dysplasia. However, the expression of Cyclin B1 was similar among cervical cancer patients, dysplasia and controls ( P >0.05). The expression of all the above proteins showed significant ( P <0.01) and inverse relation with the survival of cancer patients. Among the selected candidate proteins, it was LIMK1 that showed the most positive correlation with the aggressiveness of the disease and negative correlation (r= -0.64; P <0.01) with the survival of patients.

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Background: The evaluation of the agreement between measured and calculated dose plays an essential role in the quality assurance (QA) procedures of intensity-modulated radiation therapy (IMRT). Aim: The purpose of this study is to compare performances of the two dosimetric systems (EDR2 and I'matriXX) in the verification of the dose distributions calculated by the TPS for brain and head and neck dynamic IMRT cases. Materials and Methods: The comparison of cumulative fluence by using Kodak extended dose rate (EDR2) and I'matriXX detectors has been done for the evaluation of 10 brain, 10 head and neck IMRT cases treated with 6 MV beams. The parameter used to assess the quality of dose calculation is the gamma-index (g -index) method. The acceptance limits for g calculation we have used are 3% and 3 mm respectively for dose agreement and distance to agreement parameters. Statistical analyses were performed by using the paired, two-tailed Student t-test, and P< 0.01 is kept as a threshold for the significance level. Results: The qualitative dose distribution comparison was performed using composite dose distribution in the measurement plane and profiles along various axes for TPS vs. EDR2 film and TPS Vs I'matriXX. The quantitative analysis between the calculated and measured dose distribution was evaluated using DTA and g-index. The percentage of pixels matching with the set DTA and g values are comparable for both with EDR2 film and I'matriXX array detectors. Statistically there was no significant variation observed between EDR2 film and I'matriXX in terms of the mean percentage of pixel passing g for brain cases (98.77 ± 1.03 vs 97.62 ± 1.66, P = 0.0218) and for head and neck cases (97.39 ± 2.13 vs 97.17 ± 1.52%, P = 0.7404). Conclusion: Due to simplicity and fast evaluation process of array detectors, it can be routinely used in busy departments without compromising the measurement accuracy.

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The aim of this work is to develop a wireless local area network (LAN) between different types of users (Radiation Oncologists, Radiological Physicists, Radiation Technologists, etc) for efficient patient data management and to made easy the availability of information (chair side) to improve the quality of patient care in Radiation Oncology department. We have used mobile workstations (Laptops) and stationary workstations, all equipped with wireless-fidelity (Wi-Fi) access. Wireless standard 802.11g (as recommended by Institute of Electrical and Electronic Engineers (IEEE, Piscataway, NJ) has been used. The wireless networking was configured with the Service Set Identifier (SSID), Media Access Control (MAC) address filtering, and Wired Equivalent Privacy (WEP) network securities. We are successfully using this wireless network in sharing the indigenously developed patient information management software. The proper selection of the hardware and the software combined with a secure wireless LAN setup will lead to a more efficient and productive radiation oncology department.

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We report a case of a 45-year-old male patient with intraventricular cystic meningioma located in the left lateral ventricle. He presented with complaints of global headache, progressively increasing loss of memory, and frequent episodes of abnormal behavior, of 1 month duration. At the time of hospital admission, his general and neurological examination was normal. Neuroimaging studies showed a left lateral ventricular enhancing mass, composed of mixed solid and cystic areas. The tumor was completely excised via the anterior transcallosal approach. A histological examination revealed a meningothelial meningioma without any atypia. The aim of this report is to present the occurrence of an intraventricular cystic meningioma.

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The co-occurrence of two or more brain tumors with different histological features is rare. The authors report three rare cases of intracranial tumors associated with pituitary adenomas. Two of the pituitary tumors were functioning adenomas: a prolactinoma and a thyrotropin secreting adenoma. Two of the associated intracranial neoplasms were gliomas and one was a meningioma. Radiological and clinical examination for syndromal association was negative in all cases. We briefly discuss the presentation and treatment options of these cases and review the 19 previous publications in the literature of pituitary tumors occurring in association with other neoplasms and explore the possible links underlying these co-occurring neoplasms. Our three cases represent 0.86% of all pituitary tumors operated at our institute over a 9-year period.

