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Year : 2014  |  Volume : 10  |  Issue : 6  |  Page : 17-72

Poster Presentations

Date of Web Publication29-Oct-2014

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How to cite this article:
. Poster Presentations. J Can Res Ther 2014;10, Suppl S2:17-72

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. Poster Presentations. J Can Res Ther [serial online] 2014 [cited 2021 Jun 19];10:17-72. Available from: https://www.cancerjournal.net/text.asp?2014/10/6/17/143626

Head and Neck Cancer

Comparison of three dimensional conformal radiotherapy with cobalt-60 teletherapy in squamous cell carcinoma of the larynx

Akhil Kapoor, Kamlesh Kumar Harsh, Murli P., Rajesh Kumar, Ramesh Purohit, Harvindra Singh Kumar

Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Hospital, Bikaner, Rajasthan - 334 003, India. E-mail: [email protected]

Aim: The aim of the study was to compare the results of radical radiotherapy performed by three-dimensional conformal radiotherapy (3D-CRT) and by two dimensional radiotherapy (2DRT) realized with Cobalt-60 (780-E) teletherapy for squamous cell carcinoma of the larynx. Materials and Methods: Between January 2008 to December 2010 (3 years) a total of 98 newly diagnosed cases of Stage-I to IV-B of the carcinoma larynx were consider for study. All cases were staged according to the TNM-Staging system. Ninety eight patients with previously untreated were irradiated with curative intent at our institute. Radical Radiotherapy with the cobalt-60 teletherapy unit was performed on 56 patients and 42 patients were treated with a Linear Accelerator using 3D-CRT and were analyzed for overall survival, local recurrence rate, acute and late radiation reactions, lost to follow up and deaths. Results: The 2 and 3 years O.S. (Overall Survival) rates for control group irradiated with the telecobalt therapy were 75.0% and 71.4% and for the study group treated with 3D-CRT were 76.2% and 73.8% respectively. The 2 and 3 years Local recurrence rates for control group irradiated with the telecobalt therapy were 66.0% and 69.6% and for the study group treated with 3D-CRT were 66.7% and 69.0% respectively. Conclusion: No Statistically significant difference were observed either in overall survival or loco regional control between the patients treated with two different radiotherapy techniques. The grade of acute reactions of the skin and the larynx differed significantly between the accomplished radiotherapy techniques. There were statistically significant difference observed in the grade of late effects in the skin and in the subcutaneous tissue between the radiotherapy techniques used. According to the confirmed advantage of 3D-CRT in terms of reduced treatment toxicity observed in the our study, we consider conformal techniques being a basis in definitive radiotherapy of squamous cell carcinoma of the larynx until the new revolutionary techniques will be clinically available.

Is simultaneous integrated boost (sib) imrt superior over sequential imrt in nasopharyngeal cancer - radiobiologic and dosimetric analysis

Anbarasi.K, G. Selvaluxmi, Sam Deva Kumar

Cancer Institute, Chennai. E-mail: [email protected]

Aim: Intensity modulated radiotherapy (IMRT) has been accepted primary treatment in nasopharyngeal carcinoma due to its better conformity, increased tumor control and lesser dose to critical organs at risk. The choice between simultaneous integrated boost (SIB) IMRT and sequential IMRT are always matter of debate. The aim of this study is to compare SIB IMRT with sequential IMRT radiobiologically and dosimetrically. Materials and Methods: Twenty patients diagnosed as nasopharyngeal cancer treated in our institute in 2013 were taken for study. The planning CT scans reviewed and for all patients PTV1 and PTV2 contoured. The target dose prescribed to PTV1 and PTV2 were 54Gy and 70Gy respectively. The critical structures contoured were brain stem, optic nerve, spinal cord, parotid, temporal lobe and mandible. Two plans IMRT to PTV1 followed by sequential IMRT boost to PTV2 and SIB IMRT to both PTV1 and PTV2 were planned. Dosimetric comparison is made by DVH and NTCP and TCP is calculated using MATLAB software for both plans. Results: Among twenty patients analyzed all of them having better parotid sparing in SIB IMRT compared to sequential IMRT. Dose to other critical structures are less in SIB IMRT compared to sequential IMRT. D95, Dmax, Dmean are comparable in both plans. Also there is low NTCP in SIB IMRT compared to sequential IMRT. Conclusions: SIB IMRT is superior in reducing dose to critical organs at risk. As different dose per fractionation can be delivered to different target regions simultaneously in SIB IMRT with less toxicity, there is possibility of reducing overall treatment time with increases dose to tumor.

Can neck irradiation be an alternative to neck dissection in stage 1 carcinoma tongue patients operated for primary alone?

Bansal Anshuma, Ghoshal Sushmita

Department of Radiotherapy, Pgimer Chandigarh, E-mail: [email protected]

Introduction: There is limited literature on the efficacy of neck irradiation in controlling the occult lymph node metastasis from early stage carcinoma tongue, when neck dissection has not been done. Most of the data has been extrapolated from the survival benefits achieved by chemoradiation in patients with carcinoma oropharynx, where neck irradiation has shown results similar to nodal dissection in controlling the neck disease. Aims: To study the pattern of failure, locoregional control rates and disease free survival in different stages in post-operative patients of carcinoma tongue, and to study the effect of nodal dissection on nodal failure rates and disease free survival particularly in stage 1 patients. Materials and methods: This retrospective study analyzed 102 post-operative patients of carcinoma tongue treated at our institute between January 2009 and December 2013. All patients were operated for the primary disease, but neck dissection was done in 78 (76.5%) patients only. However, all patients had undergone radiation to both primary site as well as neck region. Pattern of failure has been studied in these patients. Stage wise locoregional control rates and disease-free survival curves were estimated with the Kaplan-Meier method. Survivals have been compared using log rank test, among stage 1 patients, based upon nodal dissection. Results: At a median follow up of 12 months, local failures as well as nodal failures were seen in 10.8% patients each. 2.9% patients failed both at local and nodal site, and 5.9% patients failed distally. The 1 year disease free survival was 82.4%, 80%, 57.8% and 20.4 % in stage 1, 2, 3 and 4 respectively. The 1 year disease-free survival in stage 1 post operative patients of carcinoma tongue, who underwent nodal dissection (14 patients) was 83.3 % and in those in whom nodal dissection was not done, but only neck irradiation was done (15 patients), it was 80.2 %, and the difference was not statistically significant (p = 0.5). Number of positive lymph nodes post dissection was identified as a single dominant prognostic factor for disease free survival in the multivariate analysis. Conclusion: The study indicates that neck dissection can be replaced by neck radiation alone for stage 1 patients of carcinoma tongue. However a large well randomized study is needed before inculcating the results into clinical practice.

Clinical outcomes with hdr surface mould brachytherapy in head and neck malignancies.

Archya Dasgupta, Ashwini Budrukkar, Prakash Pandit, Sarbani Laskar, Vedang Murthy, Jamema Swamidas, Rituraaj Upereti, Tejpal Gupta, Jai Prakash Agarwal

Department of Radiation Oncology and Medical Physics, Tata Memorial Centre, Mumbai, E-mail: [email protected]

Background: Surface mould brachytherapy (SMB) is a century old technique which can be used for various sites such as skin, nose, ear and hard palate in the head and neck region. There is scarcity of data on high dose rate (HDR) SMB. Aims and Objectives : To study the outcomes of patients treated with SMB technique. Methods and Materials: Patients with malignant localized early T1 or T2, node negative lesions in the head and neck region treated with SMB during 2008-2013 were considered. Individualized mould was prepared for all patients. Three dimensional CT based planning was carried out with the mould in situ using the Plato planning system (Nucletron). The median number of catheters was 5 (Range 3-7). Treatment was delivered using HDR 192 Ir source to a dose ranging from 39 to 52.5 Gy (mean 49 Gy) with 350cGy per fraction, using bid regimen for radical SMB alone. Median number of catheters used were 5 (range 3 to 7). For the present analysis the data was extracted from a prospective brachytherapy database as well as from patient charts. The data was analysed using SPSS software (V18). Survival analysis was done using Kaplan Meier method. Results: Thirty one patients were treated with SMB. The median age at presentation was 53 years (range 25-82 years). Most of the patients were males (n=24). The most common site was hard palate in 14 (45%), followed by nose in 7 (22.5%), soft palate in 5 (16%), tonsil in 2 (6.5%), skin over face in 2 (6.5%) and pinna 1 (3.5%). The histology was squamous carcinoma in 27 patients, while the rest were basal cell carcinoma. The median tumor size was 2 cm. Treatment was given in the primary setting in 29 and recurrent setting in 2 patients. Twenty three patients received the SMB as definitive, radical treatment while in 8 it was used as boost after external beam radiotherapy. Acute skin toxicity was seen in 17 patients of which 10 were grade II reactions. Acute mucosal reactions were seen in 19 with grade II in 10 and grade III in 1. Median follow up was 29 months (range 4 to 78 months). Eight patients had recurrent disease (4 primary, 3 isolated nodal recurrences and 1 primary and nodal recurrence). Two patients had died at 4 months and 14 months. Three year DFS was 70% and 3 year overall survival was 91%. Grade 1 mucosal atrophy was seen in 22. Grade 1 xerostomia was seen in 6 and grade II for 1 patient (all of them had received external radiotherapy). On long term follow up osteo- necrosis was seen for 2 of which 1 recurrence had at the primary site. Skin hypopigmentation was seen in 3 while telangiectasia was seen in 9 patients. Conclusion: Surface mould brachytherapy results in acceptable locoregional control rates and good overall survival with excellent organ and function preservation.

Clinical profile and treatment outcomes of carcinoma parotid: A single institution study

Cessal Thomamachan Kainackal, Arun Vasudevan, Rejinish Kumar, Malu Rafi, Biju Azariah, K. Ramadas

Division of Radiation Oncology, Regional Cancer Centre, Trivandrum, Kerala, India. E-mail:[email protected]

Introduction : Surgery with or without post operative Radiotherapy is the standard treatment for carcinoma parotid. The treatment outcome depends on various factors like tumor stage, histology, grade of the tumor and the completeness of surgery. Aim and Objective : To analyze the clinical profile and treatment outcomes of malignant parotid tumors treated at Regional cancer centre Trivandrum, during the time period 2008-2010 and to identify the various factors influencing the outcome. Materials and Methods : Ninety six patients treated at Regional cancer centre Trivandrum for malignant parotid tumor from 2008 to 2010 are included in the study. The patients were followed up until June 2014.The median follow up is 52 months. Observation and Results : Among the patients analysed,the male to female ratio is 1:1.All the patients underwent primary surgery.Sixty four patients(66%) had mucoepidermoid carcinoma,fifteen(15%) had adenoid cystic carcinoma,seven (8%) had acinic cell carcinoma and ten(10.4%) had carcinoma of other histologies. Seven patients in the analysis had pT1 status, sixty one patients had pT2 status, twenty seven had pT3 status and one patient had pT4 status.Post operatively thirteen patients(13.5%) were found to have positive nodes.Mucoepidermoid carcinoma constituted the major histology among the patients analysed. Adjuvant radiotherapy was given to fourty seven patients(48%) at a dose of 55-60Gy. The 3 year disease free survival with respect to Tstage are100% for pT1,96.3% for pT2,85.7% for pT3 stage.The three year DFS with respect to histology are 96.7% for mucoepidermoid carcinoma,100% for acinic cell carcinoma and 89% for adenoid cystic carcinoma. Conclusion : The most common histology in our series is mucoepidermoid carcinoma.The most common pathologic T stage is pT2.The disease free survival for the whole group analysed at 3 years is 94.5%.The various factors determining the disease outcome will be discussed.

Dysphagia following total glossectomy and adjuvant chemo-radiation in a recurrent malignancy of tongue: Cure versus quality of life?

Chigurupati Namrata, Rahul Ravind, Surya Prakash Vankina, Chelakkot G. Prameela

Clinical Associate Professor, & Consultant, Department of Radiation Oncology, Amrita Institute of Medical Sciences, Kochi. Kerala. 682041. E-mail: [email protected]

Introduction: Surgery and radiation are factors which can alter normal functioning of DARS (Dysphagia Aspiration Related Structures), and can lead to disorders of different grades, post treatment. Priorities are being placed on better quality of life with, dysphagia optimized intensity modulated radiation therapy (doIMRT) as advocated by Eisbruch et al [1]. The Case: A 36 year old lady was diagnosed with primary malignancy of tongue, T1N0M0 in September 2010, at a local hospital. She underwent wide local excision of lesion of right lateral border of anterior two thirds of tongue, with modified neck dissection of ipsilateral level 2 and 3 nodal stations. She was on regular follow up there and was disease free till January, 2014, following which she had local recurrence and was referred to our institute for further care. At presentation she was found to have T3 lesion with suspicious level IA node. She underwent total glossectomy, with right marginal mandibulectomy, left selective nodal dissection (Level I to IV), and right level IIA dissection; and ALT free flap reconstruction and tracheostomy. Postoperative histo-pathological staging was recurrent pT3N0M0, Stage III. Surgical margins being positive, she received concurrent chemoradiotherapy to a dose of 60 Gy in 30 fractions to tumour bed, and lymph nodal basins bilaterally and a simultaneous accelerated dose of 66 Gy to positive margin, using 3DCRT (due to financial constraints), and 3-weekly cisplatin. Postoperatively she had dysphagia and her nutritional support was maintained with a PEG tube and continues to be on PEG support. Swallowing Rehabilitation Procedures: Swallowing assessment using FEES (Fibre-optic endoscopic evaluation of swallowing) and video fluoroscopy (VFS) showed poor hyo-laryngeal elevation, leading to aspiration. Oral and pharyngeal phases of swallowing were affected, with pooling in oral cavity and poor mobilization of food bolus to pharyngeal phase. Maneuvers like tilting the head back while swallowing and jet feeding taught to her, had failed to improve her swallowing status. Her case was discussed with experts in swallowing and she is still on swallowing rehabilitation. Discussion : Total glossectomy is a morbid procedure, which by itself deranges oral phase of swallowing, and to a certain extent the pharyngeal phase also. Radical radiation dose could worsen the pharyngeal phase as well. An earlier analysis from our centre [2] had shown that dose exceeding 63 Gy to superior and middle constrictors and 56 Gy to inferior constrictors does compromise swallowing. Radical intent treatment like this poses dilemmas to treating oncology team and also drains personal, social, economical, and emotional resources of patient. Whether a less morbid organ-preserving oncological surgical procedure, with supportive optimized adjuvant radiation with or without brachytherapy could have given the same results, with an improved quality of life need to be looked into.

A prospective comparative study of hyperfractionated radiotherapy alone versus concurrent chemoradiation with conventional fractionation in locally advanced squamous cell carcinoma of head and neck

Debottam Barman*, Rajanigandha Tudu, Arkoprovo Halder, Kazi S. Manir, Asit Ranjan Deb, Anjali Majumder

Department of Radiotherapy, Medical College, Kolkata, West Bengal, India. E-mail:- debottam.barm[email protected]

Introduction: Loco regional failure represents the major cause of treatment failure in locally advanced head neck cancer (LAHNCC). Hyperfractionated radiotherapy (HFRT) increases loco-regional control (LRC) by increasing total tumor dose. Randomized Control Trials (RCTs) showed that HFRT schedules improved LRC rates with a modest impact on survival. Concurrent chemo-radiotherapy (CTRT) improves survival in LAHNC. Aims and Objectives: This single institutional prospective comparative study was conducted to compare LRC (primary end point), Disease Free Survival (DFS) at 1 year and toxicities (secondary end points) between CTRT with conventional fractionation and HFRT alone in LAHNC. Material and Methods: Between October 2012 to August 2013, 63 patients with locally advanced squamous cell carcinoma of the larynx and hypopharynx, American Joint Committee on Cancer (AJCC,7th Edition) stage III or non-metastatic stage IV, ECOG performance status 0-2 with normal blood parameters were enrolled in this study.The patients in Arm A (Control Arm) received conventional External Beam Radiotherapy (EBRT) with 2Gy/fraction, 5 days/week for 7 weeks to a total dose of 66-70Gy along with concurrent inj. Cisplatin 100mg/m2 every three weeks during radiation and Arm B (Study Arm) received HFRT with 81.6 Gy in 7 weeks, 1.2Gy/fraction twice daily with 6 hours gap between the two fractions. Patients were followed up for response and toxicities using Response Evaluation Criteria in Solid Tumors [RECIST version 1.1] and Common Terminology Criteria for Adverse Events [CTCAE version 4.0] respectively. Results: 63 eligible patients were enrolled. Two patients of each arm were excluded from analysis due to protocol deviation. At the end of the study, 59 patients were eligible for analysis with 33 and 26 patients in Arm A and Arm B respectively. Both groups had comparable baseline parameters. Median follow up was 14 months for Arm A and 13 months for Arm B. Both groups had comparable (p value=0.618) Complete Response (CR) rates (assessed after 6weeks of completion of treatment), 60.61% (20/33) and 65.38% (17/26) in Arm A and B respectively. Overall response [= CR +Partial Response (PR)] was better in Arm B [88.5% (23/26)], than Arm A [81.8% (27/33)], but statistically insignificant (p value=0.379). DFS rate at 1 yr was comparable (p value=0.553) [Arm A (63.63%) versus Arm B (69.23%)]. Both the arms did not show any significant difference in recurrence free survival [Arm A (12.5months) versus Arm B (12.707 months), p=0.782]. Grade 3 and 4 acute mucositis [Arm A=8/33(24.24%), Arm B=8/26(30.77%), p value= 0.4365] and acute skin toxicity [Arm A=6/33(18.18%), Arm B=7/26(26.92%), p value=0.2478] were comparable in both arms. Grade 3 dysphagia was significantly higher in Arm B [Arm A=5/33(15.15%), Arm B=8/26, p value=0.0263] but it did not cause treatment interruption. Grade 2 and 3 xerostomia [Arm A=13/33(39.39%), Arm B=9/26(34.62%),p=0.6187] and subcutaneous tissue fibrosis [Arm A=12/33(36.36%), Arm B=7/26(26.92%),p=0.3178] showed a non-significant trend towards lesser incidence in Arm B. Conclusions: HFRT is a well-tolerated treatment regimen with comparable toxicity events. In this small study HFRT schedule had better, but statistically insignificant overall response and DFS rate. Larger multi-institutional studies are required to validate these results.

Assessment of late thyroid toxicity in head and neck irradiation-follow up analysis.

C. Priyadarsini, Vishal Manik, S. Shanmugakumar, N. V. Kalaiyarasi, Baskar, Madhumathi, Sundaresan, Prabhakar

E-mail: [email protected]

Introduction: Thyroid dysfunction commonly develops after ionsing radiation therapy at therapeutic doses of neck as a result of direct radiation effects to thyroid gland.(non-stochaistic effects). Aim: To analyse the late thyroid toxicity in previously asymptomatic head and neck cancer cases that were treated with radiation including the neck portals and to identify the occurrence of clinical and sub clinical hypothyroidism. Materials And Methods: A total no of 45 head and neck cancer patients who received radiotherapy in our institute during 2011-12 were analysed. Thyroid function tests were performed 2 years after patient received radiotherapy and the results are evaluated. Results: Out of 45 patients, who received radiation to the dose of 60 Gy, 26 patients developed hypothyroidism. 20 are sub clinical and 6 are clinical. All patients are in the age group of 40 to 60 years. Patients were asked to follow up with endocrinologist for thyroid replacement therapy. Conclusion: Hypothyroidism causes considerable morbidity to the patient who undergo external beam radiation therapy. Screening tests for thyroid dysfunction should be made mandatory as a routine follow up. Thyroid shielding and designing portals so as to avoid thyroid gland irradiation should be considered during irradiation.

Expression of p53 and epidermal growth factor receptor (egfr) is associated with higher possibility of recurrent and residual disease in squamous cell carcinoma of head and neck region

Archana Jha 1 , Arun K. Rathi 1 , Mayank Aggarwal 2 , Kishore Singh 1 , Savita Arora 1 , J. D. Baruah 1

1 Department of Radiotherapy, Maulana Azad Medical College and LN Hospital, 2 Department of Radiation Oncology, BL Kapur Superspeciality Hospital, New Delhi, India. E-mail: [email protected]

Introduction: Elevated levels of EGFR mRNA have been detected in the normal mucosa of head and neck cancer patients. It is implicated in the pathogenesis of head and neck cancer and has been shown to be significant predictor of disease free survival in these patients. p53 mutations are found in over 50% of HNSCC which are commonly associated with tobacco and alcohol use. Mutated p53 is often incapable of proper functioning and is unable to induce apoptosis, which result in uncontrolled progression through cell cycle and tumor development. Aims and Objectives: The present study was done to study the expression of p53 and EGFR in recurrent and residual squamous cell carcinoma of head and neck region and correlate the expression with the timing of recurrence. Materials and Methods: The pretherapy biopsy of the 20 selected patients with recurrent or residual disease were reviewed and the expression of p53 and EGFR was evaluated by immunohistochemistry. The biopsy of matched control of 20 patients of HNSCC, who were disease free for 2 or more years after treatment were evaluated and compared with the study group. The expression of p53 and EGFR was then correlated with the time of recurrence. Results: In the study group, the Mean percentage of cells that were positive for p53 was 45.5 ± 30.40, whereas in control group it was 16.55 ± 18.73 (p-value 0.0008). Mean percentage of cells that were positive for EGFR in study group was 45.8 ± 30.82, whereas in control group 13.15 ± 23.27 (p-value 0.0005). On evaluating the correlation with the time of recurrence it was seen that in case of p53 vs time of recurrence, Pearson correlation factor was -0.12 i.e. negative linear relationship with small correlation, whereas in EGFR vs time of recurrence, Pearson correlation factor was -0.43 i.e. small negative correlations. Conclusion: The p53 and EGFR status when correlated with the time of recurrence showed small negative linear relationship, however the study shows that expression of EGFR and p53 is associated with higher possibility of residual/recurrent disease. More specific and aggressive approach of treatment could be taken with prior knowledge of the EGFR and p53 status

Re-irradiation in head and neck malignancy- a prospective study

Jyoti Poddar

E-mail: [email protected]

Introduction: Head and neck carcinoma forms a major part of all diagnosed cancers in developing countries. Despite of recent advances in management of locally advanced head and neck cancers, incidence of recurrences and second primary malignancies is very high. Treatment of recurrences by re-irradiation is a very challenging situation. Aim and Objectives : Single arm prospective analysis to evaluate the outcome of re-irradiation, among patients with recurrent and second primary head and neck carcinoma in previously irradiated area with respect to acute and late radiation induced morbidity, loco-regional control and disease free survival. Materials and Methods : Between August 2012- August 2013, 47 patients of recurrent or second primary malignancy of head and neck region in previously irradiated area(>45Gray) were treated with re-radiation either post-operatively or as definite treatment with or without chemotherapy in our institute. The median follow-up period was 13 months.

(1) Inclusion criteria


Biopsy proven recurrence or second primary tumour of head and neck invicinity of previously irradiated area


Minimum Interval between initial radiation and re-irradiation of 18 months


Previously treated with curative dose radiotherapy with minimum dose 45Gray

(d) No evidence of distant metastasis

(e) Age between 30 to 80 years


Exclusion criteria-Patients with severe sequelae of the initial course of radiotherapy eg. severe subcutaneous fibrosis etc


Treatment-Out of the 47 patients, 24 were of recurrence and 23 patients had second primary tumour. All patients were delivered 60-66 Gray in 30-33# with daily dose of 2 Gray for 6.5 weeks on Linear accelerator with 6 MV photons. Initial 50 Gray were delivered to the primary site and the lymphatic drainage area with adequate margin. After 50 Gray, patients were re-simulated and spinal cord was taken out of the field. If there was any persistent node, it was treated with a separate electron field.

Disease free interval between primary treatment and the recurrence or second primary tumour was of the range 18-156 months with median range being 60 months. 79% patients underwent surgery followed by radiotherapy. 20% received only radiotherapy and only 1% patient received concurrent CT and RT.

Results: Disease free survival at 6 months, 9 months and 12 months was 72.3%, 53.1% and 40% respectively.

Regarding Late Toxicity: 57% developed grade II, 27% developed grade I and 14% developed grade III subcutaneous fibrosis. Four patients developed trismus and one patient developed osteoradionecrosis. Conclusion: Second course of high dose radiotherapy is feasible in recurrent and second primary tumours of head and neck in both operable and inoperable lesions with acceptable toxicity. Severe treatment related morbidity is the major concern while delivering second course of radiation. Conformal techniques like IMRT and IGRT can reduce the dose to the organs at risk with better coverage of the target.

Inverted papilloma of mastoid cavity-a case report

Jyotiman Nath

E-mail: [email protected]

Introduction: Inverted papilloma originating primarily from the mastoid cavity is an extremely rare entity. It is a locally aggressive benign condition with increase risk of recurrence and malignant transformation. Surgery is the primary treatment for this condition. Radiation therapy should be considered in patients with incompletely resectable lesions, multiple recurrent tumors, and tumors associated with malignancy1. Here we are reporting a case of inverted papilloma of mastoid with dysplastic changes. Case Report : A 60 year male presented to ENT OPD of Assam medical College Dibrugarh in March 2014, with purulent fowl smelling discharge with severe pain in the right ear associated with marked hearing loss. There was no history of tinnitus, vertigo, autophony, hyperacusis or any features of facial nerve palsy. Histories of two similar episodes were there 40 years back for which surgery was done but no documentation available. The patient undergone radical mastoidectomy in May 2014. But after 2 months the patient again presented with profuse thick purulent discharge from right ear with sever earache and gaping in the right post auricular wound with exposed mastoid cavity filled with purulent discharge. The patient again underwent mastoid exploration on 1st August 2014 with removal of extensive granulation tissue. Histopathology report came out to be inverted papilloma with marked dysplastic changes with areas of microinvasion.Immunohistochemistry was done for ki67 and came out to be positive. The patient was then referred to the Radiotherapy department for a course of Radiotherapy. In Radiotherapy department treatment started with external beam radiation with cobalt 60.Now the patient is in Radiotherapy inpatient department of Assam medical College Dibrugarh, Undergoing a course of cobalt teletherapy, completed 16 fractions at 200cGy per fraction,5 days in a week. At present the postoperative wound is healthy and the earache has also subsided.The patient will complete the course of radiotherapy within few days and he will be followed up in due course of time.

Volumetric changes in gross tumour volume during radiation therapy in head and neck cancer- need for adaptive radiotherapy

Mohammed Raees, Hhasib Ag, Shridhar

E-mail: [email protected]

The treatment period over which radiation therapy is administered extends over several weeks. The anatomical changes of tumor and parotid should be taken into consideration, since tumor shrinkage in response to radiation therapy and weight loss due to radiation induced mucositis may impact on the dose distribution in both target and organ at risk with patients with head and neck cancer. After the implementation of the plan, CT scans were repeated after 5# and 20#, the volumetric changes were noted. We investigated the anatomical changes that occurred in the tumor during radiation therapy for head and neck cancer and evaluated the necessity of an adaptive replanning strategy.

Prospective study of voice outcomes post concurrent chemoirradiation in non laryngeal head and neck cancer

Nikhila K. R.*, Iqbal Ahmed, Rajesh J, Chendil V, Amruth Kadam

Department of Radiotherapy, Bangalore Medical College; Shivshankar, Yamini H.K, Department of Speech Pathology and Audiology, NIMHANS, Bangalore, India. E-mail: [email protected]

Introduction: Concurrent chemoirradiation (CCRT) is the standard of care in conservative management of head and neck squamous cell carcinoma (HNSCC). Radiation induced laryngeal toxicity causes compromise of voice and speech, thus affecting the patient's quality of life (QOL). Objective: To assess the acute changes in the quality of voice post CCRT in patients with non laryngeal HNSCC and identify its effect on their QOL. Methodology: 20 patients, diagnosed with HNSCC were treated with CCRT to a total dose of 66-70 Gy/33-35 fractions by shrinking field technique at 5 fractions/week with 5 cycles of weekly cisplatin. Vocal cord was examined by nasopharyngolaryngoscopy (NPL). Acoustic analysis was performed at the baseline, 6 weeks and 3 months post RT using the MDVP - CSL (multi dimensional voice program - computerized speech laboratory) 4500 software. Sustained phonation of vowels a, i, o and speech sample in the native language were analysed. The vocal parameters assessed were fundamental frequency (fo), jitter, shimmer, noise to harmonics ratio (NHR) and electroglottographic contact quotient (E-CQ). Subjective assessment of voice was performed at the same intervals using the 30 item VoiSS questionnaire. Statistical correlation was done using ANNOVA. Results: Of the 20 recruited patients, 14 could be evaluated. 6 weeks post treatment, Grade II laryngeal toxicity was recorded in 5/14 (35.7%); grade III in 9/14 (64.28%) patients by NPL. 3 months post treatment, only 9/14 were available for analysis. 2/9 (22%) had improved with residual grade I toxicity only, 5/9 (55%) had grade II toxicity and 2/9 developed grade IV toxicity. Acoustic analysis revealed 9/14 (64%) patients had a decrease in the Fo from baseline and 5/14 (36%) patients had an increase in Fo. The jitter, shimmer and NHR values showed a significant increase, indicating the toxicity of CCRT. The E-CQ showed a variable insignificant change. The VoiSS scores showed a statistically significant deterioration in the total score 6 weeks post treatment (p <0.05) following which an improvement in the scores were recorded over next three months. Conclusions: Acute radiation toxicity of larynx is a common but understudied impact of CCRT in non laryngeal HNSCC. Acoustic analysis helps to map and correlate the vocal toxicity and its impact on QOL.

Synchronous dual primary malignancy of urinary bladder and hypopharynx in a 62-year-old male patient; An extremely rare phenomenon

Pranabandhu Das

E-mail:[email protected]

Aims and Objectives: The diagnosis of multiple primary malignancy (MPM) is not very uncommon. Nevertheless synchronous MPM involving urinary bladder and hypopharynx is an extremely unusual event.No such cases have been reported so far in English literature as evidenced by extensive review through MEDLINE in english literature.We present one such case who was treated with favourable outcome at our center. Materials and Method: A 62-year-old male who was a chronic smoker without any significant medical comorbidities presented with three months history of nocturia and ten days history of hematuria. Routine hematological investigations were within normal limits. On routine and microscopic examination of urine revealed plenty of epithelial and pus cells. Cystoscopic evaluation revealed flat sessile growth measuring about 6x3x2 cm extending over bladder base involving left vesicoureteric junction. Transurethral resection of bladder tumor (TURBT) was done.Histopathology report was suggestive of poorly differentiated carcinoma of urothelial origin. During this work up period patient had complaint of dysphagia to solids.Upper gastro intestinal endoscopy showed proliferative lesion at post cricoid region of hypopharynx. Biopsy from hypopharynx revealed squamous epithelium with underlying poorly differentiated malignancy.Whole body 18F-Fluro deoxy glucose Positron emission tomography with computed tomography (18F-FDG PET/CT) was advised as part of metastatic work-up which showed intense FDG concentration noted in post cricoid region of dimension 5x3x1 cm as well as in right para tracheal and left Level V cervical lymph node. Intense FDG concentration noted in the bladder wall on postero lateral aspect causing left sided hydroureteronephrosis.The diagnosis of synchronous dual malignancy involving urinary bladder (cT2N0M0) and hypopharynx (cT3N2cM0) was thus conferred. Patient was planned to receive radical radiotherapy to hypopharynx as the primary concern was progressive dysphagia. It was to be followed by radical cystectomy.Patient received 59.4 Gy in 33 fractions,1.8 Gy per fraction and five fractions per week within seven weeks to hypopharynx along with concurrent cisplatin chemotherapy 40 milligrams per week. Results : Following treatment he had symptomatic improvement of dysphagia as well as hematuria which was present prior to the above treatment. Radical cystectomy was planned to be accomplished four weeks after chemoradiation. But because of difficulty in intubation for general anesthesia before surgery the planned radical cystectomy was deferred and then he was planned for radical radiotherapy treatment to the urinary bladder.Later with progressive deterioration of his general condition, he expressed his unwillingness to afford for further treatment that enabled him to be kept under close observation and best supportive care at home. Currently the patient is in symptomatic remission six months after completion of the above treatment. Conclusion: While dealing with a cohort of patients with known malignancy this is always customary to keep in mind the possibility of occurrence of a second neoplasm and hence a high index of suspicion should warrant an aggressive work up for early detection of malignancy and treatment intervention for an improved outcome.This case is being reported because of its extremely rare occurrence, diagnostic as well as therapeutic challenges being encountered during the management of this rare entity in our clinical practice.

Systematic review and meta-analysis of conventionally fractionated concurrent chemoradiotherapy versus altered fractionation radiotherapy alone in the definitive management of loco-regionally advanced head and neck squamous cell carcinoma

Tejpal Gupta

ACTREC, Tata Memorial Centre, Mumbai,

E-mail:[email protected]

Background: Treatment intensification either by using concurrent chemoradiotherapy (CCRT) or altered fractionation radiotherapy (AFRT) improves outcomes in loco-regionally advanced head and neck squamous cell carcinoma (HNSCC). However, superiority of one approach over the other remains to be firmly established. Aims: To compare outcomes of CCRT with AFRT in the definitive management of loco-regionally advanced HNSCC for evidence-based decision-making regarding the best form of treatment intensification. Methods: Randomized controlled trials directly comparing conventionally fractionated CCRT with AFRT alone were identified through a systematic literature search. Only appropriate arms were included in the comparison from multi-arm trials. Overall survival was the primary outcome of interest whereas disease-free survival, loco-regional control, and toxicity were secondary endpoints. Outcome data was extracted independently by two reviewers and pooled using the Cochrane methodology for meta-analysis and expressed as hazard ratio (HR) or odds ratio (OR) as appropriate with 95% confidence intervals (CIs). Results: Five randomized controlled trials (involving 1117 patients and 627 deaths) directly comparing conventionally fractionated CCRT with AFRT alone were included. The risk of bias in included studies was low for efficacy outcomes, but high for toxicity outcomes. The overall pooled HR of death was 0.73 (95%CI=0.62-0.86) that significantly favored conventionally fractionated CCRT over AFRT alone (p<0.0001). Similarly, disease-free survival (HR=0.79, 95%CI=0.68-0.92; p=0.002) and loco-regional control (HR=0.71, 95%CI=0.59-0.84; p<0.0001) were significantly improved with CCRT. There was no significant difference in severe acute dermatitis between both approaches of treatment intensification; severe acute mucositis though was borderline increased with AFRT. Late xerostomia was significantly increased with CCRT. Significant hematologic toxicity and nephrotoxicity was seen exclusively with chemotherapy. Conclusion: Conventionally fractionated CCRT improves disease outcomes compared to AFRT alone in the definitive management of loco-regionally advanced HNSCC, although at increased risk of toxicity. No form of acceleration can compensate fully for lack of concurrent chemotherapy.

Treatment of carcinoma of external auditory canal and middle ear: a tertiary cancer centre experience of 50 patients

Ajeet Kumar Gandhi

MD, DNB, Senior Resident, Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India-110029, E-mail: [email protected]

Introduction: Carcinoma of EAC (external auditory canal) and ME (middle ear) is an extremely rare disease entity accounting as a cause of 1 in 5,000 to 15, 000 ear complaints [1]. Due to rarity, the available literature does not provide a complete understanding of this disease entity. There is also conflicting and limited information available on clinical staging of this malignancy leading to discrepancy in staging and management of this tumour in different series [1, 2] Aims and Objectives: We aimed to analyze treatment modalities. and outcomes in patients of carcinoma of EAC and ME treated at our institution. Materials and Methods : Fifty patients of carcinoma of EAC and ME (2000-2012) were analyzed for clinical presentation, lymph node involvement, stage, histopathology, surgical procedures and radiation modalities employed. Stell and McCormick's staging system was used. The primary end point of the study was assessment of Progression free survival (PFS). Results: Median age at presentation was noted to be 50 years (range: 12-84 years). Male to female ratio was 17:8. Forty five patients had carcinoma of EAC. Stage was T1, T2 and T3 in 21, 21 and 2 patients respectively. Twenty two patients underwent surgery and 16 of them received post-operative radiotherapy (PORT). Fifteen patients underwent definitive radiotherapy (RT) and 13 received RT with palliative intent. After a median follow-up of 16 months (range: 5-251.4 months), median PFS for the entire cohort was 14 months. At 2 years, PFS rate was 90% for patients treated with surgery and PORT, 52% for definitive RT and 0% for patients treated with palliative RT (p=0.0001). Stratified according to Stell`s staging system, median PFS for patients with T1/T2 tumours was 17.6 months (2 year actuarial PFS rate-48%) versus 7.5 months for those with T3 tumours (2 year actuarial PFS rate-22%) (p=0.03). Median PFS of patients with facial nerve palsy was 7.54 months versus 17.6 months for those without facial nerve palsy. Two year PFS rates were 90%, 52% and 0% for patients treated with surgery and PORT, definitive RT and palliative RT respectively. On univariate analysis, Stell and McCormick tumour stage (HR: 2.67; 95% C.I: 1.06-6.71; p=0.03), lymph node involvement (HR: 2.63; 95% C.I: 1.04-7.40; p=0.03), facial nerve palsy at presentation (HR: 3.04; 95% C.I: 1.5-9.5; p=0.01) were found to have significant impact on PFS. Conclusion: Patients with carcinoma of EAC and ME present mostly in advanced stage at our centre. Higher stage (T3), lymph node involvement and facial nerve palsy at presentation portend poorer outcome.

Bleomycin based chemotherapy as an addition to cisplatin in concurrent chemo radiation of oral cavity cancer- cancer institute experience

Anbarasi Kumaresan

E-mail: [email protected]

Background: Oral cavity cancer constitutes two thirds of locally advanced head and neck cancer in India and majority presents in advanced stage. Despite aggressive treatment disease outcome is poor. The aim of this study is to compare concurrent chemo radiation with cisplatin and bleomycin versus concurrent chemo radiation with cisplatin alone. Patients and Methods: Patients with locally advanced squamous cell carcinoma of oral cavity cancers registered at cancer institute from 2009 - 2011 were included in the study. Patients who were either taken up for initial surgery or treated with radiation therapy alone were excluded from study. Of 515 patients treated with concurrent chemo radiation, 112 patients were treated with three weekly cisplatin along with biweekly bleomycin and 104 patients were treated with 3 weekly cisplatin alone concurrent with radiation therapy. Results: Among the patient treated with three weekly cisplatin and biweekly bleomycin there is increased two year disease free survival (45.5% versus 35.6%) and two year overall survival(60% versus 45.2%)on comparison with patients treated with three weekly cisplatin alone.(P <0.05). Among the patients with treatment breaks there is increased two year disease free survival (52% versus 11.1%) and overall survival(60% versus 11.1%) in patients treated with cisplatin and bleomycin.(P<0.02). Three weekly cisplatin alone has lesser incidence of grade III mucositis, treatment breaks but comparable haematological toxicity, vomiting, treatment response when compared to three weekly cisplatin along with biweekly bleomycin. Conclusion: The addition bleomycin to cisplatin concurrently with radiation therapy increases disease free survival and overall survival, with acceptable toxicity.

Impact of molecular profiling on the response rates in head and neck cancer patients: An observational study.

Arvind S, Kirthi Koushik A.S, Mangala Gowri*, Janaki M. G,

Arul Ponni T. R, Ram Charith Alva

Department of Radiation Oncology, *Department of Pathology, M.S.Ramaiah Medical College, Bangalore, India.

E-mail: [email protected]

Introduction: Squamous cell carcinoma of head and neck region account for more than 25% of male and more than 10% of female cancers in India(1). Head and neck cancer treatment includes a multidisciplinary approach involving all specialties. Concurrent chemo-radiation is the standard of care in most of the subsites(2). Inspite of the multi-disciplinary approach, a plateau has been reached in terms of results with 5 year survival of locally advanced disease of around 30%(3). In order to improve outcomes, there has been considerable interest in molecular profiling of head and neck cancers(4-10). However there is still significant paucity in terms of Indian data, hence the need for the study. Objectives: •To Assess the HPV-p16,EGFR and p53 status


To Correlate HPV-p16,EGFR and p53 status with the response rates


To Correlate HPV-p16,EGFR and p53 status with other factors like age,sex,tobacco use.

Methods and Materials: 25 consecutive cases of histopathologically proven head and neck cancers were accrued. All patients were treated with external radiation to a dose of 66Gy in 33 fractions along with concurrent weekly cisplatin chemotherapy at a dose of 40mg/sqm. HPV-p16,EGFR and p53 mutation analysis was done on paraffin embedded histopathological blocks.PCR technique used for HPV-p16,EGFR and p53 status detection. Response assessment was done based on RECIST Criteria. Correlation of HPV,EGFR and p53 status on Response was done. Results: •Mean Age of the study population: 59 years

• Sex: 76% Male and 24% Female

• Stage: I-8%,II-4%,III-36%,IV-52%


Tobacco Use: 92% were tobacco consumers either in the smoke or smokeless form and 8% were non-tobacco users

• The EGFR positivity rate was 84%

• The p53 positivity rate was 76%

• The HPV p-16 positivity rate was 28%


Out of 25 patients, 13(52%) had Complete Response, 7(28%) had Partial Response, 3(12%) had Stable Disease and 2(8%) had Progressive Disease.


On correlation of molecular profile with response, there was no statistical significance between EGFR status and response(p 0.5) or HPV-p16 and response(p 0.8).However,p53 positivity was significantly associated with good response (p 0.03)


Among other factors there was significant correlation between smoking and HPV status (p 0.01). However there was no significant correlation between other factors like age, sex and socio-economic status. Conclusion: The HPV, EGFR and p53 positivity rates were in concordance with hitherto published literature. The HPV and EGFR did not have significant impact on response rate however p53 positivity was associated with higher percentage of complete response rate which was statistically significant.

Patterns of failure after intensity modulated radiotherapy for nasopharyngeal cancer.

Avinash Pilar, Sarbani Ghosh Laskar, JaiPrakash Agarwal, Ashwini Budrukkar, Tejpal Gupta, Vedang Murthy

E-mail: [email protected]

Purpose: To evaluate the patterns of failure, clinical outcomes and factors affecting these outcomes in patients of nasopharyngeal cancer (NPC) treated with intensity-modulated radiation therapy (IMRT). Methods and Materials: One hundred and thirteen patients of non- metastatic NPC treated radically with IMRT between 2008 -2013 were included in the study. All patients had been treated with 7-9 field LA-based IMRT/tomotherapy. Prescribed dose was 66Gy/30# to high risk PTV (primary and involved lymph node regions with margins) and 54Gy/30# was delivered to the uninvolved neck. One hundred and four patients (92%) completed the planned radiotherapy. One hundred and eleven patients (98%) received concurrent chemoradiotherapy. Hundred patients (88%) also received Neoadjuvant chemotherapy prior to chemo- radiation. Results: The median age was 46years (range: 18-85yrs). Undifferentiated Carcinoma was the most common histology (95%). Seventy nine percent patients were in stage III/IV. At a median follow-up (FU) of 27 months (range: 6-78months), 86 patients were alive at last FU. The 3 year local (LC) and regional control (RC) rates were 86% and 85%, respectively. Freedom from distant metastases (DMFS), progression-free survival (PFS), and overall survival (OS) at 3 years were 81%, 65%, and 87%, respectively. The LC for Stage I/II disease was 91%, compared to 84% for III/IV disease (p=0.23). RC for stage II disease was 100% while for stage III/IV it was 81% (p=0.035). Estimated 3 year OS for stage I/II was 96% and stage III/IV was 87% (p=0.31). Nodal stage had a significant impact on DMFS, early nodal stage (N0-N2) had 3 year DMFS of 84% as compared to N3 which had 3year DMFS of 69%. (p = 0.04). Nodal stage also had a significant impact on RC with early stage (N0-N1) having a 3 year RC of 97.6% v/s 77% for N2-N3. (p=0.009). Nodal stage influenced PFS with 3 year estimate being 75% for N0-N1 and 57% for N2-N3 disease. (p=0.03). T stage influenced only the DMFS with T1-T3 showing a 86% 3 year DMFS while T4 had a 63%, 3 year DMFS. Age, gender and endemicity had no influence on the LC, RC, DMFS or OS. There were 35 failures of which 3 (8.5%) were at primary site alone, 6 (17%) were nodal failures, 8 (23%) failed both at primary and nodal sites and 18 patients (51.5%) had distant metastases. Median time to failure was 4 months (Range 0-38months). All the primary and nodal failures were inside the high dose region (66Gy/30#) with exception of 1 patient (failed at edge of high dose volume). 9 of the 35 patients who failed were effectively salvaged (n=4 solitary distant metastases, n=5 nodal recurrences) and remain controlled at last FU. Conclusions: IMRT results in high locoregional control in NPC. The predominant site of locoregional failure is within the high dose region. Despite a good locoregional control, distant failure remains a common problem and is influenced by nodal stage.