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Aims: To analyze the differences in dose distribution, with ovoid separation in various applications, by different radiotherapists in the same patient of carcinoma of the uterine cervix treated by multiple fractions of high-dose-rate (HDR) intracavitary Radio therapy (ICRT). Settings: Pravara Rural Hospital and Rural Medical College. Design: Retrospective study. Materials and Methods: Retrospective analysis of six cases of carcinoma uterine cervix, randomly chosen in the period from January 2004 and December 2007. Three selected radiotherapists performed the applicator placement for ICRT on the aforementioned patients in a consistent pattern-three consecutive ICRT treatments separated by weekly intervals. Ovoid separation was categorized into three groups: < 25 mm, 26-35 mm and > 36 mm. Prescribed point 'A' isodose lines with maximum separation laterally in right and left parametrium and antero-posteriorly in lateral plane was calculated for all 36 isodose charts for the 18 ICRT applications. Results: In this study, there proves to be a significant difference in the ovoid separation between the applications of the different radiotherapists in the same patient with multiple fractions of HDR-ICRT. The applications done by 'A' radiotherapist resulted in an ovoid separation of < 25 mm more often, 'B' radiotherapist of > 36 mm while, 'C' radiotherapist fell in between the two. Discussion and Conclusion: With more ovoid separation, lateral dose to parametrium was improved; however, antero-posterior dose was not significantly affected. In order to determine the best dose distribution, as evident in the dose charts of 'C' radiotherapist, it is recommended to choose the optimum ovoid separation in accordance to the patient's anatomy.

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We present the case of a 45-year-old female patient who harbored two synchronous primary malignant neoplasms-an anaplastic oligodendroglioma of the right frontal lobe and a squamous cell carcinoma of the tongue. Both neoplasms were in advanced stage and carried a dismal prognosis. To the best of our knowledge, this is the first documentation in the english literature of such a presentation. The purpose of this article is to alert clinicians to this possibility and to outline the management approach in a different manner in patients presenting with multiple primary neoplasms.

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Intramedullary spinal tuberculosis is a clinical curiosity. A 19-year-old female was diagnosed and treated for lumbosacral myxopapllary ependy moma (MPE). Three years later, she presented with back pain and hypoesthesia of the left upper limb. Besides revealing local recurrence, the MRI demonstrated a fresh lesion in the cervicomedullary area. The latter was operated and the histopathology revealed a tuberculoma.

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The occurrence of multiple primary malignant neoplasias (MPMN) is a rare but increasingly frequently reported event. Many theories have been proposed to explain MPMNs, but none have been proven. The key risk factors appear to be smoking and family history. While numerous studies have been published on the development of second malignancies following a first primary, the literature contains only few case reports and reviews of patients with three or more malignancies. We report a case of a young female who, over a period of 30 years, developed four different malignancies and was treated radically on each occasion.

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Background: To study the long term results of two phase II concurrent chemoradiotherapy protocols and conduct pooled data analysis with special emphasis on nodal density. Materials and Methods: In the period from April 2001 to May 2003, phase II Mitomycin C (MMC) and late chemo-intensification (LCI) protocols were started in the same institute, enrolling 69 and 74 patients respectively. Long term results for these individual trials are reported along with pooled data analysis. Results: Median follow-up time for whole group, MMC protocol and LCI protocol was 43.8 months (SD619.8), 55 months (SD 618.5) and 47.5 months (SD 620.9) respectively. LRFS, DFS and OS at five years for whole group was 59.4, 43.5 and 47.1% respectively, for MMC protocol was 59.9, 45.5 and 49.5% respectively and for LCI, protocol was 53.6%, 41.5% and 44.4% respectively. Subgroup analysis revealed that MMC protocol was more effective than LCI protocol in terms of DFS and OS in patients with hypo dense nodes while opposite was true for Isodense nodes. Multivariate analysis revealed nodal density as an independent variable that had an impact on treatment outcome. Risk of death in patients with hypo dense nodes was 2.91 times that of Isodense nodes. Conclusions: Innovative and pragmatic approach is required to address locally advanced head neck cancer. Long term results for MMC and LCI protocols are encouraging. Integrating the basic concepts of these protocols may help develop new protocols, which will facilitate the search for the optimal solution.

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