Radiation treatment in cemento ossifying fibroma of paranasal sinus first of its kind in human bieng

Kanhu Charan Patro*, Parthasaradhi Bhattacharaya*, Chittaranjan Kundu*, E. B. Rajmohon**, A. C. Prabhu**, Subhra Das**

*Radiation Oncologist, **Medical Physicyst, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, A.P., E-mail: [email protected]

Case Detail: A 45yaer old female, p/w-nasal obstruction, Facial swelling, Proptosis of left eye, duration of more than one year and later stage she presnted with pain due to expansion of tumor.Patient presented to surgical oncologist with this feature. On imaging CT scan reavled mass in left maxillary sinus involving and destructing the sphenoidal, zygomatic bone, nasal cavity, nasopharynx and extension to subcutaneous tissue and total tumor volume was 250 cc approx. Biopsy of the tumor came out to be a cemento ossyfying fibroma. Because of inoperability patient was sent for opinion about radiaton therapy. The case evaluated by radiaton oncologist and planned for radical radiotherapy after tumor board decission. Material and Method: Radiation plannng was done by IMRT techinque with an aim of sparing the opposite optical apparatus. Plan evaluated with accaptable constraint specification planned for 50Gy in 25 fractions. Patient copmpleted radiation therapy over 5 weeks and with dry desquamation of skin [RTOG grade II]. Results: At the end of the treatment the response evaluated morphologically and which is an insignificant response, then patient was kept under follow up. After 3 months the proptosis decreased, pain was minimal and patient was better than before. CT scan volume revealed around 170 cc comparing pre radiation volume of 250cc. Review of Literature: Cemento ossyfying fibroma a bony origin of benign cause, sugery is the most desirable option, frequently from mabndible and facial bones. Pathologically it mostly comprises of fibrous, ossificaton with cement formation. If not removed completely recurrance is common. Radiation therapy is reserved for recurrent and incompleted removal cases. Radiation therapy offered in most of the cases which are reported in literature was on animal studies and not a single case reported in human studies. Discussion: This is the first case in literature where we treated with radiation as extreme indication in a human bieng. Benign conditions can be taken care when there is no option. The response should not be expected as for malignant condition. Radiation usually takes care of rapidly proliferating tissue. As benign it is a slow growing tumour, response evaluation as not like others-it will take time to decrease the volume. Hypofractonation schedule may be tried. Needs more cases to reach the conclusion about dose farctionation schedule, response etc.

Re-irradiation in head and neck cancer: Outcomes with conformal techniques from a single institution

Lavanya G, Sarbani Ghosh Laskar, Ashwini Budrukkar, Tejpal Gupta, Vedang Murthy, Jai Prakash Agarwal

Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India. E-mail: [email protected]

Introduction: Despite improvement in disease related outcomes of Head and Neck Cancer (HNC) with the use of aggressive multi-modality treatments, locoregional recurrences and second primary neoplasms (SPM) remain a common problem. Treatment of these patients is a challenge for the oncologist. Re-irradiation (reRT) is one of the options in the management of these patients. Aims and Objectives: To evaluate the outcomes and toxicities of HNC patients undergoing reRT with curative intent radiotherapy, using conformal techniques. Materials and Methods: Records of 63 patients with HNC who had been treated with curative intent, conformal reRT between January 2007 to May 2014 were analysed. Target volumes included the grossly involved regions with an adequate margin. Elective nodal irradiation was not carried out. Disease free survival (DFS), overall survival (OS) and toxicities were analysed. Results: Median age at the time of reRT was 55 years (range: 17-63 years). Majority (86%) of the patients were males. Median time to the development of recurrence was 48 months (range: 5-239 months). Most common site of primary for reRT was the nasopharynx (29%) followed by oral cavity (22%) and oropharynx (22%). Twenty-four (38%) patients received adjuvant reRT. Chemotherapy was used in 19 patients (30%) in neo-adjuvant/concurrent setting. Median dose of reRT was 60 Gy (range: 38-66 Gy). Total cumulative dose to the target was 124 Gy (range: 110-136 Gy). Median mean doses to the spinal cord and brainstem were 8.72 Gy (range: 0.41-25.4 Gy) and 12 Gy (range: 1.64-38.24 Gy). Median mean cumulative doses to the spinal cord and brainstem were 53 Gy (range: 37.89-71.4 Gy) and 57 Gy (31.8-84 Gy), respectively. At median follow up of 10 months (range: 1-113 months), median DFS and OS were 8.5 and 10 months, respectively. Thirty-one patients were alive and disease free at last follow up. Locoregional control rates at 1 and 2 years were 58.9% and 47.7% respectively. The 1 and 2 year actuarial DFS and OS were 54.8%, 44.3% and 72.3%, 63.9%, respectively. The 2 year distant metastases free survival was 70.8%. On univariate analysis patients who received adjuvant reRT after salvage surgery had a significantly better 2 year OS compared to RT/CTRT alone (85.6% vs 50.8%, p-0.04). Age at the time of reRT, time to reRT, site of recurrence, stage, dose of reRT and addition of chemotherapy did not influence DFS or OS significantly. Patients with treatment time < 45 days had worse OS as compared to patients with a treatment time > 45 days (2 yr OS: 36.6% vs 76.7%, p-0.06). This was because most of the patients < 45 days treatment time did not complete the planned radiotherapy due to various reasons. Two patients died on treatment. Seventeen patients (26.9%) developed grade III/IV late sequelae requiring intervention. Conclusion: reRT with conformal techniques to a dose of 60 Gy with conventional fractionation is an effective option in the treatment of recurrent HNC with acceptable toxicity. Further follow up is needed to assess long term outcomes.

A comparative study of hypofractionated versus conventional radiotherapy in terms of toxicities and treatment outcome in early stage glottic cancer

Monidipa Mondal, Arnab Adhikary, Shyamal Kumar Sarkar

Department of Radiotherapy, Medical College, Kolkata, India. E-mail:[email protected]

Introduction: Radiotherapy is the treatment of choice in early stage glottis cancer because it provides excellent local control rate along with a good preservation of the voice. A range of radiation fractionation schedules exists for the treatment of early glottic cancer. Several studies have shown that hypofractionated radiotherapy with short overall treatment time provides better local control and survival than conventional radiotherapy. In our institution, both of the radiation fractionation schedules are practised. We therefore conducted a comparative retrospective analysis of the two fractionation schedules. Aims and Objectives: The aim of the study was to compare the two radiation fractionation schedules - hypofractionation and conventional fractionation in terms of treatment outcome and treatment related toxicities in patient of early glottis carcinomas. Primary objectives were (1) to compare the response rates after radiation in two treatment groups, (2) to compare acute and late radiation toxicities in between the two groups and (3) to compare 3-year local control rates and loco-regional recurrence free survival in between the two groups. Materials and Method : Between January 2009 and December 2012, 78 patients of newly diagnosed, biopsy proven, early stage (stage I and II) squamous cell carcinoma of glottis treated in Radiotherapy Department of our Institution were retrospectively analyzed. Two fractionation groups were identified with respect to daily fraction size and overall treatment time. Arm A consisted of 38 patients who received radiation dose of 60 GY at 2.5Gy per fraction, 5 days a week for a total of 24 fractions over 32 days (5 weeks). Arm B consisted of 40 patients who received radiation dose of 66 GY at 2 Gy per fraction, 5 days a week for a total of 33 fractions over 46 days (7 weeks). All patients were treated with EBRT using conventional planning in cobalt-60 teletherapy machine. Response to radiation was assessed at 6 weeks after completion of therapy by RECIST Criteria version 1.1. Acute and Late toxicities of Radiation were recorded according to RTOG Acute and Late Radiation Morbidity Scoring Criteria. 3-year local control and loco-regional recurrence free survival were analyzed using the Kaplan-Meier method. Results: Median follow-up was 37 months. After completion of radiotherapy, patients treated in Arm A had a complete response rate of 91.8% vs 87.5% in Arm B (P=0.71), partial response rate of 8.2% vs 12.5%, respectively. There was no treatment interruption due to toxicity. No statistically significant difference in acute and late toxicity rates were found in the two treatment group. The 3-year Loco-regional Control rates (LRC) were 86% for the entire study population, 91.4% in Arm A and 81.1% Arm B. No significant differences in the 3-year LRC rates were detected between treatment groups. (p= 0.20, log rank test). Conclusions: Hypofractionated radiotherapy has the same response rate and local control rate as that of conventional radiotherapy without significance increase in toxicity in early stage glottic cancer.

Prospective study of palliative chemotherapy in recurrent locally advanced head and neck squamous cell carcinoma

Ramya A

E-mail: [email protected]

Background: Patients with recurrent head and neck cancer after concurrent chemoradiotherapy have poor prognosis thus need to be treated with palliative chemotherapy. Aim: To assess different palliative chemotherapy regimens based on outcome and quality of life. Materials and Methods: 100 patients with recurrent head and neck cancer after completion of chemo-radiation at the Dept. of Radiotherapy during the period of one year were given palliative treatment under three arms having 36, 38, 26 patients respectively- Arm A:Inj.Methotrexate 100mg q15days and Tab.Geftinib 250mg od for 30days till progression; Arm B:Inj.Cisplatin75mg/m2 in divided doses and Inj.5-Fluorouracil 750mg D1-D3 q21days for six cycles. Arm C:Inj.Cisplatin 75mg/m2in divided doses D1-D3 and Inj.Paclitaxel 175mg/m2 D1q21 days for six cycles. Symptom relief and toxicity was assessed also quality of life analysedusing EORTC QOL questionnaire. Results: Of the 100 patients, toxicity assessment as per CTCAE version 4- Anaemia Gr II 16% in Arm A; 20-22% in Arm B and C. Neutropenia Gr III 30% in Arm C.Acute kidney injury Gr II 25-30% in both Arm B and C.MucositisGr II and III 15- 30% in Arm B and C.Symptomatic relief,regression of residual disease and quality of life were better in Arm A. Conclusion: Based on these results Inj.Methotrexate with Tab.Geftinib as palliative chemotherapy in recurrent head and neck cancer patients has improved the quality of life; reduction in symptoms and is less toxic as compared to other chemotherapy regimens.

Simultaneous integrated boost (SIB)-intensity modulated radiotherapy in nasopharyngeal carcinoma(NPC) - a single center experience from Nepal

Subhas Pandit

B.P. Koirala Memorial Cancer Hospital, Chitwan, Nepal. E-mail: [email protected]

Objective: NPC is relatively common cancer in our center with around 50 cases per year.The purpose of this study was to retrospectively analyze the Simultaneous Integrated Boost - Intensity-modulated radiotherapy (IMRT) results in patients with nasopharyngeal cancer (NPC) treated in a single center under a single protocol. Methods: Patients with early and loco-regionally advanced NPC were treated with inverse-planned dynamic IMRT. Contouring, planning and plan evaluation was done as per RTOG 0615 protocol. The prescribed dose was 70Gy, 59.4 Gy and 54 Gy in high-risk, intermediate-risk and low-risk PTV in 33 fractions by SIB technique. IMRT was given alone or with chemotherapy in induction, concurrent or adjuvant setting. Cisplatin was used in concurrent setting while Cisplatin/5-Fu or Taxane/Platinum doublet was used in indiction/adjuvant setting. Loco- regional control (LRC) and overall survival (OS) were calculated from the start of radiation. Results: SIB-IMRT was used in 12 patients, of whom 11 also received chemotherapy (Concurrent only in 5;Concurrent/adjuvant in 4 and Induction/concurrent in 2). All patients completed their planned course of treatment with median duration of radiation of 61 days (range 49-71days). Acute toxicity scoring revealed 3 cases (25%) of grade 3 skin toxicity and 4 cases (33%) of grade 3 mucosal toxicity. After a median follow-up of 13.1 months, 2 patients had tumor recurrence and one died. The LRC, LRRFS and OS at 1 years are 83.3% and 91.6%.Regarding late toxicity,1 patient experienced grade 2 xerostomia and no patient have neck fibrosis. Conclusion: We consider SIB-IMRT for NPC is feasible in our setup and results are comparable to published series when a standardized protocol is strictly followed.

Analysis of carcinoma hypopharynx treated in a tertiary cancer center

Valiyaveettil Deepthi

E-mail: [email protected]

Introduction: Hypopharyngeal cancer is usually diagnosed at a locally advanced stage. Prognosis for patients with hypopharyngeal cancer is poor compared to the other head and neck cancers. Multimodality treatment with concomitant chemoradiotherapy is the standard of care. Aims and objectives: Retrospective survival analysis of Carcinoma Hypopharynx. Compare the stricture formation based on dose of radiotherapy. Materials and Methods: A total of 67 patients with the pathological diagnosis of carcinoma hypopharynx admitted for radiotherapy at NIMS, Hyderabad from January 2011 to March 2014 were analyzed. Statistical analysis was done by Kaplan Meier Method using SPSS 22 software. Results: The median age was 50.5 years with M: F ratio of 1.9:1. History of tobacco use was seen in 20 patients. 14% patients presented in early stage and the rest were in advanced stage. Out of 67, 30 patients had Post Cricoid, 30 patients had Pyriform Sinus, and two patients had Posterior Pharyngeal Wall as the primary site of involvement. In 5 patients the primary site was not specified. Out of 67 patients, 2 patients presented with metastasis and received palliative radiotherapy while 65 patients received Radical radiotherapy. Most of them received concurrent chemotherapy with Cisplatin. 33 patients received 70 Gy and 34 received ≤ 66 Gy. The median overall survival was 11 months. Median survival in males was 10 months and in females was 11 months (log rank p=0.77). Median Survival in Carcinoma Post Cricoid was 13 months; in Carcinoma Pyriform Sinus was 9 months and in Carcinoma Pyriform Sinus with post cricoid involvement was 4 months. 19 patients (29%) developed stricture on follow up. Among them 10 received 70 Gy and 9 patients received ≤66 Gy. i.e 30% patients who received 70 Gy, 26% patients who received ≤66 Gy developed strictures on follow up.6 patients had local recurrence and two patients had distant metastasis on follow-up. Conclusions: Median overall survival was 11 months as most patients in the study had advanced disease at presentation. There was no significant difference in the stricture formation based on the dose of radiotherapy.

Split-course hypofractionated radiotherapy for palliation of advanced head and neck squamous cell carcinoma.

Vishal D Manik

Madras Medical college, Chennai, E-mail: [email protected]

Introduction: A significant proportion of patients with head and neck squamous cell carcinoma (HNSCC) are unsuitable for radical treatment due to factors including tumour stage, performance status (PS) and co-morbidity. Palliative radiotherapy has a useful role in the control of local symptoms. Aim: To assess the local symptom control of advanced HNSCC treated with split course hypofractionated radiotherapy. Additionally, to assess the Quality of Life (QoL); the acute toxicity to the treatment and the immediate loco-regional response. Materials and Methods: Thirty patients of very advanced HNSCC with PS of 2-4 were selected. All the patients after basic work up, were planned to receive initial course of 20Gy radiation (4Gy/5 fractions) followed by a two week gap and then re-assessment. All patients with absent or manageable toxicity were further treated with one more course of 20 Gy radiation. Symptom relief was assessed before and after each course of radiation. QoL was assessed using the EORTC QoL questionnaire, before and after radiotherapy. Results: Out of the study population, 70% were males, 50% belonged to age group 61-70years and all had a PS ≥3. Oropharynx (33.3%) was the commonest site with base of tongue (20%), the commonest subsite. Stage grouping was IVB in 56.67% with 46.67% having a N3 node and dysphagia (43.3%) at presentation. Only 3 patients could not complete the planned courses of RT. Good symptom relief was observed in 83.3%. Improvement in symptom scales was seen, however, functional and global health scores remained low. None had more than Grade 1-2 toxicity from first course. Grade 2 toxicity was seen in majority of patients after second course. Partial response to treatment was observed in all cases. Median progression free survival was 2 months post-treatment. Conclusion: Split course hypofractionated palliative RT is feasible in advanced HNSCC and allows for shorter treatment time with acceptable symptom relief.

Sandwich mould brachytherapy for cancer lip-a non invasive approach

Kanhu Charan Patro, E. B. Rajmohon

E-mail: [email protected]

Carcinoma lip one of the common malignancies among gutkha chewers. Surgery is the mainstay of treatment. Radiotherapy is another option for cosmetic region. External beam radiotherapy can be considered for where surgery is not feasible, medical co morbidity, and when surgery is not acceptable for cosmetic disfigurement. Brachytherapy can be considered for node negative diseases, interstitial brachytherapy is a established procedure. Here we are describing another brachytherapy procedure called sandwich mould as a curative option for node negative disease. A 67 year old male presented with 2 skip lesions on lower lip, one is measuring 3cm x 3cm and another is at right angle of mouth 3cm x2cm without any neck node. Patient was not interested for surgery because of cosmetic issues. Options are discussed with patient and patient was agreed for sandwich mould brachytherapy. A mould was made on a orfit frame.around 22 needles are planned in two plane. A CT based plan was done. Patient received @3.5Gy twice dally fraction for 15 fractions BED 2Gy equivalent calculated and discharged with grade 3 RTOG skin and mucosal toxicity. The toxicity increase till 3 weeks of radiation.now there is complete response of tumor. We concluded that sandwich mould brachytherapy is a good option and can be accepted as good option comparing to other options and more suitable for patients having medical co-morbidity and patients are not accepting the cosmetic defects. It is also a good option comparing to interstitial as non invasive.

Impact of human papillomavirus infection on treatment response and outcome in oral cavity and oropharyngeal cancer: An Indian perspective

Monidipa Mondal

Radiotherapy Dept, Medical College, Kolkata. E-mail: [email protected]

Introduction: India has the highest prevalence of oral cancers globally and its incidence is rising. Several studies suggest that HPV infection is an independent risk factor for development of oropharyngeal and oral cavity cancers and it is associated with better prognosis. [1] But most of the studies are based on Western population and not much data is available regarding prognostic significance of HPV infection in Indian scenario. Aims and Objectives: Aim of the study was to assess impact of HPV status on response to therapy and survival in oral cavity and oropharyngeal carcinoma patients attending Radiotherapy and ENT OPD of a tertiary care centre of Eastern India. Primary Objectives were (1) to compare response rates in HPV positive and negative patients receiving induction chemotherapy followed by concurrent chemoradiation and (2) to compare progression free survival and overall survival in HPV positive and negative patients. Material and Method: 42 patients of newly diagnosed, stage III, IVA and IVB squamous cell carcinoma of oral cavity and oropharynx were prospectively evaluated. Biopsy specimens were collected from the patients before receiving any treatment, and stored in - 80°C. Resectable cases of oral cavity cancer underwent surgery including modified lymph node dissection followed by adjuvant radiation or chemoradiation. All cases of oropharyngeal cancers and unresectable cases of oral cavity cancers received 2 cycles of induction chemotherapy with Inj Paclitaxel, Inj Cisplatin, and Inj 5-Fluorouracil (TPF) followed by concurrent chemoradiation with weekly Cisplatin. Dose of radiation used were 60-66Gy in postoperative setting and 66Gy in definitive setting using conventional fractionation. Presence or absence of HPV DNA was determined by real time PCR in fresh frozen biopsy samples. Tumor DNAs were also tested for HPV16 and HPV18 by use of type-specific primers. Two-year overall and progression-free survival for HPV-positive and HPV-negative patients was estimated by Kaplan- Meier analysis. Results: Genomic DNA of high risk HPV was detected in 38% of tumor specimens. HPV16 was detected in 16% and 65% of tumor specimens from oral cavity and oropharynx respectively. 12 out of 16 HPV positive tumors (75%) were found in the oropharynx (p<0.001). 30 patients received induction chemotherapy followed by concurrent chemoradiation. There was no difference in the response rates seen after induction chemotherapy (p=0.28) and after chemoradiation (p=0.67) for HPV-positive and negative tumors. After a median follow-up of 25 months, patients with HPV-positive tumor had better 2-year progression-free survival (85% vs 65%, p=0.17) and 2-year overall survival (93% vs 69%, p=0.19) but these were not statistically significant. Conclusions: HPV positive oral cavity and oropharyngeal cancers patients have a trend towards better progression-free survival and overall survival although not statistically significant due to the small patient number. HPV positivity did not confer any significant difference in response to therapy.

Objective assessment of swallowing dysfunction and aspiration after chemoradiation for head and neck cancer with its impact on quality of life

Nithin Bhaskar. V, Iqbal Ahmed, Rajesh. J, Chendil V, Amruth Kadam

Bangalore Medical College and research institute. Email: [email protected]

Background/Objective: To assess the prevalence, severity and morbidity of dysphagia following concurrent chemo-radiation for head and neck cancer. Materials/Methods: Between November 2012 and October 2014, 20 patients with squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx were studied. All patients received conventional EBRT on Telecobalt to a total dose of 66-70 Gy (by shrinking field technique) with concurrent weekly cisplatin 40 mg/m2. All patients were given symptomatic care in the form of analgesics, antiemetic. Patients were evaluated before and after RT to assess the swallowing dysfunction by nasopharengeal larygoscopy. Results: Flexible endoscopy was performed pre-therapy in 22 patients, early post treatment in 17 patients and late post-therapy in 12. Post therapy dysfunction was characterized by pooling of food in and around pyriform sinus. Defective swallowing characterized by pooling of liquids/solids was noticed in 15 patients (68%) in the early post-therapy period and nine patients (41%). Aspiration noted in the post therapy period was mostly silent aspiration eliciting no cough reflex. Post-therapy aspiration was noticed in 11 patients (50%) out of which 10 patients (45%) had silent aspiration. 8 patients were diagnosed of pneumonia and required admission and i.v antibiotics. 2 patients expired in the early post treatment time due to pneumonia. One patient was lost to follow-up in the early post treatment period and four in the late post treatment periods. Conclusions: After concurrent chemo-radiotherapy, significant objective swallowing dysfunction is prevalent. It promotes aspiration, which may not elicit a cough reflex and can contribute to pneumonia.

Three weekly versus weekly concomitant chemoradiation with cisplatin in locally advanced head and neck cancer- a prospective, randomised study

Parna Basu*, Krishnangshu B. Chowdhury*, Abhishek Basu*,

Kazi S. Manir*, Partha Dasgupta*, Subir Gangopadhayay*

*Department of Radiotherapy, R.G.Kar Medical College and Hospital, Kolkata, India. E-mail: [email protected]

Background: Concurrent Cisplatin based chemoradiotherapy (CTRT) is now the standard of care for locally advanced head neck cancer patients (LAHNC). The most common chemotherapy regimen is high dose (100mg/m2) three weekly Cisplatin with CTRT. This protocol is associated with significant acute and late toxicities which resuls in either early treatment termination or decrease in treatment compliance. Therefore splitting full dose three weekly Cisplatin as weekly Cisplatin schedule (30 mg/m2) maintaining the dose intensity might decrease toxicity and increase compliance. Objectives: This prospective study compares the differences in response rate, acute toxicity and PFS outcomes between weekly Cisplatin and 3-weekly Cisplatin based concurrent chemotherapy (CTRT) regimens given to patients of Stage III/IV head and neck cancer. (T3-4b, N1-3) Methods : The study was designed as single institutional, open label, parallel 2 arm phase 3 randomized controlled clinical trial. LAHNC (squamous cell histology) patients with Eastern Co-operative Oncology Group (ECOG) performance status 0-2, normal hematological parameters, creatinine clearance > 50 ml/min, with no significant co-morbid conditions were randomized into 2 arms: Arm A was treated with weekly Cisplatin (30 mg/m2) concomitantly with conventional RT and Arm B received 3 weekly Cisplatin(100 mg/m2) for 3 intended cycles along with similar RT schedule, i.e.,66-70 Gy in conventional fractionation. The groups were compared for response rate (RECIST V1.1), acute toxicity (CTCAEv4) and progression free survival (PFS, Kaplan Meier Survival). The statistical analysis was done using two tailed tests with alpha < 0.05 statistical significant, SPSS v16, Chicago. Results: Initially 80 patients were recruited in study with 60 patients elgible for analysis for PFS (intention to treat). At median follow up period of 12 months (range 5- 19 months)the baseline parameters of demographic profiles and tumour characteristics were comparable in both arms. Majority of patients were in stage III, 20 (66.7 %) and 14 (48.3%) for Arm A and B. Response rates at the end of 2 months post treatment were comparable in both arms Arm A (N=27) patients and Arm B (N=30) patients, with Complete Response in Arm A 17(65.4%) vs 19 (63.3%) in Arm B, Partial Response 8 (30.8%) in Arm A vs 6 (20%) in Arm B and Progressive Disease 1(3.8%) in Arm A vs 5(16.7%) in Arm B, p value 0.248. Response at last follow up CR 15 (57.7%) in Arm A vs 17 (56.7%) in Arm B, and PD 10 (38.5%) in Arm A vs 9 (30%) in Arm B, p value 0.427. Majority of patients with oropharngeal subsite had local recurrence or progressive disease. Median PFS was 16 months (mean ± SE: 10.36 ± 1.25 months; 95% CI 7.903, 12.81) in Arm A vs 14 months (mean ± SE: 12.15± 0.74 months; 95% CI 10.70,13.60) in Arm B, log rank test 0.062. Weekly cisplatin arm was showing statistically significant toxicities in the form of dysphagia (Grade3- 36.7%); mucositis (Grade3 - 30%) and dermatitis (Grade 3- 13.3%). Among hematotoxicies,neutropenia was numerically more in Arm A and anemia and thrombocytopenia more in Arm B. Conclusion: In this study, Three weekly high dose Cisplatin treatment showed better locoregional response and lower acute toxicity compared to weekly low dose Cisplatin treatment.

Study of role of HPV in oesophageal carcinomas

P. U. Prakash Saxena

Kasturba Medical College, Mangalore (Manipal University).

E-mail: [email protected]

Background: The role of HPV as one of the causative agents in oropharyngeal malignancies has been established. Evidence suggest that such cases may fare better than conventional head and neck malignancies and for such subtypes dose de-escalation studies are already being conducted. The method of transmission is yet to be defined, most of the studies implicate oral sex (from mouth to-genital or mouth-to-anus contact).As oesophagus is anatomically a continuous structure with the upper aero-digestive tract, we hypothesized that HPV may be associated with some oesophageal cancers as well. Methods: 21 cases of squamous cell carcinomas oesophagus treated with radical chemo-radiotherapy were included. Post treatment these patients were followed up every month for dysphagia assessment.The tissue biopsy sample preserved in wax block were sent for analysis. HYBRID DNA CAPTURE technique was used for identifying HPV DNA in the sample. The HPV types included in the test were: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68.A cut-Off Ratio of 0 to 0.99 is NEGATIVE for HR HPV; Cut-Off Ratio 1.0 or above is POSITIVE for HR HPV based upon the semi -quantitative viral load, represented as a numeric positive cut-off value. The Cut -Off Ratio at 1.0 correspond to viral DNA load of ~5,000 copies/assay or 1 picogram/ml at a threshold of finding a clinical disease. Results: There were 10 male (47.61 %) and 11 female patients (52.38%) with median age being 60 yrs. Out of 21 samples analysed 9 were positive for high risk HPV DNA (42.8 %), one was classified as borderline negative (4.76%). Out of positive samples 3 were males (33%) and 6 were females (66%). 77.77 % of the HPV positive group were non-smokers. 55 % of the HPV positive tumours (5/9) were located in the lower third of oesophagus. 77.7% of HPV positive tumour patients had no evidence of dysphagia after 1 month of finishing treatment as compared to 66.6 % of HPV negative tumours. Conclusions: This study shows that there may be a possible association between HPV viruses and oesophageal cancers despite having small numbers. A possible association also may exist between non-smokers and HPV. In future we plan to conduct studies where in addition to other predictive markers available for response assessment to chemo-radiation, HPV will also be tested.

Delay in primary cancer treatment of head and neck

R. Narmadha, S. Shanmugakumar, N. V. Kalaiyarasi, Baskar, Madhumathi, Sundaresan, Prabhakaran, Vishal Malik

Dept. of Radiotherapy, Madras medical college, chennai

E-mail: [email protected]

Introduction : In India, Head and neck cancers accounts for about 30% of all cancers.60% to 80% of patients present with advanced disease. Head and neck cancer can cause varying degrees of structural deformities and functional handicaps thereby compromising the self-esteem and quality of life. Objectives: Our aim was to identify the cause for delay in primary treatment of the head and neck cancer patients under two categories as `patient delay` that is, interval between onset of symptoms to diagnosis and `Professional delay` that is interval between diagnosis and initiation of treatment. Method and Materials: Study included 140 primary head and neck cancer patients diagnosed and treated in our dept, Barnard Institute Of Radiation Oncology, MMC Chennai. Result: Among 140 patients, there was a delay of >2 months of symptom duration in 34%. There was a hospital related delay in 20% patients of which there was a mean delay of 7 days for the investigations (Imaging) and time taken for dental prophylaxis was 20 days. Conclusion: There s a significant overall delay of 2.5 months due to all reasons in initiation of treatment which is found to exceed the tumour doubling time of head and neck cancer. This might be a significant contributing factor causing the patient to present in advanced stage. Delay can be avoided by educating the people to seek health care soon after the onset of symptoms. Hospital delay can be reduced by shortening the time taken for investigations.

Patterns of care and treatment outcomes of squamous cell carcinoma(scc) Hypopharynx: a single institution experience

Rejinish Kumar K, R.Resmi, Cessal Thomamachan Kainackal, Malu Rafi, Preethi Sara George, K. Ramadas

Division of Radiation Oncology, Regional Cancer Centre, Trivandrum, Kerala, India. E-mail: [email protected]

Introduction: Hypopharyngeal cancers constitute about 7% of all head and neck malignancies. Early stage disease is treated either by radiotherapy or surgery. Advanced stage (stage III and IVA) disease is managed by combined modality treatment. Most patients present late, are nutritionally compromised and due to poor general condition a substantial number will undergo palliative treatment unlike in other head and neck cancers. Aims and Objectives: To analyze the clinical profile and treatment outcomes of hypopharyngeal squamous cell carcinoma treated at Regional Cancer Centre, Trivandrum, during the time period 2010-2011 and to identify the various factors influencing the outcome. Materials and Methods: This is a retrospective analysis of all squamous cell carcinoma(SCC)of hypopharynx treated at Regional Cancer Centre(RCC) from 2010 to 2011.Data was retrieved from case sheets using a structured proforma. Observation and Results: One hundred and sixty four patients with SCC hypopharynx were included in the study. Median follow up time was 16.9 months.Majority of patients were males(137 -83.5%). Most common subsite was pyriform sinus 114 (70 %), followed by postcricoid 42(25.6%) and posterior pharyngeal wall 5(3%). Eleven patients(6.7%) had stage II disease, thirty one patients(18.9%) had stage III, sixty three patients (38.4 %) had stage IVA, fifty four patients(32.9%) had IVB disease and two patients(1.2%) presented with stage IVC disease. One hundred twenty eight(78%)patients were treated with radical intent and thirty six(22%) with palliative intent. Among patients who underwent radical treatment,fourty five patients (27.4 %) were treated with concurrent chemo radiation, thirty four patients(20.7%)underwent RT alone and twenty one patients(13%) underwent induction chemo followed by chemoradiation. Four patients(6.25%) underwent primary surgery, of which three received adjuvant RT. All patients were treated either with 6 MV photon or in cobalt 60 to a total dose of 60-66 Gy. Concurrent chemotherapy used was cisplatin at a dose of 80 mg/m2 given 3 weekly. Six patients had treatment interruptions.Thirty four patients(20.7%)developed recurrence with the most common site being the primary site. Median time to recurrence is 11.63 months. Six patients(3.65%) developed 2nd malignancies. At 3 yrs, disease free survival was 69.5% and overall survival was 43.7%. Conclusion : In our series, most common subsite at presentation was pyriform sinus.Most patients presented with advanced stage-T4a disease. Twenty two percentage of patients received palliative treatment. Disease free survival at 3 yrs was 69.5%.

Role of sialography in head and neck cancer

Rahul misra, R. K. Vyas, Rahul, Maitrik Mehta, J. P. Neema,

Om Prakash

GCRI, Ahmedabad. E-mail: [email protected]

Introduction : Xerostomia is a common complication of head and neck irradiation depending upon the cumulative dose and volume of parotids involved. But there are almost no objective tests to compare patients treated by different modalities of radiotherapy. Hence, we decided to use sialography to compare patients treated by different modalities. Aims and Objectives: To assess role of sialography in head and neck cancer. Material and Methods: 32 newly diagnosed stage T1-3oropharynx or oral cavity cancer patients were chosen. They were treated with conventional radiation with amifostine. (500mg of amifostine diluted in 3mL.of normal saline subcutaneously in the shoulder region 20 to 30 minutes before the radiotherapy fraction every day). All patients had a ECOG performance status above 2 and were treated upto doses of 66gy/33#. 99mTcpertecnetate scintigraphy scan (sialography) was performed as a baseline scan, after 1 month,6 months and 1 year post treatment. Sialography is of value in determining changing, preserved or lost salivary gland function during radiation. Sodium pertechnetate (Na-99mTcO4) is injected followed by oral administration of oral sialagouge (lemon juice). Dynamic image acquisition is started 1minute after administration of technicium to determine its uptake. Later with good accrual these values were also compared with sialography of patients undergoing imrt. Result: The values of sialography correlated well with the subjective improvement of symptoms of the patients. They also varied among the different arms showing that each intervention has its own importance. significant improvement was noted 6 months post treatment in those with preserved salivary function. Conclusion: The salivary scintigraphy tests support the finding of improvement in excretory parameters (SEF and SEF ratio) salivary gland function of the patient cohort undergoing radioprotective interventions.

Concurrent chemoradiotherapy in locally advanced squamous cell carcinoma of head and neck with capecitabine and weekly cisplatin

Ramya.A*, S. Shanmugakumar, N. V. Kalaiyarasi, Bhaskar, Madhumathi, Sundaresan, Prabakaran, Arun ramanan

Department of Radiotherapy, Madras Medical College, Chennai. E-mail: [email protected]

Aims and Objectives: To assess the immediate loco regional response rates and acute toxicity in patients of locally advanced squamous cell carcinomas of the head and neck with conventional radiotherapy with weekly cisplatin and capecitabine. Materials and Methodology: Single arm prospective study with 30 consecutive patients with locally advanced head and neck cancer presented to the department of radiotherapy, Madras medical college, Chennai. All patients were treated with conventional radiotherapy 66Gy along with weekly Inj.Cisplatin 40mg/m2 and T.capecitabine 500mg/m2 daily along with radiation. The immediate loco regional response rates were assessed clinically and radiologically 4-6 weeks after concurrent chemo radiotherapy. The toxicity profile of the treatment was assessed with RTOG acute morbidity scoring criteria and CTCAE Version 4. Results: Among 30 patients, Ca Oropharynx were 9 patients, followed by Ca Hypopharynx 8 patients, Ca Oral cavity with 7 patients and Ca Supraglottis 6 patients. 73% of patients had complete response. Toxicities observed in the study were Mucositis grade 3 in 15 patients;Skin reactions grade 2 in 2 patients. Leucopenia grade 2 in 2 patients. Conclusion: Concurrent chemoradiotherapy with Inj.Cisplatin and T.Capecitabine in locally advanced squamous cell carcinoma of head and neck cancer is preferred regimen with manageable toxicity.

Undifferentiated nasopharyngeal carcinoma with bilateral inguinal lymphnode recurrence: A case report and literature review

Ravindra Nandhana

E-mail: [email protected]

Nasopharyngeal carcinoma (NPC) is a rare malignancy arising from the epithelium of nasopharynx. Unlike other malignant head and neck cancers NPC has highest propensity to develop distant metastasis. Despite of definitive treatment there is a high rate of recurrence most commonly in bone, lung, liver, distant lymph nodes in decreasing order of frequency in the literature. We present here a case of recurrent nasopharyngeal carcinoma with bilateral inguinal lymph node metastasis seven months after primary treatment. Involvement of bilateral inguinal lymph nodes is extremely rare. Management of metastatic disease is usually palliative platinum based chemotherapy.

Reirradiation for head and neck cancers with cyberknife-based stereotactic radiosurgery: Evaluation of carotid artery doses

Shikha Goyal

Division of Radiation Oncology, Medanta - The Medicity, Gurgaon, Haryana-122001. E-mail: [email protected]

Background: Carotid blowout is an uncommon but serious complication of salvage reirradiation for H and N cancer. We evaluated the doses to carotid arteries in the high dose regions during CyberKnife-based fractionated stereotactic reirradiation (CK-FSRT) of head and neck cancers (HNC), and correlated them to complication risk. Materials and Methods: Patients who received CK-FRRT at our department in the period October 2012 to July 2014 were included. Entire course of internal or common carotid arteries ipsilateral to the high dose region either within or adjacent to the target volume was contoured, and doses to these vessels evaluated (Dmax, Dmean, D0.2 cc, D0.5cc, D1cc, V25, V30). The clinical course including responses and complications were prospectively recorded. Results: Twenty-two patients received CK-FSRT during this period; of these, 13 (11 males, 2 females) with median age 56 years (range 31-83 years) received reirradiation, either for second primary (2) or recurrence (11). Of these, one received a combination of IMRT with CK-FSRT boost while 12 received CK-FSRT alone, dose delivered being 20-37.5 Gy in 3-7 fractions (commonest schedule, 30 Gy in 5 fractions). The median interval between the two RT courses was 13 months (range 3.8-47.7 months). All patients had earlier received a dose of 64-70 Gy to the reirradiated region. Median follow up post CK-FSRT was 6.5 months (range 2-17 months). During this period, only one patient developed carotid bleed 7 months post-reirradiation that was salvageable with angioembolization. There were no treatment-related deaths. Dose-volumes were noted for 16 vessels in 12 patients where Dmax exceeded 24 Gy for the reirradiation course. Median integral dose (volume in ml X dose in Gy) to the vessels was 41.8 ml-Gy (range 22.4-71.6). Median Dmax(range), D0.2cc(range) and D1cc(range) were 33.5 Gy (24.1-44.1), 30.6 Gy (22.0-37.6), and 20.37 Gy (7.6-37.6), respectively. Median V25 and V30 were 1.08 cc(39.7%) and 0.7 cc(29.7%), respectively. Six patients (7 vessels) had at least 50% volume within PTV, but only 3 of these were constrained to receive doses equal to or less than PTV dose during the initial plan. The patient who developed bleeding was a 73-year lady who had earlier undergone surgeries for 2 primaries. The first and repeat irradiation interval was 47.7 months and the respective dose-volume parameters for reirradiation (30 Gy in 5 fractions) were: Dmax 39.9 Gy, Dmean 36.2 Gy, and V30 18.9cc (100%). Conclusions: Attention to carotid doses during repeat irradiation courses and subsequent constraints to the vessels in high dose regions courses may help prevent or reduce the risk of carotid rupture or bleed. Evaluation of a larger number of patients with longer follow up and more events would help estimate the relationship between carotid vessel doses and observed toxicity, which would serve as a useful reference to define respective dose constraints for reirradiation.

Hypofractionated IMRT for early glottis cancers leads to higher local failure

S. M. Arunsingh, R. Karmacharya, P. Arun, R. K. Shrimali, R. Achari, I. Mallick, S. Chatterjee

Department of Radiation Oncology, Tata Medical Centre, Kolkata. E-mail: [email protected]

Aim: Radical radiotherapy is often a preferred treatment approach for early glottic cancers. Busy centres often use treatment hypofractionated treatment schedules. Conformal forward planned delivery is used as routine but advanced inversed planned techniques are sometimes used. Methods: 59 unselected patients of histologically confirmed glottis squamous cell cancer patients treated during September 2011 to July 2014, were analysed. Only patients with stage T1/T2 N0 as per the 7th edition of AJCC and who were treated using a hypofractionated radical radiotherapy regimen of 5500cGy delivered in 20 fractions of 275cGy each over a period of 4 weeks were included. Also, patients with a minimum follow up of six months from treatment completion, n=56, were included in the present analysis. The outcomes and treatment as well as tumour related factors associated were systematically analysed and correlated to outcome. Results: 89.3% of the patients were T1 and 10.7% were T2. 57.1% patients were treated using IMRT (93.8 % VMAT and 6.2% helical tomotherapy), the remaining were treated using 3DCRT. 18 patients in the IMRT group had undergone carotid sparing as part of a prospective study. A bolus was required for dose build up in the anterior commissure region in 72.7% patients with a risk of involvement to that area. All patients tolerated the treatment well with 7 patients (12.5%) having radiation dermatitis of grade 2 or above. 15 patients (26.8%) developed grade 2 or more dysphagia during or after the third week of the radiation therapy. All patients achieved a complete response at the first post radiation visit 4-6 weeks post therapy. 98.2% patients completed treatment within 28 days (median-26 days, range 22 to 26). Overall 10.7% patients had failure of treatment with 5 patients having a local recurrence and 1 patient failing regionally in the nodal region. One patient died due to unrelated medical condition. Clinical stage did not have any significant bearing on the control rates (T1a vs T1b vs T2 8.6% vs 13.3% vs 16.7%; p>0.05). All failures occurred in the IMRT group with 10.7% failures overall and 18.8% within the group. All failures occurred in the Helical Tomotherapy IMRT arm. Other treatment related factors like the use of bolus, carotid sparing techniques, prolongation of the duration of radiation course did not have significant relation with the outcomes. Similarly dosimetric indices like D99, D50, Mean dose (MD) and homogeneity index (HI) were also analysed. None of the CTV indices were significantly related to the outcomes. The PTV indices D99 (p=0.01), D50 (p=0.001), MD (p=0.00) and HI (p=0.00) were significantly better in those who failed. This was so because all these indices were significantly better in the IMRT group compared to the 3DCRT patients and all the failures had occurred in the IMRT group. Conclusions: Hypofractionated radiotherapy is safe with acceptable toxicities. However the early results presented above show that helical tomotherapy in early glottic cancers may lead to extra failure rates. This could be because of higher anterior dose gradient in the HT arm resulting from smaller penumbra/field width.

Clinical profile and treatment outcomes of squamous cell carcinoma (SCC) Oropharynx: A single institution study

Cessal Thommachan Kainickal 1 , Sorun A Shishak 1 , Rejinish Kumar 1 , Malu Rafi 1 , Preethi Sara George 2 , K. Ramdas 1

1 Division of Radiation Oncology, 2 Division of Epidemiology and Biostatistics, Regional Cancer Centre, Trivandrum, Kerala, India. E-mail: [email protected]

Introduction: Oropharyngeal carcinomas constitute about 7% of all head and neck cancers. Radical Radiotherapy is the standard treatment for early stage disease. Locally advanced disease (Stage III and IVA) is treated by combined chemo radiation. The role of surgery is very limited and is mostly done as a salvage measure. Aims and Objectives: To analyse the clinical profile and treatment outcomes of SCC oropharynx treated at Regional Cancer Centre (RCC), Trivandrum, during the time period from 2007 to 2008. Materials and Methods: A retrospective analysis of all Squamous Cell Carcinoma (SCC)of oropharynx treated at RCC Trivandrum from 2007 to 2008 are included in the study. The patients were followed up until September 2014. Observation and Results: One hundred and ninety five patients were analysed, of which majority were males(95.4%). The median follow up was 23.9 months. The median age was 61.1 years. The sites involved were tonsil (47.2%),base of tongue(21%),soft palate(17.9%), uvula(7.7.%),vallecula(3.1%) and pharyngeal wall(3.1%).One patient (0.5%) presented in stage I disease, eighteen patients(9.2%) in stage II, fifty patients (25.6%) in stage III, ninety five patients (48.7%) in stage IVA, twenty seven patients (13.8%) in stage IVB and three patients (1.5%) had stage IVC disease. One hundred seventy four patients (89.2%) were treated with a radical intent, while twenty one patients(10.8%) were treated with palliative intent. Among the patients treated radically, eighteen patients (9.2%) received induction chemotherapy followed by chemoradiation, fifty nine patients (30.2%) received induction chemotherapy followed by RT, forty nine patients(25.1%) received concurrent chemo RT, three patients(1.5%) received cetuximab with RT. Sixty six patients (33.8%) received RT alone. Patients radically treated by RT received doses 60-66Gy, while chemotherapy was platinum-based regimen. Majority of the patients (97%) were treated using 2D technique, while six patients (3%) were treated using 3D technique. Four patients (2.1%) had treatment interruptions while receiving RT. Forty four patients(22.5%) had recurrence, for which eight had salvage surgery, and the remaining received either palliative chemotherapy or best supportive care. Seven patients (3.5%) developed 2nd malignancy. The 3-year Disease free survival was 59.4% and 3-year overall survival was 79.3%. Conclusion: In our centre, the most common subsite was tonsil. Majority of the patients presented in stage IV disease. The median age was 61.1 years. Forty four patients (22.5%) had recurrence and salvage rates are poor. Disease free survival at 3 years was 59.4% and overall survival at 3 years was 79.3%.


A study of conventional vs. Hypofractionated radiation therapy in breast cancer

Alok Chand*, K. M. Kamble, A. K. Diwan, V. K. Mahobia

Department of Radiation Therapy and Oncology, GMC Nagpur

Introduction : Numerous studies have shown that hypofractionated radiation therapy, in the treatment of breast cancer, is safe and results in comparable over all survival and disease relapse rates to that of Conventional Fractionation. In this study we aim to evaluate the clinical tolerance of patients of breast cancer receiving hypofractionated radiotherapy and comparing them with those receiving conventional doses of radiotherapy by 1) Monitoring and comparing the skin reactions between two groups 2) Evaluating and comparing the cardiopulmonary toxicity by monitoring ECG, Echocardiography and lung functions. Material and Methods : It is a Prospective Randomized Concurrent Parallel Open Labeled Two-Arm Study in which 60 (Mean Age 49.067 ± 10.93yrs) post-operative patients of breast cancer, referred for adjuvant treatment at the Radiation Therapy and Oncology department, GMC Nagpur, were evaluated from January 2013 to August 2014. The adjuvant treatment was sequenced as Adriamycin based chemotherapy followed by radiation therapy. The patients were divided into two groups. Group A (n=31; Mean Age 50.93 ± 11.70yrs) received radiation therapy with Conventional Fractionation (50Gy/25#) and Group B (n=29; Mean Age 47.07 ± 9.86yrs) with Hypofractionation (42.5Gy/16#). They were evaluated thrice - i.e. - at the initiation of chemotherapy, at the initiation of radiation therapy and at 6 months of follow up after completion of radiation therapy. They were evaluated for Radiation Induced Early and Late Skin Reactions; Cardiac Toxicity by ECG (QTc) and Echocardiography (LVEF and Myocardial Performance Index/Tie Index) and for Pulmonary Function by Spirometry (FVC, FEV1 and FEV1/FVC ratio). Results: Group A and B were comparable in terms of Demographic profile, Personal history, Comorbidities, Performance Status, Side affected, Stage of Cancer, ER/PR positive Status, Surgical procedure carried out and mean Adriamycin dose received. All patients had Infiltrating ductal Carcinoma on histopathology except one patient in each group. There was a significant QTc prolongation, Decrease in LVEF and increase in the value of Tie index pre and post chemotherapy in both the groups, with the values being within normal limits. No significant change in QTc, LVEF and Myocardial Performance Index was found after Radiotherapy in both the Groups. There was a significant decrease in FVC and FEV1 post Radiotherapy in both the Groups; however the delta values of Group A and B were comparable. The grades of skin changes in both the groups were comparable, with 7(22.58 %) in Group A and 9 (31.03 %) in Group B patients having Grade 2 Skin Reactions at the end of Radiotherapy. Late Skin Reactions at the end of 6 months were seen in 3 (9.68 %) in Group A and 4 (13.79 %) in Group B. Conclusion : The results of this study shows that the dermatological, cardiac and pulmonary toxicity is not increased with Hypofractionated Radiation Therapy. Thus it offers the advantage of a more efficient and productive use of radiotherapy departments' resources; whether Machine Time, Staffing of Treatment Units, Lower Expenses in addition to far better patients' convenience.

A prospective, randomized trial showing impact of neoadjuvant chemotherapy on downstaging tumours, comparing anthracycline based versus taxane based regime in locally advanced carcinoma breast in female

Arijit Sen

MBBS, MD PGT, Department of Radiotherapy, R. G. Kar Medical College and Hospital 1, Khudiram Bose Sarani , Kolkata - 700004, West Bengal, India.

E-mail: [email protected]

Introduction: Locally Advanced Breast Cancer (LABC) (AJCC TNM stage group IIIA, IIIB, IIIC) is associated with high risk for distant relapse compared to earlier-stage cancers, despite modern multimodality therapy. Neoadjuvant chemotherapy (NACT) plays an important role in downstaging initially unresectable tumours to operable disease. Although, anthracycline remains the cornerstone for NACT in LABC, the efficacy of non anthracycline based regimes in this setting have seldom been studied. We therefore designed this study to compare taxane based (non-anthracycline) versus anthracycline based CT in LABC with special emphasis on tumour downstaging. Aims and Objectives: To compare the efficacy of two chemotherapy regimens (anthracycline based vs. taxane based) on tumour downstaging in LABC. Material and Methods: In this prospective, randomized, single-institutional, crossover phase II study, between Jan 2013 to Mar 2014, 60 patients of biopsy proven LABC without any evidence of distant metastasis and with normal baseline haematological, biochemical and cardiological parameters (LVEF ≥ 50%) and ECOG PS 0 - 1 were randomised into two arms (30 in each arm) by computer generated random number sequencing to receive either Inj Doxorubicin (60mg/m2) and Inj Cyclophosphamide (600mg/m2) (Arm A; AC; Control) or Inj Paclitaxel (175 mg/m2) and Inj Cyclophosphamide (600mg/m2) (Arm B; PC; Study) every 3 weeks for 3 cycles. After completion of 3 cycles of NACT response and toxicity were assessed clinically and radiologically and the patients having CR or PR were sent for MRM. After MRM patients were treated by three more cycles of adjuvant chemotherapy with patients on AC arm receiving PC and vice versa (crossover design). Adjuvant External Beam Radiotherapy (50 Gy/25 #/5 weeks) and/or adjuvant endocrine therapy were administered if indicated. Results: 60 patients were analysed to compare the response to NACT. The baseline characteristics were comparable in both the arms and median age of the patients were 47.5 yrs, 45% patients were premenopausal and 56.67% were ER (+). Tumour downstaging after NACT was similar in between the two arms with ycCR 13.3% vs. 10%; p = 0.687; PR 76.7% vs. 66.67%; p= 0.573; SD 6.67% vs. 10% p = 0.640; and PD 6.67% vs. 13.33% p = 0.389; in Arm A and Arm B respectively. There was also no significant difference in ypCR between the two arms (16.67% vs. 10% in Arm A and Arm B, p = 0.448). Significantly more haematological toxicities were in Arm A (74.67% total; 16.67% Grade 3) (p = 0.004) and neuropathy in Arm B (83.3% total; 16% Grade 3) (p = 0.017). Conclusion: Although this study suffers from low sample size and short follow up, it demonstrates that non anthracycline based NACT can be a viable alternative option in patients with LABC.

Triple negative breast cancer: Is androgen receptor expression a promising target?

Chelakkot G Prameela, Smitha N Vijayan, Rahul Ravind, Sheejamol V. S, Keechilat Pavitran

Clinical Associate Professor, & Consultant, Department of Radiation Oncology, Amrita Institute of Medical Sciences.

Kochi. Kerala. 682041. E-mail: [email protected]

Background: Triple negative breast cancers (TNBC) comprise 15%-20% of breast cancers. These do not express estrogen or progesterone, nor is there an over expression of human epidermal growth factor type-2 receptor (Her 2). There are no tumors marker which could be targeted, and conventional chemotherapy remains the main treatment till date. Investigators are on the look-out for newer targets in TNBC. Molecules that have gained interest recently are, PARP (poly-ADP-ribose polymerase) inhibitor, and EGFR (epidermal growth factor receptor) inhibitor [1]. Androgen receptor is one other such extensively experimented bio-marker. Aim: We conducted this pilot study to retrospectively analyze androgen receptor status in TNBC patients, treated from 2004 to 2011, at our tertiary cancer care centre, and, the disease profile in this group, and to look into the viability of this as a biomarker. Methods: Details of all TNBC patients, who had follow up till 2011, and whose pathological slides and blocks were retrievable, were analysed for AR status. The slides were reviewed for androgen receptor status using Androgen receptor Monoclonal (F 39.4.1 clone) Mouse antibodies (pre-diluted), IgG1, Kappa (AM 256-10ME) reagent and SS Polymer SRP detection kit DAB (QD 400-60KE) of Biogenex, USA. Retrieved slides were de-paraffinised in xylene and hydrated in ethanols. Antigen was heat-retrieved using microwave oven for a period of 30 minutes (2x15 minutes) in citrate buffer at pH 6.0. Horse-radish-peroxidase was used with diamine-benzaldehyde for antibody detection. Androgen receptor positivity was read as percentage and intensity of nuclear staining as for estrogen and progesterone receptors. Nuclear expression >10% was taken as nuclear positive. All slides were interpreted by a single breast-onco-pathologist. Results: 316 TNBC patients were treated. 149 were followed up till 2011. Pathological slides and blocks were retrievable for 72. Three had nuclear AR expression and six isolated cytoplasmic expression, and both were analysed. Mean follow up was 52.53 months. Five year progression free survival (PFS) for entire TNBC group was 80.01%, for AR negative 80.41% and for AR positive 75%. Two of the three nuclear positive patients fared poorly, one with disseminated disease and one with hepatic metastasis; and had a median PFS of 19.93 months. Cytoplasmic positive group were disease free at the end of follow up, though the significance is unclear. 5-year PFS for pre-menopausal AR positive group was 83.3%. Post-menopausal group had a median PFS of 19.93 months. Higher grade had less AR expression. Node positive TNBC with AR expression (both) had 5 year PFS of 60%. Conclusion: AR expression was seen in elderly, post-menopausal, node positive group as claimed by MacGhan, and Lou et al [2,3]. Luminal androgen receptor (LAR) sub-set, one of the recent six sub-classifications of TNBC, which might encompass this poor prognostic group, might be more sensitive to anti-androgen molecules 4, and can be the sub-set where targeted tailored treatment options could be considered, there by improving the poor outcomes.

Helical tomotherapy based intensity modulated radiotherapy for the management of difficult clinical situations in breast cancer: A case series with review of literature

Animesh Saha, Sanjoy Chatterjee, M. S. Anurupa mahato

Tata medical center, kolkata. E-mail: [email protected]

Introduction: Image-guided intensity modulated radiotherapy (IMRT) using helical tomotherapy (HT) can achieve a homogenous dose distribution in the planning target volume (PTV) while minimising the dose to the organs at risk (OAR). Tomotherapy is being used in various complex situation in breast cancer radiotherapy e.g, Bilateral Breast Irradiation, Bilateral Breast and Left Supraclavicular Fossa (SCF) Irradiation, Pectus Excavatum, Bilateral Implants and Breast Irradiation, Internal Mammary Chain Nodal Irradiation. Aims and Objectives: To reports our experience of treating three difficult clinical situations in breast radiotherapy where HT was used. Materials and Methods: In case 1 the right chest wall and SCF were treated with adjuvant radiotherapy (40 Gy in 15 fractions) with a sequential boost (10 Gy in five fractions) to the SCF PTV. In case 2 high right level III axillary nodal recurrence was salvaged by reirradiation of the disease to a dose of 60GY in 30 fractions (for both of these brachial plexus sparing IMRT was done) with the brachial plexus allowed a maximum biologically effective dose (BED) of 120 Gy. In case 3 adjuvant radiotherapy was given to complex volumn of interal mammary chain, SCF and chest wall to a dose of 40GY in 15 fractions. Results: It was possible to treat the SCF to a higher dose and to treat complex treatment volumn of breast,SCF and internal mammary chain; using helical tomotherapy-IMRT with adequate homogeneity and conformity indices; respecting the tolerance of critical organ. At a short follow up period of 9 months,The treatment was found to be successful in controlling disease locoregionally. No patients reported symptoms suggestive of brachial plexopathy. Conclusions: Helical tomotherapy is a technique where complex volume treatment in breast cancers could be delivered with adequate homogeneity and conformity indices and high capabilities of critical organ sparing. Further long term studies are required to assess local control and late toxicity.

Clinical outcome of postmastectomy chest wall radiotherapy using electrons: A retrospective analysis

Asha Arjunan, Priyanka Raju, Preethi Sara George, Aleyamma Mathew, Ratheesan K, Parameswaran S

Regional Cancer Centre, Trivandrum, Kerala, India. E-mail: [email protected]

Introduction: Randomised trials and metaanalyses have demonstrated improvement in locoregional control and overall survival in high risk women who receive postmastectomy radiation therapy (PMRT) after systemic treatment. Two opposed tangential photon beams to the chest wall is the commonest technique for PMRT. Electron beam RT to chest wall is also used routinely in many centres. At our centre, for CT based 3D conformal planning of PMRT, the supraclavicular field (SCF) is treated with photons. The chest wall (CW) is either treated with tangential photon or enface electron. The decision to use postmastectomy electron beam therapy (PMEBT) for the chest wall is based on patients' anatomic features (like curvature and thickness of chest wall) and potential for heart/lung in the radiation field. We do not routinely treat internal mammary nodes (IMN). This is a retrospective analysis to assess local recurrence rate (LRR), Disease Free Survival (DFS) and overall survival (OS) after PMEBT in our patient population. Methods: Fifty two patients who were candidates for PMRT and underwent PMEBRT from January 2009 to December 2013 were identified from Hospital Registry after obtaining Institutional Review Board (IRB) approval. Data regarding patient demographics, tumour characteristics, treatment protocols and follow up were collected. Local recurrence was defined as tumour recurrence in the irradiated portal. DFS and OS curves were generated using Kaplan Meier method. RTOG scale was used to score acute and late toxicities. Results :The median age at diagnosis of breast cancer was 48 years (range, 33-65 years). Twenty eight patients (53.8%) were premenopausal. Left sided cancers were more common than right sided cancers (53.8% v/s 46.1%). Twenty patients (38.5%) had TNM stage II disease and thirty two patients (61.5%) had stage III disease. Twenty nine patients (55.7%) received neoadjuvant chemotherapy and the remaining twenty three patients (44.2%) received adjuvant chemotherapy. Thirty patients (57.6%) received adjuvant hormonal therapy and five patients (9.6 %) received trastuzumab. CW and SCF was irradiated in fifty patients. Two patients received radiotherapy to CW, SCF.and IMN. All patients received a dose of 50 Gy in 25 fractions. There were no treatment breaks. Two patients (3.8%) developed acute grade 3 skin toxicity. The median follow up was 24 months (range 8-49 months). None of the patients have developed local recurrence. Fifty patients (96.5%) were alive at the time of analysis. There were two deaths (breast cancer death=1, acute myeloid leukaemia=1). At last follow up forty three patients (82.7%) were alive without evidence of disease. There were no cases of symptomatic pneumonitis or cardiac injury. Conclusion: Electron beam therapy is an effective method to deliver radiation to postmastectomy chest wall. It offers a high degree of local control with acceptable acute and late toxicities.

Atrial fibrillation during chemotherapy with docetaxel for breast cancer: A case report

Asha Arjunan*, Anjali V. R.*, Sheela Nandakumar**, Susan Mathews*

*Regional cancer Centre, Trivandrum, **Department of Cardiology, SUT Hospital, Trivandrum, Kerala, India. E-mail: [email protected]

Aim: To report a case of atrial fibrillation (AF) in a 63 year old woman while on chemotherapy with Docetaxel for breast cancer. Case Report: A 63 year old woman with stage III A breast cancer was planned for systemic chemotherapy with Adriamycin/Cyclophosphamide (AC) followed sequentially by Docetaxel. There was no past history of ischemic heart disease. Electrocardiogram (ECG) and echocardiography (ECHO) prior to initiation of anthracycline based chemotherapy was normal. ECHO revealed good left ventricular function with ejection fraction (EF) of 77%. She was on Tab. Methotrexate for rheumatoid arthritis, which was stopped prior to initiation of chemotherapy.She received 4 cycles of AC as planned. 2 days after 2nd cycle of docetaxel she reported to casualty with complaints of palpitation and excessive tiredness. ECG was suggestive of Atrial Fibrillation (AF) with fast ventricular rate. Rate and rhythm was controlled after admission to intensive care unit and administration of intravenous amiodarone. Her serum creatinine, electrolytes and TSH levels during this episode were within normal limits. ECHO showed no drop in EF compared to baseline and coronary angiogram was normal. She was discharged 2 days later and completed the next 2 cycles of docetaxel as planned. Conclusion: There are only a few case reports of Docetaxel-induced AF. Nevertheless, physicians treating patients with taxane chemotherapy should be aware of the potential of Docetaxel to induce AF, especially in elderly patients.

Concurrent chemoradiation is an integral part in the treatment of metastatic breast cancer

Balaji Sivagnanam

E-mail: [email protected]

Background: Mastectomy for local control in metastatic breast cancer does have potential advantages, which warrant consideration. But loco regional radiation also has similar results and can be considered. Aim: To evaluate the role of external radiation to whole breast for local control in metastatic breast cancer. Materials and Methods: All metastatic breast cancer registered at cancer institute were analysed from the year 2003 to 2008. Patients with metastatic breast disease, excluding brain metastasis at presentation were included. 105 Patients were analysed. Results: Out of the 105 patients, 68 patients were treated with local therapy and 37 patients were not treated with local therapy. local therapy was not offered to the 37 patients, mainly because of widespread metastasis and poor performance status. out of the 45 patients who underwent loco regional radiation, 18 succumbed to progressive disease and 27 patients who did not have any metastasis at the end of 1 year, offered surgery, but patients were not willing. out of 23 patients who underwent mastectomy 19/23 patients are alive at the end of 5 years. Conclusion: Loco regional radiation can be made a integral part in metastatic breast cancer treatment to improve the quality of life in patients with progressive disease and if the patient did not have any metastasis at the end of one year, mastectomy can be added to still more improve the local control.

Economic evaluation and assessment of early toxicity of hypofractionated radiotherapy compared to standard fractionation in breast cancer.

Chandralekha*, Selvamani B, Balukrishna, Jasmine Prasad

Christian Medical College, Vellore. E-mail: [email protected]

Introduction: Breast cancer is the most frequent cancer among women with the global incidence in women to be 25.2% of all reported new cancers (1). In India, breast cancer is the most common cancer at 27% of all new cancers (2). Breast cancer is associated with substantial medical and economic burden and henceforth the management of breast cancer accounts for a large percentage of health care budget(3). Radiation therapy as an integral part in the multi-modality management of breast cancer significantly reduces the locoregional recurrence and also improves the overall survival. To overcome the economic burden related to radiotherapy in breast cancer various hypofractionated schedules like 39 Gy in 13 fractions, 40 Gy in 15 fractions were tried and have proven to achieve similar local control rates, survival rates and cosmetic outcome (4). This study aims to do the economic evaluation and to assess the acute toxicities associated with 40 Gy in 15 fraction(hypofractionated regimen). Aims and Objectives : To analyse the cost difference in breast cancer radiotherapy between conventional fractionation and hypofractionated radiotherapy. The study also aims at assessing the early toxicities of patients receiving post mastectomy radiotherapy. Methods and Materials : This Prospective study group consisted of 30 consecutive patients seen in the Radiation therapy department of Christian Medical College, Vellore from February to August 2014, treated with standard fractionation and hypofractionated post mastectomy radiotherapy by conventional technique. Each patient was interviewed using a pilot tested questionnaire to collect data on the health economics. The costs imparted to the patient were classified as direct and indirect costs. The cost effect for each was assessed at the end of the treatment. The occurrence of early toxicity in patients treated with standard and hypofractionated radiotherapy was recorded and analysed using RTOG acute skin toxicity criteria. Results: Twenty three patients were included in the 40 Gy in 15 fractions arm and 7 patients were in the 50 Gy in 25 fractions arm. Of the 30 patients 15 were treated in the Cobalt and 15 were treated in Linear accelerator. The analysis showed that there was significant reduction in costs in hypofractionation with conventional treatment in Cobalt 60. The difference in Linear accelerator was not found to be significant. Conclusion: Adoption of hypofractionated radiotherapy in breast cancer treatment can lead to significant reduction in resource utilisation and is especially pronounced for conventional radiotherapy settings with high patient loads.

A case of metastatic malignant phylloidies

Kundu C. R., Patro K. C., Bhattacharay P. S.

E-mail: [email protected]

Malignant phylodes tumor of breast with RT temporal and occipital bone metastasis. Malignant phyllodes tumor (MPT) of breast is a rare malignacy. Because of its rarity there is no evidence based treatment or follow up guidelines established. The present study is a case report of a 49 yr old parous perimenopusal female diagnosed as phylodes tumor of rt breast. Her blood chemistry CBC, RFT LFT are all within normal limits. Tru cut biopsy from the tumor was s/o phyllodes with an associated abscess. The mass was excised with dimension of 8x5x6 cm. microscopically it is established to be MPT- high grade. No heterotropic element was present. Later of the month she under went MRM rt side and HPE report s/o FB Granuloma with no residual disease. No adjuvant RT was given and was kept on f/u. she was triple negative. After 1 ΍ yrs he developed a swelling in rt temporal area. Tru cut biopsy pointed towards metastatic lesion from MPT rt breast and PET CT proving it to be metabolically active expansile lytic lesion of rt temporal and occipital bone. Dicussion: phyllodes tomor constitutes a spectrum from benign and locally recurrent to malignant and metastatic. Malignancy is determined by characteristic of stroma. Metastasic spread is mainly hematogenous to lung with ifrequent lymphativ involvement. On searching pub med for mets it is found that metastasis is infequent nad to lungs, bone, adrenals but none is like the present case invoving temporal and occipital bone. In view of rarity of incidence it merits reporting.

Reproducible deep inspiration breath hold to reduce heart dose in left-sided breast cancer irradiation

S. Lalitha kameshwari M.B.B.S 1 , Shital Kumar Surana M.B.B.S., D.N.B. 1 , Pratap Reddy M.B.B.S., M.D. 1 , Ram Mohan Reddy M.Sc 1

1 Department of Radiation Oncology, Krishna Institute of Medical Sciences, Hyderabad, E-mail: [email protected]

Introduction: Left side breast/chestwall irradiation in carcinoma breast patients resulting in cardiac morbidity has long been eshtablished(1), leading to increased interest in developing radiotherapy techniques to minimize further the volume of cardiac tissue irradiated. Respiratory gating techniques to optimize left-breast radiotherapy, and delivery of radiotherapy during reproducible deep breath hold have been suggested by many studies to minimise the cardiac volumes within the irradiated tangential fields without compromising target volumes(2-4). In the present study treatment plans using deep inspiratory breathhold versus conventional way of treatment are compared and evaluated for cardiac dose reduction using DIBH Aims and Objectives: To evaluate the cardiac dose reduction using reproducible deep inspiration breath hold (DIBH) in comparison with free breathing for irradiation of left-sided breast cancer patients post mastectomy. Materials and Methods : 8 patients with locally advanced left-sided breast cancer post mastectomy underwent computed tomography scans in free breathing and in DIBH after prior respiratory training for breath hold. The RPM system was used to monitor respiratory motion. For each scan, treatment plans were generated.The DIBH plans for each patient were compared with FB plans using dosimetric parameters. Results: All patients were successfully treated with the DIBH technique. Significant differences were found between the FB and DIBH plans for mean heart dose (6.72 Gy vs. 2.84Gy, p = 0.013), heart V30 (52.6 vs. 12.8 cm3), V20 (58.7 vs. 16.6 cm3) (p< 0.015 for both), mean left anterior descending coronary artery (LAD) dose (31.9Gy vs. 21.85 Gy, p < 0.001). The mean heart dose was found to be lower with increase in breath hold amplitude. Conclusion: We report that the use of DIBH technique in breathing adapted radiotherapy for left-sided breast cancer significantly reduces the radiation doses to the heart and LAD, therefore potentially reducing cardiac risk.The cardiac dose sparing linearly increases with DIBH amplitude.

Retrospective analysis of cancer breast in young females at biro, mmc

V. U. Salini, Shanmugakumar, N. V. Kalaiarasi, Madhumathi, Baskar, Sundaresan, Prabakar

E-mail: [email protected]

Introduction: Although the diagnosis of breast cancer is much less common in women under the age of 40,it tends to present at a later stage,be more aggressive and have a poorer prognosis. Aim: To retrospectively analyse the disease pattern and treatment outcome of cancer breast in females less than 40 yrs who presented in the department of radiation oncology,RGGH,MMC during the year 2010-2014. Materials and Methods: A total of 60 records of the females aged less than than 40 yrs were analysed.The factors that were studied are risk factors,clinical staging,histopathological grading,hormone receptor status,metastasis and recurrence rate. Results: Out of the 60 cases,64% of cases were between 35-39 yrs of age,25% between 30-34 yrs, 8% between 25-29 yrs and 3% were under 25yrs of age.Majority of the patients had infiltrating ductal carcinoma of which 30% presented with lymphovascular invasion.The commonest histological grade was grade II.18 cases had their hormone receptor status done,of which 30% were triple negative.Most of the patients were in stageIII at the time of presentation; 1% of cases presented with metastasis at the time of diagnosis.20 cases had either recurrence or mets at a later stage.Out of these 20 cases,12 cases had surgery and adjuvant chemotherapy as their primary modality of treatment. Conclusion: Breast cancer in young females tends to present at an advanced stage either because of its biological aggressive subtype or because of low index of suspicion and delayed diagnosis.Surgery combined with chemotherapy and adjuvant radiotherapy significantly reduced loco-regional recurrence and metastasis.

Prospective study of phantom breast syndrome and psychological distress among breast cancer patients

Madhulika Vijayakumar*, Vishal Manick*, S. Shanmughakumar,

N. V. Kalaiarasi, Prabhakaran, Sundaresan, Baskar, Madhumathi

Department of Radiation Oncology, Rajiv Gandhi Govt General Hospital, Chennai - 3, E-mail: [email protected]

Introduction: Mastectomy is still a cornerstone in the management of breast cancer. It seriously affects the patient's quality of life through pooled effect of physical impairments and psychological distress. Phantom breast syndrome is a complex post mastectomy complication. It's the sensation of continued presence of breast after its removal. It can include painful or non painful sensations. Aim: To assess prospectively the incidence of PBS after mastectomy and to identify the risk factors associated with phantom sensations. To establish correlation between PBS and psychological distress. Methods: Participants: Women who underwent radical mastectomy in Rajiv Gandhi Government General Hospital between Jan 2010-Jan 2014. Patient Selection: Patients who have completed adjuvant chemotherapy and radiotherapy, on follow up with no evidence of recurrence or metastasis. Assessment Instruments: Patients were interviewed using a structured questionnaire collecting socio demographic and clinical data. Treatment details were obtained from medical records. They were also given a self administered psychometric test-dass 21 anxiety and depression scale. Results: Of the 100 patients:27% PBS- High in younger age< 50 yrs, unemployed and pre/post mastectomy pain. Sensations-discomfort 52%, pain 37%, abnormal shape 18%. 60% anxio-depressive disorders. Women with PBS had higher scores of anxious and depressive symptoms. Psychological distress related to PBS and mastectomy loss of breast as a symbol of femininity, the feelings of rejection, inability to cope or make decision, feelings of helplessness and loss. Discussion: PBS is an independent risk factor of depression.More attention should be paid for screening and evaluation of its impact among patients who achieve long term survival.

A retrospective epidemiological study of age incidence of primary breast carcinoma and correlation of prognosis to age

Mousumi Das

Dept. Of Radiotherapy Medical College and Hospital Kolkata.

E-mail: [email protected]

Introduction: Breast cancer is a major public health problem for women throughout the world. With rising incidence and awareness, breast cancer is the commonest cancer in urban Indian women and the second commonest in the rural Indian women[1].Over 100,000 new breast cancer patients are estimated to be diagnosed annually in India[2].In general, breast cancer has been reported to occur a decade earlier in Indian patients compared to Western countries. A significant proportion of Indian breast cancer patients are younger than 35 years of age. This proportion is approximately 11%[3].Young age has been associated with larger tumour size, higher number of metastatic lymph node, higher tumour grade, low rates of hormone receptor positive status, earlier and more frequent locoregional recurrences and poorer overall survival[4]. Aims and Objective: Aim of the study is to document the age pattern of incidence of breast cancer in Eastern zone of Indian population and to investigate whether young age at diagnosis is a negative prognostic factor in primary breast cancer. Materials and Methods: This is a retrospective, epidemiological, single institutional study from period of January 2008 to December 2009, conducted in Department of Radiotherapy, in a superspeciality hospital in Eastern zone of India. 250 cases (females) of histologically confirmed non-metastatic carcinoma of breast with 5 years follow up are included in the study. Clinical, histopathological data and details of therapeutic management of all cases are reviewed and correlated. Progression free survival is analyzed by Kaplan-Meier survival analysis. Result: Among the patients studied 26% patients are less than 40 years of age. Among the early age group patients (<40 years) 66.6% patients are triple negative breast cancer in compared to 47.5% in late age group patients (>40 years). 60% patients of early age group are grade III whereas 50% of late age group patients are grade III. Progression free survival is less in early age group patients. Conclusion: The incidence of breast cancer is more in older age group. This study suggested that young women with breast cancer, on the basis of age only, should be regarded as high risk patients.

Clinico-morphological profile and receptor status in breast cancer patients in a South Indian institution

Saptarshi Ghosh

GSL Medical College and General Hospital.

E-mail: [email protected]

Background: Breast cancer is the most common malignancy in women worldwide and the second most common cancer in women in India. Hence, clinico-morphological parameters and receptor status in breast cancer patients were studied in a South Indian institute. Objective: To analyse and correlate the clinical and morphological parameters with receptor status in breast carcinoma patients in a tertiary care institution in Southern India. Materials and Methods: This is a retrospective study done among 320 patients of breast cancer diagnosed in an oncology hospital over a period of 3΍ years. Statistical Analysis: Data was analysed by using SPSS Version 21. Results: In our study, 60.6% patients of breast carcinoma belonged to the age group of 40 to 60 years. Most common histological type of breast cancer was infiltrating ductal carcinoma, not otherwise specified, consisting of 84.4% patients. On immunohistochemistry, estrogen receptor (ER) and progesterone receptor (PR) were expressed in 56.25% and 53.1% of our patients respectively. Conclusion: Breast cancers in developing countriesoccur in younger women and tend to be more aggressive with lower rates of ER and PR expression and higher histological tumor grades. Both ER and PR status of the tumors had a significant association with the age of the patient, pathological TNM stage and histological tumor grade.

Evaluation of 3D CRT planning of bilateral breast cancer treated with mono isocenter technique

P. Suman Kumar

Department of Radiotherapy & Oncology, Kasturba Medical College Hospital, (An associated teaching hospital of Manipal University), Attavar, Mangalore-575001. Karnataka State, INDIA. E-mail: [email protected]

Objective: To evaluate mono isocentric plan of bilateral breast carcinoma treated with three dimensional conformal radiotherapy (3DCRT) and to study the volumetric doses to lung and heart. Materials and Methods: A patient with Carcinoma of bilateral breast stage IB who underwent lumpectomy following 9 months of neo-adjuvant hormonal therapy was considered for postoperative radiotherapy with a prescription dose of 42.5 Gy in 16 #. A 3D CRT plan was generated by using mono isocenter technique to plan target volumes (PTV) with CMS Xio treatment planning system. The plan was evaluated in terms of dose volume histograms (DVHs) pertaining to planned dose coverage, maximum and mean doses for both PTVs and volumetric doses of organs at risk (OAR). Results: The whole volumes of both PTVs were encompassed within 95% isodose line. The mean and maximum doses for PTVleft were 43.7Gy, 48.3Gy and for PTVright are 42.08Gy, 49.6Gy respectively with hotspots (110%) inside the volume of both PTVs. Right and left lungs were received a mean dose of 17.6 Gy and 15.0 Gy respectively. V20 and V30 of right lung were 41.9% and 28.8% respectively. V20 and V30 for left lung were 33.1% and 25.2% respectively. Heart received a mean dose of 12.64 Gy and V10 and V40 of the heart were 30% and 12.7%. Conclusion: The results of our study demonstrated that the target volumes were sufficiently irradiated with the mono isocentric 3DCRT which reduces on-table time and positional errors. The lung and heart volumes irradiated were well within tolerance dose limits.

Extra Lung is irradiated when treating right sided breast cancer with radiation: Results from dose volume histogram analyses of a tertiary cancer centre database

V. K. Reddy^, Kanishka Sarkar^, Rosina Ahmed*, Sanjit Kumar Agarwal*, Anurupa [email protected], Indranil Mallick^, Raj Kumar Shrimali^, Rimpa Basu Achari^, Sanjoy Chatterjee^

^Department of Radiation Oncology, *Department of Breast Surgery, Department of Medical [email protected] Tata Medical Centre, Kolkata. E-mail: [email protected]

Background: 10 year follow up after hypo-fractionated radiation therapy has been reported as safe and effective in both post breast conservation therapy and mastectomy. The incidence of pulmonary fibrosis and ischemic heart disease were 1.7% and 1.5% which was no different from the standard arm(1). The maximum heart distance (MHD) and central lung distance correlated strongly with the mean heart dose and the volume of the lung irradiated which can help in prediction of toxicity. Aim: This study compares normal tissue dosimetric data to lungs and heart, to ensure compliance to safety and report comparative data following hypofractionated radiation therapy. Methods: The dosimetric plans of all 367 patients who underwent 3DCRT (4005 cGy in 15 fractions) to the whole breast or chest wall and supraclavicular fossa, where indicated, from September 2011 to August 2013 at Tata Medical Centre were analysed. Mean dose and V30 of heart (left sided cancers), mean dose and, V5/V10/V20 of ipsilateral lung alongside mean contralateral breast dose (MCBD) were collected from the Dose volume histograms (DVH). The maximum lung distance in mid slice (MLD-MS), maximum lung distance in all slices(MLD-AS), maximum heart distance in mid slice(MHD-MS), maximum heart distance in all slices(MHD-AS) was measured from anterior border of the organ to 50 % isodose curve. Comparison of the above variables was done between the whole breast irradiation (WBRT) and chest wall irradiation (CWRT) using the Independent samples T test. Comparison of lung and contralateral breast DVH were done for left and right sided cancers separately. Univariate and multivariate analyses were done to evaluate significant contributors to MLD, MHD and MCBD. All plans were optimized using MLCs and acceptance criteria of target breast dose homogeneity complying to ICRU62 was followed. Results: The mean lung dose was 629.4 cGy (range - 14.6 cGy to 1296.5 cGy). The mean V5, V10,V20 of ipsilateral lung were 22.4, 15.7 and 12.8 % respectively. The MCBD was 13.2 cGy (range - 1.0 cGy to 43.6 cGy). The mean of the MLD-MS was 2.1 cm (range - 0.5 cm to 3.4 cm) and MLD-AS was 2.3 cm (range - 0.80 to 3.60 cm). The 90th percentile of MLD-MS is 2.8 cm and MLD-AS is 3.0 cm. The mean heart dose and V30 in the left sided breast cancers were 381.3 cGy (range - 9.8 cGy to 858 cGy) and 5.8 % (range - 0.2 to 16.7%). The mean MLD-MS (1.9 cm vs 2.2 cm), MLD-AS (2.2 cm vs 2.4 cm, p = 0.0001), V10 and V20 were significantly lesser with WBRT than CWRT. The mean dose to the heart and V30 were significantly lesser with WBRT. The lung doses V5, V10, V20, mean lung dose, MLD-MS were higher in the right sided irradiation (p=0.0001), with no significant correlation between tumour laterality and mastectomy versus conservation surgery (correl=0.015, p>0.79). MLD correlated to V5,V10 and V20, showed a coefficient of 0.451, 0.933, 0.923 (P=0.0001) respectively. Similarly correlation between mean heart dose and V30 to MHD was 0.959 and 0.941 (p= 0.0001 and 0.0001). Conclusions: Significant correlation existed between MHD and MLD for mean heart dose,V30 and V5, V10, V20 respectively, making them surrogate markers for future lung and heart toxicities. As expected post mastectomy irradiation results in more lung and heart irradiation. Lesser Lung irradiation occurs when treating left sided breast cancers. Whilst modern techniques have resulted in safe practice in our patient cohort, special attention must be given to reduce right sided lung dose when treating both right sided breast and chest wall, to further reduce future morbidity.


Can we predict molecular subtypes of medulloblastoma based on MRI? Encouraging data from a blinded study

Archya Dasgupta, Tejpal Gupta, Sona Pungavkar, Amit Janu, Neelam Shirsat, Girish Chinnaswamy, Rakesh Jalali

Tata Memorial Centre, Mumbai. E-mail: [email protected]

Background: Recent investigations on medulloblastoma has revealed at least 4 different subgroups with diverse clinical, demographic profiles rendering better insight in understanding the heterogenous entity of the disease. Aims and Objectives: The study deals with the radiogenomics as an attempt of unifying the molecular subgrouping obtained from biological material with the radiological features obtained through the MRI scans of the patients. Methods and Materials: After obtaining the IEC approval the pre-operative scans of 35 patients were collected with due consent or assent. Interpretation was done on a set of 22 prefixed radiological parameters based on our previous experience and few other recent studies Molecular subgrouping into either of the four groups- WNT, SHH, group 3 or group 4 was done based on miRNA profiling of a set of 9 genes. The scans were discussed in the institutional joint meeting of neuro-oncology group comprising of specialists from each of neuroradiology, radiation oncology, neurosurgery, pediatric oncology, who were blinded to the results regarding the molecular groups. Based on the features studied and our previous experience a provisional diagnosis was given predicting the molecular subgroups. In cases of controversy, a second probable diagnosis was also noted. Statistical analysis was done using IBM SPSS software (V20). Pearson's chi square test was used for finding the correlation between the variables and the molecular groups. Cohen's kappa test was used to find out the agreement for prediction. Results: Patients ranged from 2 years to 36 year (mean-13 years) and 22 of 30 were male. RT-PCR based miRNA profiling revealed 6 patients to be in WNT, 12 in SHH, 5 in group 3 and 7 in group 4 molecular subtypes. Radiological assessment analysis revealed 75% of SHH tumors to have lateralized location with less propensity for involving dorsal brainstem. Presence of perifocal edema and a trend for higher association with macrocyst was also highrer in SHH. Features suggestive of WNT subtype were midline location or involvement of C-P angle, homogenous contrast enhancement in more than 80% areas and presence of intratumoral hemorrhage. All group 3/group 4 tumors had midline position and higher chances for epicentre of the tumor being located inferiorly (NS). Group 3 tumors were showing heterogenous patchy contrast enhancement whereas calcification was a significant finding for group 4 tumors. Cross tab analysis revealed four distinct radiological features, viz horizontal tumor location (p-0.001), involvement of dorsal brainstem (p-0.032), perifocal edema (p-0.02), intratumoral calcification (p-0.002) significantly predictors of accurate molecular subtype. A separate analysis was done for WNT, SHH and combining the group 3/group 4 tumors, as per recent international norms. Three more features in the form of pattern of contrast enhancement (p-0.05), T2W homogeneity (p-0.027) and intratumoral hemorrhage (p-0.017) were found to be significantly predictive, as well. Overall, the prediction was correct for 20/30 (66%) taking 2nd prediction into account with kappa correlation coefficient for agreement being 0.43 (moderate agreement). Conclusion: We have demonstrated significant correlation between sets of certain radiological parameters with the molecular subgroups in medulloblastoma, which can have important implications in our clinical practice. These features need to be confirmed in the ongoing study and in an independent cohort of patients.

Central Neurocytoma: Treatment outcome of 5 cases

Asha Arjunan*, Anjali Vijayakumar Ramdulari*, Beela Sarah Mathew*, Anitha Mathews**, Ratheesan K*, Parameswaan S*

*Department of Radiotherapy, **Department of Pathology, Regional Cancer Centre, Trivandrum, Kerala, India. E-mai- [email protected]

Introduction: Central Neurocytoma (CNC) is a rare tumor of neuronal origin, first identified as a histologically distinct entity in 1982. It has an incidence of less than 1%, occurs most commonly within the ventricles and has a favorable prognosis. We retrospectively evaluated the treatment outcomes for CNC at our institute. Methods: The clinical data on five patients diagnosed with CNC since 2009 were retrospectively reviewed. Data regarding patient demographics, symptoms at presentation, tumour location, date of first CT/MRI scan that showed tumor, tumor size, extent of tumor resection based on imaging or surgical record (gross-total resection [GTR]or subtotal resection [STR]), pathological details, including immunohistochemistry(IHC), radiotherapy, date of tumor progression, treatment at progression and last known status were collected. Local control was defined as the absence of any tumor regrowth or progression on imaging and was calculated from date of first surgery Results: Of the five patients identified from our review, two were females and three were males. The median age at diagnosis was 22 years (range, 19-31 years). Headache (80%) and nausea/vomiting (60%) were the most common symptoms (others included weakness, visual changes and vertigo). Signs included paresis, visual deficits and bladder incontinence. All patients had intraventricular neurocytomas. The median tumour size was 4.7 cm (range 2.3 to 8.2 cm). All (100%) of the tumors were positive for synaptophysin and 3 cases (60%) showed expression of glial fibrillary acidic protein (GFAP). All patients received surgery as primary treatment (GTR: 2, STR: 3). None of them received adjuvant radiotherapy. Median follow up was 24 months (range, 6-48 months). All patients are alive without recurrence. Discussion: There is no general consensus on management of CNC. Surgery is the primary modality of treatment. The role of adjuvant radiotherapy still remains unclear. In our series none of the patients have recurred after surgery alone, however longer follow up is required to further assess patterns of failure.

High mitotic index is associated with poor survival in patients with intracranial meningioma

Dodul Mondal, G. K. Rath, D. N. Sharma, Supriya Mullick, Soumyajit Roy, Haresh K. P, Subhash Gupta, P. K. J. ulka

Department of Radiation Oncology, DRBRAIRCH, All India Institute of Medical Sciences, New Delhi, India. E-mail: [email protected]

Introductoin: Meningiomas comprise approximately 15-20% of all primary intracranial tumors[1]. They arise from the arachnoid layer of meninges. Radiotherapy is usually indicated for higher risk of recurrence and for unresectable tumors. Several prognostic factors are thought to be important to predict outcome. Grade III meningiomas and transformed histology are found to be significantly associated with poor outcome[2]. Aims and Objectives: To retrospectively analyze treatment outcome of patients with intracranial meningioma and to find out any correlation between different factors with overall survival. Materials and Methods: Patients receiving adjuvant radiation from July 1995 to May 2012 for intracranial meningioma were reviwed. Different factors suspected to have potential role on tumor recurrence and survival were analyzed.ͼͼ These include age, sex, duration of symptoms, history of seizure, use of antiepileptics, presence of hydrocephalus, tumor location in relation to dura and brain parenchyma, completeness of surgery, tumor grade, mitotic index, radiotherapy dose and overall treatment time. Univariate analysis for overall survival was performed. Results : 44 patients received the intended treatment. Mean age of the cohort was 40.5 years (14-64 years). Male:Female ratio was 1:1. Headache was commonest symptom followed by visual disturbance. 17, 20 and 7 patients had grade 1, grade 2 and grade 3 tumor respectively. Average duration of symptom before seeking treatment was 10 months (1-36 months). Nine patients required antiepileptic support for seizure. 25 patients had dural based tumor while 19 patients had tumor infiltrating brain parenchyma. Two patients presented with hydrocephalus requiring placement of shunt. Indication for radiation were residual tumor, high grade tumor or tumor infiltrating brain parenchyma as part of departmental protocol. Dose of radiation ranged from 45-60 Gy. 8 patients had recurrence after adjuvant treatment. Average treatment duration was 44 days (37-62days). 8 patients were planned with 2D technique, 34 patients were planned with 3DCRT technique and 2 patients were planned with SRT. OS for the entire cohort was 4.4 years. When analyzed with different factors with univariate analysis, only mitotic index was found to be significantly associated with survival. Mitotic index was analyzed into three different groups. Group1 was 0-4, group 2 was 5-20 and group 3 was more than 20 (sum of mitotic figures per 10 HPF in the area of highest mitotic activity). Group 1 had mean survival of 14 years while that for group 2 and 3 is 5.9 years and 4.1 years respectively. The 3 yr os rate of group 1, group 2 and group 3 are 100%, 71% and 41% respectively. The survival of group 1 is significantly higher compared to group 2 and 3 (p=0.01 for both groups) while no significant difference found between group 2 and 3. Conclusion: High mitotic index was associated with poor survival whereas no significant association could be found with other factors analyzed in our study.

Assessment of quality of life in brain metastases patients receiving palliative Whole Brain Radiotherapy

Mekap Himanshu S, Padhi Sanjukta, Routray Biswaranjan, Bose Chaitali, Pattanayak Lucy, Panda Niharika, Senapati S. N.

Department of Radiation oncology, AHRCC, Cuttack, E-mail: [email protected]

Background: An estimated 20%-40% of cancer patients will develop brain metastases in their life time. They are associated with poor prognosis both from a length of life as well as a quality of life stand point. Whole-brain radiotherapy (WBRT) is the standard treatment for patients with brain metastases. Although WBRT can reduce neurologic symptoms, the median survival following WBRT is limited. Given this limited survival, it is important to consider quality of life (QOL) when treating patients with brain metastases. Aim and objective : The primary objective of this study was to assess whether there was an improvement in quality of life for patients with brain metastases receiving palliative whole brain radiotherapy. and to determine which quality of life domains improve or worsen with radiation therapy. Materials and Methods: From jan. 2013 to jun. 2014, 25 patients with previously untreated brain metastases were included at AHRCC, CUTTACK. All patients received Whole Brain Radiotherapy 30 Gy at 300 cGy per fraction. Quality Of Life was measured with the EORTC-QLQ-C15-PAL, and EORTC Brain module- BN 20 questionnaire and barthel index of activities of daily living calculated before the start of radiotherapy, and at 1 month, and at 3 months. Results: Total 25 patients received whole brain radiotherapy 30 Gy at 300 cGy per fraction. The most prominent symptoms at baseline were headache(EORTC QLQ BN 20), fatigue(EORTC QLQ C15-PAL) and nausea(EORTC QLQ C15-PAL). After completion of whole brain radiotherapy significant improvement was seen for EORTC BN 20 headache scale and EORTC C15 PAL nausea scale, but there is worsening of EORTC C15 PAL fatigue scale. Baseline KPS and Barthel index was positively correlated with improvement in global quality of life at 1 and 3 months. Conclusion: At 1 month there were improvement in certain QOL scores such as headache and nausea but there was worsening of fatigue score. At 3 months after whole-brain radiotherapy, there was a trend toward worsening general and brain specific quality-of-life scores.

Epworth Sleepiness Scale- a novel tool to assess somnolence syndrome post radiotherapy to brain

Ritika Harjani*, Janaki MG*, Uma Maheshwari#, Ram C Alva*, Arul Ponni TR*, Kirthi Koushik TS*, Mohankumar S*

*Department of Radiotherapy, #Department of Chest Medicine, M S Ramaiah Medical College, Bangalore, Karnataka, India. E-mail: [email protected]

Introduction: Radiation to brain causes early, early-delayed and delayed side effects.1 Although early and delayed effects are well studied, there is paucity of literature regarding early-delayed effects like somnolence syndrome. The existing studies use general symptom assessment and visual analog scales.2 Epworth Sleepiness Scale is a time tested tool to assess daytime sleepiness in various conditions.3 This study is an attempt to determine the presence of somnolence in our patients using this novel scale. It is a simple questionnaire and we expect this will be able to grade the severity of somnolence. This is the first study to our knowledge to determine post radiation somnolence using Epworth Sleepiness Scale. Objective: To study the incidence of somnolence syndrome in patients receiving radiotherapy to brain. Materials and Methods: 23 patients with primary brain tumor or metastases to brain were the subjects of the study. Patient demographics and tumor type- primary or metastatic along with grade was noted. Patients with Karnofsky performance status less than 70 and those with pre-existing sleep disorders were excluded from the study. Patients were treated with palliative whole brain radiation for brain metastases and conformal adjuvant radiotherapy for primary brain tumors as per standard guidelines. Patients were subjected to Epworth Sleepiness Scale3 at baseline, thereafter every week during radiation; also continuing weekly after cessation of radiation until 6 weeks post treatment. Results : All 23 patients (median age 50 years) completed the planned questionnaires until 6 weeks post radiation. 20 had primary brain tumors whereas 3 had metastatic lesions in brain. Of the 23 patients, 14 patients (60.86%) had abnormal or increased daytime sleepiness; of which 3 had ESS scores greater than 16. Conclusion: Somnolence occurred in 60.86% of the patients who underwent radiation treatment for brain tumors, which is in accordance with existing literature.4,5 Epworth Sleepiness Scale is an effective tool to detect and quantify somnolence, however it does not consider other symptoms of somnolence syndrome and hence should be combined with visual analog scale to get complete information.

Pineal parenchymal tumour of intermediate differentiation: 5-year experience of a single institution

Asha Arjunan*, Minolin Dhas*, Beela Sarah Mathew*, Anitha Mathews**, Ratheesan.K*, Parameswaran.S*

*Department of Radiation Oncology, **Department of Pathology, Regional Cancer Centre, Trivandrum, Kerala, India. E-mail: [email protected]

Introduction: Pineal Parenchymal tumour of intermediate differentiation (PPTID) was first classified by WHO in 2000 as a pineal tumour with an intermediate prognosis between pineocytoma and pineoblastoma. It is a rare disease and is pathologically classified as WHO grade II or III based on mitotic activity and immunoreaction to neurofilaments. There are only a few studies on the clinical outcome of PPTID. Methods: We retrospectively reviewed the clinical data on five patients with PPTID treated at our centre since 2009. Data regarding patient demographics, pathological details, treatment details such as extent of tumor resection based on imaging or surgical record (gross-total resection [GTR] or subtotal resection [STR]), radiotherapy, date of tumor progression, treatment at progression and last known status were collected. Local control was defined as the absence of any tumor regrowth or progression on imaging and was calculated from date of first surgery. Results: Of the five patients identified from our review, four were females and one was a male. The median age at diagnosis was 23 years (range, 16-39 years). All patients underwent surgery as the primary treatment (GTR=1 and STR=4) followed by postoperative radiotherapy. Cytological evaluation of CSF and MRI of the entire neuraxis was performed prior to radiotherapy in all patients. None of them had cerebrospinal dissemination at diagnosis. All patients were treated with 3-Dimensional conformal technique targeting the Gross Tumour Volume (GTV) with adequate margins. None of them received craniospinal irradiation or whole ventricular radiotherapy. Dose ranged from 54.0 to 57.6 Gy in conventional fractionation. Median follow up was 24 months (range, 6-48 months). All patients are alive without recurrence. Conclusion: The optimal management of this rare disease remains to be determined. In our series none of the patients developed recurrence at a median follow up of 2 years - in spite of STR and partial brain radiotherapy targeting the primary disease. However some of the previous studies have suggested aggressive behaviour of this disease with potential for spinal seeding.

Evaluation of prognostic factors and treatment outcome in young versus elderly patients with high grade gliomas: A retrospective analysis

Naman Utreja*, Meenu Gupta*, Manju saini**, Saurabh Bansal*, Vipul Nautiyal*, Jyoti bisht*,Ravikant*,Mushtaq Ahmad*

Department Of Radiation Oncology*, Radiodiagnosis**, Cancer Research Institute, Swami Rama Himalayan University, Dehradun. E-mail: [email protected]

Background: There is very limited data on specific prognostic factors in patients with high grade Gliomas in India. Therefore this project was taken to identify prognostic factors in young and elderly patients with high grade gliomas. Material and Methods: In this retrospective chart audit, analysis of 79 young (≤ 59 yrs) and 26 Elderly >60yrs patients with histopathologically proven high grade Gliomas. Results: among 79 patients of young age group males and females were 60.4% and 39.6% and 53.8% and 46.15% in elderly age group respectively. The mean age was 34.6 yrs and 64.5yrs in young and elderly age group. In young age group 73.14 % of patients presented with features of raised intracranial pressure whereas >50% of patients presented with neurodeficit in elderly age group. In young age group (48)60.4% patients underwent total resection and (31)39.6% patients underwent subtotal resection as compared to (17)65.3% and (9)34.6% in elderly age group. All patients received post operative focal radiotherapy (54-60GY, 2GY/#) in both the groups. Concurrent chemotherapy was given in 76.5% of patients in young age group and 42.3% in elderly age group. Median survival was 13 and 11 months in young and elderly age group respectively. The overall survival for young and elderly at 3 months, 6 months, 1 year and 1.5 year was 92.4%, 82.34%, 55.6% and 34.17% and 92.3%, 61.5%, 50% and 34.6% respectively. Overall survival was significantly impaired by KPS score in both the groups (19months for KPS<70 to 24months for kps≥70 for young age group) and (6months for KPS <70 to 12 months for kps≥70 for elderly), Extent of Resection (15 months for total resection vs 9 months for subtotal resection in young) and (12 months for total resection vs 6months for subtotal resection in elderly) and chemotherapy (with chemo 16 months vs. 11 months without chemotherapy in young) and With chemotherapy 12 months and without chemotherapy 10 months in elderly). Conclusion: The prognosis of adult patients with GBM remains poor, complete surgical resection and adjuvant treatments improve progression-free and overall survival.Despite aggressive radiotherapy approach, survival of elderly high grade gliomas is <12 months. Prospective randomized multimodality clinical trials are required to validate these results and to study newer agents on brain cancer progression and impact on the elderly and younger age group as well.

Intensity-modulated radiation therapy (IMRT) for craniospinal irradiation (CSI) on helical tomotherapy (HT): effect of low-dose bath on acute hematologic toxicity

Tejshri Telkhade, Tejpal Gupta, Gourav Jain, Sadhana Kannan, Jayant Goda Sastri, Rakesh Jalali

Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India. E-mail: [email protected]

Introduction: Intensity-modulated radiation therapy (IMRT) for craniospinal irradiation (CSI) on helical tomotherapy (HT) may lead to a low-dose bath effect with implications for increased hematologic toxicity. Objectives: 1. To find correlation between acute haematological toxicities and doses received by red bone marrow volumes. 2. To find association between acute haematological toxicities and patient characteristics. Materials and Methods: Brain tumor patients with propensity for cerebrospinal fluid dissemination (medulloblastoma, germinoma, etc) treated with low-dose CSI (25Gy) or standard-dose CSI (35Gy) on HT without upfront chemotherapy were included in the study. Pelvis including proximal femora, vertebral bodies, and cranium - sites containing ≈90% of red marrow were contoured to estimate dose-volume relationships. Nadir blood counts during radiotherapy were correlated with doses to different volumetric indices. Nadir blood counts were also correlated with relative volume of total body and marrow receiving a specified dose (V2Gy till V6Gy). Analysis of factors predicting grade 2 or worse hematologic toxicity was also undertaken. Results: Eighteen patients treated with CSI on HT constituted the study dataset. Median age of the study cohort was 14 years (inter-quartile range 9-23 years). HT resulted in excellent high-dose conformity but was associated with large volumes of total body and bone marrow receiving low doses resulting in varying degrees of grade 2 or worse hematologic toxicity. Acute hematologic toxicity was largely reversible and self-limiting excepting in two patients (needing growth factor support and platelet transfusion respectively). A significant correlation was observed between nadir hemoglobin and several body and marrow indices. Similar correlation was also seen for nadir lymphocyte counts. No correlation was observed between dose-volume indices and nadir platelet, leukocyte or neutrophil counts. The incidence of grade 2 or worse acute hematologic was not affected by age (children vs adults); gender (males vs females); histology (medulloblastoma vs germinoma); or CSI dose (25 vs 35Gy). Conclusion: IMRT for CSI with HT results in excellent high-dose conformity, but is associated with a significant low-dose bath effect which has implications for increased acute hematologic toxicity.

Study of incidence and estimation of risk factors associated with hippocampal metastasis

Nanditha Sesikeran

Apollo Hospitals, Jubilee hills, Hyderabad, India. E-mail: [email protected]

Background: Modern radiation techniques are being used to attempt hippocampal-sparing whole brain RT in brain metastasis in order to minimize neurocognitive decline. However this technique is accompanied by potential risk of recurrence in hippocampal region. Aims: To evaluate the incidence of metastasis in the hippocampal region and identify factors which can predict the occurrence of metastasis in this region. Method: Pre-treatment MRIs of 40 cases (median age 55) with single or multiple brain metastases between Jan 2010-Dec 2013 were analysed. The hippocampus was contoured on 1mm thick planning-MRI on T1 image as per RTOG guidelines. All gross lesions were contoured, volume and minimum distance from hippocampus measured. Hippocampus was expanded by 5mm to represent peri-hippocampus. All lesions within this volume were considered as "hippocampal region metastases". Various clinical parameters were analysed by Pearson's test for correlation with presence of hippocampal disease. Results: A total of 120 lesions were found in 40 patients. Incidence of metastasis in the hippocampal region was 20% (7.5% intra-hippocampal, 12.5% peri-hippocampal) of which 50% had primary in breast, 27.5% in lung and 12.5% in endometrium. Primary was controlled in 62.5%. Most of them had received chemotherapy (62.5%) before diagnosis of brain metastases. Eighty Seven percent of patients with hippocampal metastases also had lung metastases. Median aggregate volume and number of brain metastases was 5.5cc and 2, while in those with hippocampal disease it was 23.81cc and 6. Among the parameters tested for correlation with presence of hippocampal metastasis, median aggregate volume (p=0.001) and number of metastasis (p=0.0001) had significant correlation, while presence of lung metastasis had a trend towards significance (p=0.09). Conclusion: Metastasis in the hippocampal region are more likely to be present in patients who have more number of brain metastases and larger aggregate volume of brain metastases and in advanced systemic disease especially lung metastases.

Brain metastases from solid tumors: A clinical and demographic profile

Saptarshi Ghosh

GSL Medical College and General Hospital. E-mail: [email protected]

Introduction: Brain metastases are the most common intra-cranial neoplasms and occur ten times more commonly than primary brain tumors. The incidence of brain metastases is on a rise due to advanced imaging techniques. Aims and Objectives: The objective of the study was to analyse the clinical and demographic profile of patients with brain metastases from primary solid tumors. Materials and Methods: This is a retrospective single institutional study done from January 2009 to March 2014 consisting of 65 consecutive patients with brain metastases. Results: 64.6% of the patients were females. Majority of the patients were in the sixth decade of their life. In 46.1% of the patients, the histology of the primary malignancy was adenocarcinoma. The site of the primary tumor was lungs in 50.8% of the cases. The overall median time from the diagnosis of the primary malignancy to detection of brain metastases was 20 months. Oligometastases was present in 60% patients. Majority of the cases belonged to the Recursive Partitioning Analysis (RPA) Class II group. Whole brain radiation therapy was delivered to 79% of the patients. Conclusion: Most of the patients with brain metastases in the study belonged to RPA Class II or III, and hence had poor prognosis. In our scenario, majority of the patients with metastatic brain tumors present late in the disease course, thereby making the treatment even more challenging.

Lung Cancer

A randomised study comparing neoadjuvant chemotherapy followed by radiotherapy against concurrent chemoradiotherapy in inoperable or unresectable locally advanced non-small cell lung cancer

Deshmane N. V., Seam R. K., Gupta M. K., Gupta M. G., Parmar B, Kaushal V, Thakur P, Tiwari A, Nilesh V. Deshmane

E-mail: [email protected]

Introduction: Aim of this study was to compare disease response toxicity profile and quality of life in sequential chemoradiation, with concurrent chemoradiation in patients of inoperable and unresectable locally advanced non small cell lung cancer. Material and Methods: 25 along with radical radiation(56Gy/28#). Toxicities and Quality of Life using EORTC QLQ-LC-13 questionnaire were recorded every week. 1st follow up was at 6 weeks after completion of protocol treatment where patients were assessed for disease response.◊5 and #21◊This study was conducted on new diagnosed, previously untreated patients of locally advanced NSCLC enrolled during the period of July 2012 to June 2013. The interim analysis of the study after enrolling 39 patients is indicative of: The study arm (n=19), patients received 2 cycles of neoadjuvant chemotherapy with cisplatin (100 mg/m2 over 3days) and Etoposide (100 mg/m2/day for 3 days) followed by radical radiotherapy (56Gy/28#). The control arm (n=20) patients received concurrent chemoradiation with 2 cycles of cisplatin (20mg/m2) and Etoposide (50mg/m2) from #. Results: Interim analysis of the data shows various response rates as in, Control Arm - CR=4, PR=9, SD=3, PD=6; Study Arm - CR=3, PR=7, SD=1, PD=9. Toxicities Grade > 3 were 7 Vs 1 and deaths during treatment were 4 Vs 1 in control and study arm respectively. The quality of life shows better results for study arm. Conclusion: In this study, the locoregional control was seen to be achieved better in patients of control arm but at the expense of increased morbidities.

Adenocarcinoma of lung with brain metastasis and metastasis to thyroid: a case report

Das Abhijit, Panda Niharika, Pattanayak Lucy, Padhi Sanjukta, Senapati S. N.

E-mail: [email protected]

Introduction: carcinoma lung is one of the most common cancer worldwide. Lung carcinoma usually metastasizes to brain, liver, bone etc., whereas metastasis to thyroid usually occurs from breast, lung, kidney and stomach. We present here a case of primary lung carcinoma with brain metastasis and thyroid metastasis. Case Presentation: A 54 year Hindu female initially presented with enlarged midline swelling of neck for last 3 months along with dizziness and headache for last 2 months. She has complaints of mild cough, for the same duration. On examination she was found to have ECOG status 2 and ataxic gait. Also she has a thyroid swelling of 7x7 cm moving with deglutition. There was no associated neck nodes but 3x3 cm left axillary lymph node hard fixed and non-tender. Bilateral breasts were normal. Respiratory and cardiovascular system examinations revealed no abnormality, but CNS examinations revealed Romberg's test positive. All cranial nerves were within normal limit. Patient was initially evaluated by FNAC of thyroid swelling and MRI brain which revealed adenocarcinomatous cells and multiple enhancing nodular lesions in right cerebellar hemisphere, right temporal and left parietal lesions and enhancing intra diploic lesion in left frontal bone suggestive of metastasis respectively. Also left axillary lymph node biopsy was done which showed metastatic adenocarcinoma. Later patient has underwent CECT thorax which showed multiple nodules in bilateral lung parenchyma with heterogeneous enlarged thyroid left lobe. FNAC from that lung lesion showed adenocarcinoma. Immunohistochemistry from the axillary lymph node was sent and report came out to be CK7 and TTF-1 (strongly and diffusely positive), CK-20 negative as well as Napsin A positive which is suggestive of primary lung carcinoma. Thus patient was diagnosed as carcinoma lung with metastasis to brain and probable metastasis to thyroid. Patient has received palliative radiation to whole brain. Patient has also received two cycles of chemotherapy (inj. Paclitaxel, inj carboplatin). Now patient is under treatment and doing well. Conclusion: adenocarcinoma is the commonest type of metastatic cancer in thyroid from primary lung carcinoma. Here we report one case of carcinoma lung (adenocarcinoma variety) with brain metastasis and thyroid metastasis.

A study on 3d-crt plans versus imrt plans for non small cell lung cancer: Dosimetric analysis

Graima Shivastav

E-mail: [email protected]

Introduction: To compare the dosimetric parameters of three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) in some selected cases of non-small-cell lung cancer (NSCLC). Method and Material: Ten patients with inoperable NSCLC meeting the criteria of our study were selected which were treated in last one year with IMRT. 3D-CRT plans were created for all the patients following Radiation Therapy Oncology Group (RTOG) guidelines. Both kind of plans were compared on the basis of planning target volume (PTV) coverage, dose to normal organs, homogeneity index (HI) and conformity index (CI). Results: In both the techniques 95% and 99% of PTV was covered with ≥ 95% and ≥ 93% respectively of prescribed dose. As a average of all patients the V20 of contralateral lung was 1.81% and 7.25%, Dmean was 2.13 Gy and 3.58 Gy, V20 of same side lung was 23.73% and 28.42%, Dmean was 12.12 Gy and 13.05 Gy, and the dose to heart was 4.71 Gy and 4.97 Gy (D33%), 2.35 Gy and 2.61 Gy (D67%), 0.41 Gy and 0.63 Gy (D100%), 5.52 Gy and 5.73 Gy (Dmean), Dmax to spinal cord was 13.95 Gy and 19.52 Gy, HI was 1.2 and 1.7, CI was 1.73 and 1.94 in 3D-CRT and IMRT respectively. Discussion: The results for selected cases clearly indicate that 3D-CRT plans are not inferior to IMRT plans while most of them are superior. Since the planning is done on stationary computed tomography (CT) images while the lung region is not only highly heterogeneous medium but also moves with respiration. The intensity within the field of IMRT varies point-to-point within the field as per need of target on stationary CT images while in actual the target moves during the plan delivery. So, treating with 3D-CRT would be preferably good. Conclusion: The results of this study concludes that in selected cases 3D-CRT is better than IMRT, so if the 3D-CRT plan is following all the dose constraints then seeing the tumor motion, time and cost effectiveness 3D-CRT should be chosen for the treatment.

Dosimetric comparison of 3DCRT, IMRT and Helical Tomotherapy in treatment of Paravertebral Lung tumors

Mangesh B. Patil, Shagun Misra, Udita Upreti, Prasad Tanawade, S. K. Shrivastava, J. P. Agarwal

E-mail: [email protected]

Introduction: Radiotherapy plays an integral role in the management of carcinoma lung. Planning and delivery of external beam radiotherapy (EBRT) in lung is challenging because of target motion and the target being encompassed by critical normal tissues. Paravertebral location of lung tumors poses an additional challenge as the target is placed in near proximity to critical organ at risk the spinal cord. 3 Dimensional conformal radiotherapy (3DCRT), Intensity modulated radiotherapy (IMRT) and Tomotherapy are different modalities of conformal external beam radiotherapy used for treatment of lung tumours. Aims and Objectives: To compare different modalities of conformal EBRT, 1) 3DCRT 2) IMRT - Arc 3) Helical Tomotherapy, dosimetrically in terms of organ at risk (OAR) sparing and target coverage in these tumors. Methods and Materials : 5 selected patients with histologically proven carcinoma of lung with tumors close to spine treated at our hospital with curative concurrent chemoradiotherapy were part of this study. Structures contoured were - GTV, CTV, PTV along with organs at risk which included - Ipsilateral lung, Contralateral lung, total lung, heart, spinal cord and esophagus. For each patient; 3 EBRT plans for prescribed dose 60 Gy/30 # were generated on the treatment planning system - 1) 3DCRT 2) IMRT - Arc 3) Helical Tomotherapy. The plans were compared for target coverage using dosimetric indices Homogeneity and Conformity Index while dosimetric parameters for OAR constraints that were achieved were compared. Dosimetric descriptors were compared using the paired t test to compare the mean of different treatment groups. Results: Conformity index (CI) and Homogeneity index (HI) for IMRT were significantly better than for Tomotherapy (0.8vs1. 2, p=0.008 and 1.2vs2.9, p=0.04). Volume of the ipsilateral lung receiving 5, 10,20 and 30 Gy (V5, V10, V20, V30) were significantly less in 3DCRT and IMRT than Tomotherapy while there were no significant differences between 3DCRT and IMRT for Ipsilateral lung doses. Mean lung dose for ipsilateral lung was less in 3DCRT and IMRT than Tomotherapy with p value less than 0.05. V5 for contralateral lung was significantly less in 3DCRT and IMRT than tomotherapy. Mean dose to oesophagus was less in IMRT and 3DCRT than tomotherapy. Maximum dose to spinal cord were higher in 3DCRT (47.5Gy) and IMRT (47Gy) as compared to Tomotherapy(41.7Gy). Conclusions: Both IMRT and 3DCRT offer better normal lung sparing than Tomotherapy with a higher dose to the spinal cord in paravertebrally located lung tumors.

Epidemiological study on "non-smoking associated lung cancer" in india: a single centre experiance at biro

Namagiri Lavanya Lakshmi C. S.

C S Institute of Radiation Oncology BIRO MMC Chennai.

E-mail: [email protected]

Introduction: Lung cancer remains a major cause of morbidity and mortality worldwide, accounting for more deaths than any other cancer. Among males, lung cancer is the most commonly diagnosed cancer and leading cause of cancer death. Among females worldwide, it is the fourth most commonly diagnosed cancer and second leading cause of cancer death. Aim: The aim of this study was to analyse the clinical profile and the epidemiological trends in lung cancer patients from a single centre analysis with the emphasis on non-smoking. Materials and Methods: 1. Case records of registered patients in Department of radiation oncology, BIRO, RGGGH, Chennai- histological proven 198 lung cancers, Jan-2012 to Dec-2013. 2. A retrospective analysis of collected data regarding age, sex, presenting symptoms, performance status, stage of disease, treatment details are done and reports are submitted. 3. Selection criteria: Non smokers are selected by excluding tobacco chewers and passive smokers. Results: Out of 198 cases analysed, 58 patients are found to be non smokers, Medianage of presentation: 50.065, Age >60years:18, 40-60years:32, 20-40years:7, <20years:1, Sex: Females preponderance. Presenting symptom: Cough and dyspnoea: 50%, Chest-pain: 58%, Brain mets:34.48%, Bone mets:31.08%, SVC symptoms:1.72%, Choroidal mets: 1.72%. Histology: Adenocarcinoma:50%, Squamous Ca:29.31%, Smallcell Ca:3.44%, LargeCell Ca:6.89%, PNET:1.72%.. Stages: Stage II and III: 10.34%, Stage IV:77.58%. Treatment: Surgery:1.72%, Palliative RT50%,CT36%, CCRT:12%, WBRT:31%, supportivecare:3.44% Conclusion: Our study suggests that close to 30% of our cases are nonsmokers. Our study reflects rise in adenocarcinoma histology. Here we found 13% cases are <40 years so are in need of screening programme.

Patterns of care in long term survivors (>3 years) in advanced and metastatic NSCLC(stage III and IV)- retrospective analysis of 2 years from a single Institute

Th. Nirpendra, Patton,Y. Indibor, P. Linthoi, T. Dhaneshor and

Th. Tomcha

Radiotherapy Department, Regional Institute of Medical Sciences, Imphal, Manipur-795004. E-mail: [email protected]

Introduction : Long term survivors (>3years) in advanced NSCLC is steadily increasing from 5 - 10% to 15 - 20%. It is related with the more effective and better treatment given in an individualised manner along with better understanding of the tumour biology. Many factors are also associated with the improved outcome. Our Institute's 2 years data is analysed in an attempt to find out the favourable factors. Objective : To find out the pattern of treatment given and clinical profile of long term survivors >3 years in stage III and IV NSCLC. Method : Stage III and IV non small cell lung cancers treated at RCC, RIMS during 2011 to 2012 are analysed from the patient's records available in our institute. Only the patients diagnosed and treated at RIMS who survive more than 3 years are included for analysis. Patient characteristics, disease profile and treatment pattern are analysed. Results : Out of 196 patients records available- Stage III and IV comprise 160 patients of these 28 patients survived more than 3 years. The analysis shows Male: Female ratio 5:4, mean age 55 years (range 36 to 90 yrs) stage III is 18(60%) stage IV 28(20%). Histologically, Squamous cell Ca. 60% Adeno ca. 24% and small cell 12% and rest others. KPS range from 60% to 90%. Treatment given: 80% received intent to cure with Chemo ± RT. And 20% palliative care only. Long survivors (>3years) 24 patients (16F + 8M) who received intent to treat chemo or chemo+ RT compared to none in supportive care only. Conclusion : The result shows that females with Histo type adenocarcinoma who received therapy with Chemo + RT +/- targeted therapy with intent to treat are the long survivors according to this study. So treatment should be given in a sub set of patients with responders for increasing meaningful survival.

Outcome and survival analysis of patients with svco after emergency palliative rt with different schedules and fractionation

Preethi A, Vishal Manik, S. Shanmughakumar, N. V. Kalaiyarasi,

P. K. Baskar, Prabhakaran, Madhumathi, Sundaresan

E-mail: [email protected]

Introduction: Superior vena cava obstruction syndrome (SVCO) is an oncologic emergency, commonly associated with malignancy within the thorax and requires immediate intervention. Radiotherapy is considered, a standard treatment for most patients with SVCO precipitated with LUNG carcinomas. Aims and Objectives: To evaluate the outcome with respect to symptom free and overall survival of cases of lung carcinoma presenting with SVC obstruction and treated with radiotherapy. Methods and Materials: The records of 50 patients with LUNG Carcinoma presenting with SVCO, treated with radiotherapy in BIRO, Madras Medical College and RGGGH between January 2012 and December 2013 were evaluated. Telephonic follow up was done for all patients recording their symptom free and survival post-SVC treatment with radiotherapy. Results: The median survival period of SVCO was found to be 2 months. Overall symptomatic relief was observed in 74% patients. The signs observed were facial puffiness-76%,distended veins over chest wall-42%,engorged neck veins-30%,edema of upper limb and chest wall-34%. Among the 50 patients, 74% were NSCLC, 26% were SCLC of which 70.2%, 84.6% showed symptomatic relief respectively. Fifty-six percent belonged to stage IIIB and forty percent belonged to stage IV.Thirty-nine patients were exposed to 20Gy(400cGy per fraction/5 fractions) and eleven patients to 30Gy(300cGy per fraction/10 fractions),of which symptomatic relief was observed in 74.3% and 70% respectively. Field size was 100sq.cm in 66% and more than 100sq.cm in 34%,of which 70%,82.3% showed symptom relief respectively. The field treated included only mediastinum in 52%, both tumor and mediastinum in 40%,of which 73%,80% showed symptomatic relief respectively. Sixty percent patients completed all fractions, of which 93.3% had symptomatic relief. Conclusion: Radiation Therapy effectively controlled the symptoms of SVCO due to lung carcinoma but overall survival was poor. Symptomatic relief was observed more in case of radiation to both tumor and mediastinum.

Sequential and concurrent chemoradiotherapy (CT-RT) for lung cancer

Gowardhanan Doss

E-mail: [email protected]

Introduction: Majority of lung cancer patients in India present with locally advanced (stage-III) and metastatic disease. In patients without metastases (stage-III) surgery is often not possible because of tumour factors, patient factors (co-morbidity) or patient choice. Radical radiotherapy (RT) with sequential or concurrent chemotherapy offers the best chance of disease control with relatively low 5-year survival rates. We aim to review retrospectively our experience with chemoradiotherapy. Materials and Methods: 835 patients with lung cancer were seen at our hospital between June 2011 and December 2013 - Analysed untill the end of August 2014. Of these 74 patients were treated with radical doses of radiotherapy with curative intent. 15 patients received RT alone; whereas 59 patients received CT-RT. 25 patients received sequential CT-RT, whereas 34 patients received concurrent CT-RT. Medical case records and treatment intent and plans for all of these patients who were treated with CT-RT were analysed in this review. Results: 51 patients were male and 8 were female, with a median age of 63 years (30 to 77 years). All of our patients had histological confirmation of lung cancer. Six (10%) patients had small cell lung cancer (SCLC) and 53 (90%) patients had non-small cell lung cancer (NSCLC). Of the NSCLC, 30 patients had adenocarcinoma, 22 patients had Squamous cell carcinoma and 1 patient had large cell carcinoma. Most of our patients with NSCLC (90%) were staged with PET-CT. Platinum-based doublet regime was the most commonly used chemotherapy in our patients. A vast majority of patients received either cisplatin and etoposide (34 patients) or carboplatin and paclitaxel (12 patients). 48 patients (81%) did not require any dose reduction, whereas 11 patients (19%) needed a downward adjustment of chemotherapy dose. Grade-3 or greater febrile neutropenia was seen in 21 patients. All of the patients were successfully treated with the planned dose of radiotherapy (56, 58, 60, 64 and 66Gy). 3-dimensional conformal radiotherapy was used in 46 patients and intensity modulated radiotherapy was used for 13 patients. Grade-3 or greater dysphagia were not seen in our cohort of patinets. There were no treatment related deaths. Complete response was seen on CT in 2 patients, partial response in 20 patients and stable disease in 11 patients. 22 patients have since shown disease progression. Median follow-up is relatively short at 14 months. Progression free survival is projected at 25 months. Median overall survival for stage-IIIB was estimated at 21 months, but this has not been reached for the entire cohort. Conclusion: CT-RT for lung cancer was used in our patient population from eastern India with manageable toxicity. The Median overall survival for stage-IIIB and the projected progression free survival for the entire cohort are comparable with reported literature, although this is early data from a small cohort. Carefully selected fit patients with inoperable lung cancer need to be treated aggressively with CT-RT and outcomes and toxicity need to be prospectively audited.

Implementation of Lung SBRT treatment using four dimensional cone beam CT verification for target mapping; a preliminary evaluation

Isha Jaiswal, Rohini Khurana, Madhup Rastogi, M. L. B. Bhatt, Mishra S. P.

Department of Radiation Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Gomti Nagar, Lucknow, U. P.

Introduction: Respiratory motion creates artifacts such as blurring, doubling, streaking, and distortions which highly degrade the image quality and affect the target localization accuracy during radiotherapy treatment. Technical advancements have resulted in time synchronized four dimensional CBCT (4D CBCT) method for managing the respiratory motion during image acquisition which ensures the adequacy and reproducibility of planning target volume (PTV) margin in radiation treatment of thoracic malignancies. Aims and Objective: This paper aims to report the verification and reproducibility of a SBRT treatment delivery in a lung cancer patient. Materials and Method: A poorly differentiated Squamous cell carcinoma, left lung, 65 year, male, stage T4N2M0 received neoadjuvant chemotherapy(taxane and platin) 6 cycles. The disease showed PR on repeat CECT done one month after completion of last chemotherapy. In view of residual disease patient was planned for stereotactic body radiotherapy 25 Gy in 5 fractions for lung primary. Patient was immobilized using Body FIX system and underwent a free breathing contrast enhanced CT simulation using stereotactic body frame for accurate and reproducible positioning. TV and OAR were delineated. Structures delineated were: GTV, with 2 cm margin to CTV and 7 mm margin to PTV. Organ at risk included, heart, total lung, right and lung, cord with 3mm margin. Patient was planned using 9 field dynamic IMRT. Dosimetric parameters to the target volume and organ at risk were verified and achieved.Treatment was delivered on ELEKTA Infinity linear accelerator with a pretreatment 4D CBCT image guidance during each fraction using Symmetry system (XVI ver. 4.5.2).The 4D CBCT system resulted in 10 CT data set corresponding to various respiratory phases and these 10 phases are combined to form a cine image which shows the actual motion of tumor. The acquired CBCT images were registered with the planning CT images for accurate positioning of the target with respect to machine isocenter; further the cine image was used to verify the conformity of the GTV motion with PTV. The setup errors and the time weighted average position of moving tumour were accounted by applying appropriate couch shifts and corrections. Results: The Symmetry TM resulted couch shifts for each fraction was noted. The mean couch translational shift (mean + standard deviation) for lateral longitudinal and vertical direction was -0.012mm, 1.05mm and 0.337mm respectively. Conclusions: The 4DCBCT image guidance during lung SBRT ensures adequacy of PTV margin and conformity of planed and delivered volume. It is a valuable imaging tool for accurate positioning of moving tumor and it is a valuable tool in the treatment delivery of patients of thoracic and abdominal malignancy.

Evaluation of the setup accuracy of a sterotactic mask fixation system using exactrac imaging

K. Tamil Selvan, P. Ramesh Babu, Vijayanand P. Reddy, M. K. Revathy, S. Muthulingam, M. Sathiyaseelan, G. George Leo Ranjit

E-mail: [email protected]

Introduction: In Sterotactic RadioSurgery (SRS), it is essential to achieve a high degree of dose conformity and accurate patient positioning. Traditionally, accurate Sterotactic localization is achieved with fixation frames. A non-invasive frame or a frameless SRS is the preferred option in fractionated radiosurgery where, the invasive nature of fixation frames makes them a less viable option. Fractionated radiosurgery, known as Sterotactic Radiotherapy (SRT), is commonly delivered to patients where the likelihood of late toxicity makes it inadvisable to treat a large target volume in a single high-dose fraction. In our institution frameless SRT, is performed with stereotactic mask fixation system and accurate pre-treatment imaging to reduce geometric uncertainties. Aim and Objectives: Aim of the study is to evaluate the patient positioning accuracy of the frameless stereotactic immobilization mask and localization using ExacTrac 6D(dimensional) imaging system. Material and Method: 25 patients were investigated in this study who underwent cranial SRT(15-30fractions) with frameless delivery in Novalis Tx machine between January, 2013 and June, 2014. For all the patient, immobilization was made with cranial Sterotactic mask immobilization system (BrainLAB) followed by a CT scan with 1 mm slice thickness along with BrainLAB Head and Neck Localizer. The images were then transferred to the BrainLAB iPlan Treatment Planning System(TPS) where optimized plans were created. During treatment delivery, patients were positioned to isocenter using infrared tracking system with the help of frameless radiosurgery positioning array. X-ray correction was performed to obtain systematic translational and rotational shifts. ExacTrac stereoscopic oblique X-ray images were registered with the corresponding digitally reconstructed radiographs(DRRs) based on bony anatomy matching(ExacTrac 6D fusion). BrainLAB 6D robotic couch corrects the patient shifts to give 6D positioning. 627 patient setups using the Sterotactic mask and ExacTrac 6D imaging were used in the data analysis. Results: An analysis made with the 6D errors obtained from ExacTrac X-ray correction shows that the size of inter-fraction mean deviation was 0.78±0.59mm, 1.46±0.79mm, 1.18±0.54mm for lateral, longitudinal and vertical translations, respectively and for rotational deviations it is 0.76±0.53°, 1.01±0.54 °, 0.83±0.56 ° for pitch, yaw and roll, respectively. Conclusion: Inter-fraction setup variations in the Novalis Tx frameless radiosurgery system was analyzed. BrainLAB localization and automatic positioning was precise. Rotational deviations were well within the robotic couch limits to be corrected automatically with ExacTrac system reducing frequent repositioning of patients. Quality of the immobilization system is reliable with lesser variations mandated for radiosurgery. Frameless radiosurgery can be delivered with high degree of positional accuracy using BrainLAB sterotactic mask immobilization system.

Effect of number of coplanar fields and pre-optimization weighted point cloud in head and neck IMRT

Jadhav Kuldip G 1 , Vaidya Amod V 1 , Jadhav Vishal 1 , Pingly Sonali 1 , Shende Shailesh 1 , Kelkar Dhananjay S 1

1 Department of Radiation Oncology, Deenanath Mangeshkar Hospital, VLM cancer Center,Erandwane, Pune - 411 004, India. Email: [email protected]

Introduction: The new point cloud generation algorithm is used for all 8.2 +Optimization algorithms (DVO, PGO, PRO) in eclipse treatment planning system. In this study we have varied the resolution given by the optimizer depending on the volume of the organ and number of coplanar fields 5, 7, 9 and 11 for IMRT. In this study we have taken patient with cancer of PC region. We have selected a PTV Primary and PTV Comb (Primary +PTV Bilateral LN areas) as targets for the study, giving 66Gy and 60Gy in 2Gy/# respectively. The Left Parotid, Right Parotid and Spinal cord are selected as OAR. The effect of varying resolution and no. of fields for IMRT are studied. Different graphs were plotted and compared. Material and Methods: The Eclipse treatment planning system Version 10.0.28 by Varian Medical System Inc., Palo Alto USA was used in the study. We prescribe PTV primary 66Gy, PTV combo 60Gy and given constrains as 33% Volume of parotids should not get more than 26Gy and maximum dose to 10 % volume of spinal cord as 45Gy. The priorities to target set as 100 and 66 for OAR. We planed the IMRT with 5, 7, 9 and 11 Fields with varying resolution as 0.5mm, 1.0 mm, 1.2mm, 1.5mm, 1.8mm and 2mm. The limits for the resolution are 0.1 to 10 mm as per Varian. The Eclipse treatment planning gives default resolution values depending upon the volume of organs. We have changed the resolution to see if better optimization is obtained. Results and Discussion: The monitor unit increases with increase in the number of fields. The mean dose to parotids is better in 5 field geometry than 7,9,11 fields. The weighted point generation depends on the volume of organ and resolution and it is not dependent on the number of fields. Different graphs were plotted for the no. of fields, resolution verses the dose obtained for targets and OAR. No significant change was seen with resolutions. DVH comparisons of all plans shows variations but the mean doses are within the ±2%. So we conclude that we can use the optimum number of fields like 5 or7 than 9 or 11 for IMRT and default resolution for Eclipse TPS is sufficient for better optimization.

High-dose rate endobronchial brachytherapy for palliation of lung cancer: An observational study

Meenu Gupta 1 , Saurabh Bansal 1 , Girish Sindhwani 2 , Vipul Nautiayl 1 , Mushtaq Ahmad 1 , Sunil Saini 3

1 Department of Radiation oncology, 2 Respiratory Medicine, Surgical Oncology3, Cancer Research Institute, Swami Rama Himalayan University, Dehradun, E-mail: [email protected]

Background: Out-patient high-dose-rate endobronchial brachytherapy (HDREB) is a possible option in the palliation of symptoms in patients with advanced lung cancer, but literature data is limited and the technique is still under development in developing countries. Aim: Our aim was to evaluate safety and effectiveness of out-patient HDREB for palliation of malignant endobronchial tumors in the context of a multidisciplinary approach. Materials and Methods: Fifteen patients were treated with palliative intent according to a prospective observational protocol. Intra Luminal HDR Brachytherapy was performed with the applicator catheter was guided to the target bronchus under bronchoscopy. CT based dose distribution done with the aim 95% of the clinical target volume received more than 90% of the prescribed dose The radiation source tube was inserted to replace the inner tube, and ILBT was conducted using the high dose rate 192Ir thin wire remote after loading system.Brachytherapy was delivered to the endobronchial tumour length with a 1-2 cm proximal and distal margin. HDREB was delivered as two fractions of 7 Gy at weekly intervals. All patients presented with advanced lung cancer primaries and were treated because of lesions located in the trachea and/or main bronchi. Results: Overall, there was a 86.6% improvement, with migration of patients from lower to higher performance status. Bronchial obstruction was improved in 87% of the patients. The symptom that presented the best response was hemoptysis 93.3% followed by postobstructive pneumonia 87 % Symptomatic improvement in dyspnea was observed in 73.3%.Chest pain was relieved in 87% patients.Radiological and endoscopic partial response was seen in 67% and 73.3% respectively. Palliation was obtained in all patients. Temporary radiation bronchitis was observed in three patients. No fatal complication occurred.1 patients expired due to associated co-morbidities. Conclusion: This non-comparative, prospective observational study showed HDREB is an excellent modality for palliating malignant airway obstruction and control of haemoptysis resulting in better quality of life. The safety of the procedure was good and the rate of non-fatal serious complications was very low.

Keywords: Lung cancer, endobronchial, high-dose-rate endobroncial

Role of tumour markers CEA and CA125 in lung cancer

Ningthoujam Omita Devi

E-mail: [email protected]

Introduction : Lung cancer is the leading cause of cancer death for both men and women and accounts for 29 % of all cancer death (31 % in males and 26 % in female) in the world (1, 2).Some ongoing diagnostic tools at clinics include CT scans, bronchoscopy and sputum analysis, none of which turns out to be effective in early diagnosis of lung cancer (3).In oncology practice, the use of tumour markers may be helpful in the diagnosis and pathologic classification of tumours. They may reflect both, stage of the disease and prognosis. Serial estimation after diagnosis may aid in assessing the response to treatment, in monitoring the spontaneous course of illness, and in keeping surveillance for tumour recurrences (4).CEA is associated with the plasma membrane of tumour cells, from which it may be released into the blood. CA125 is associated with 80 % of nonmucinous ovarian carcinomas and is elevated in other cancers including lung, endometrial, pancreas, breast, and colon etc (5). Aim of Study: This study aims to evaluate the possible role of CEA and CA125 in serum of suspected cases in diagnosis of lung cancer. Materials and Methods: The case control study was conducted at RIMS Hospital in Imphal, during the period November 2012-August 2014. The study was approved by the institutional ethical committee and an informed consent was taken from each participant. After fulfilling the inclusion and exclusion criteria 50 newly diagnosed lung cancer subjects were selected as cases, while 100 individuals were selected in the control group.5 ml of venous blood was collected and separated and was analyzed for estimation of levels of CEA and CA125 using ELISA kits (Calbiotech, Canada).Difference between mean values of the tumour markers was assessed by ANOVA and their strength of association was analyzed by 'Pearson's bivariate correlation analyses.p value was considered to be significant at value <0.05, at a confidence limit of 95 %. Results: The study demonstrated that the levels of CEA and CA125 were higher in the cases compared to the controls. The serum values for the measured tumour markers were compared with each other and the correlation was found to be statistically significant. In the present study the cut off values for maximum sensitivity and lowest false positivity for the parameters CEA and CA125 were 4.5ng/ml and 25 U/ml respectively. The sensitivity and specificity of CEA and CA125 were 70%, 60% and 75%, 61% respectively. Conclusion: In conclusion, combined measurement of CEA and CA125 in serum is useful in diagnosis of lung cancer. These may be useful in patients in whom tumour cannot be visualized by bronchofibroscopy or to rule out false positive cases. These results need further confirmation in larger groups of patients.

Comparison of the gross tumor volume in end expiration/end inspiration (2 phase) and summated all phase volume captured in 4 D CT in carcinoma lung patients.

Pramod K. Sharmaa, Roopam Srivastavaa, Anusheel Munshib, Manish Chomala, Gagan Sainia Jayanand M. C

Department of Medical Physics, and Radiation Oncology, International Oncology Center, Fortis Hospital, Noida, Department of Radiation Oncology, Fortis Memorial and Research Institute Gurgaon, Shobit University, Meerut, India. Email- [email protected]

Objective: The aim of this study was to compare the delineation and treatment planning of two phase-based (end-expiration and end-inspiration) IGTV (Internal Gross tumor volume) with ten-phase based (4D) IGTV. Materials and Methods: Patients with lung tumours at different sites were selected for the study. The location of the tumour in Group A, B, C were at the upper lobe (attached to the chest wall),middle lobe and lower lobe respectively. We contoured the GTV on each of the ten respiratory phases of the 4D-CT data set. The combination of these GTVs produced the IGTVAllPhases. GTV was also generated on the extreme respiratory phases.Combination of these two GTVs produced IGTV2Phases.Treatment planning was done and dose to OARs were compared in both cases. Results: The average volume of IGTV2Phases and IGTVAllPhases for Group A were nearly same. But for Group B and Group C, IGTV2Phases was smaller than the IGTVAllPhases. Lung-GTV doses were less in 'exp- insp' phase than in '4DCT' for Group B,C whereas it was same for 'expiration-inspiration' and '4DCT' in Patient A. Conclusion: Patients with tumour upper lobe tumor have no difference in tumour coverage and OARs sparing in the 2 phase and all phases but middle lobe and lower lobe have a greater excursion during respiration and hence greater all phase IGTV.

Tibial metastasis in a case of squamous cell carcinoma of lung: A case report

Rajib Bhattacharjee, Suparna Kanti Pal, Ranti Ghosh,

Koushwambi Kar, Soumen Mukherjee, Siddhartha Basu

Introduction : Although skeletal metastasis is quite common in case of lung cancer, metastases beyond knee is rare. The aim of this report is to create awareness that lung cancer do metastasise to bones distal to the knee joint. Results : A 55 year old male smoker presented to the OPD with complaint of pain in the left leg during walking for the last 5 months and a dry cough for last few weeks. On examination the patient exhibited antalgic gait, and tenderness over proximal tibia. There was no other significant clinical findings. X-ray of the left knee revealed an osteolytic area in the proximal end of tibia with erosion of medial cortical margin. Biopsy from the tibial lesion revealed metastatic moderately differentiated squamous cell carcinoma. Chest X-ray showed a patchy scarry fibrotic hazyness in lower zone of right lung. CT scan thorax revealed an irregular thick walled mass in lower lobe of right lung exhibiting chest wall involvement along with right hilar lymphadenopathy but without any mediastinal lymphadenopathy. Guided FNAC from the lung mass revealed squamous cell carcinoma. Radiological staging was T3N1M1b. Discussion : The incidence of boney metastasis is reported to be around 20-40% in lung cancer pateints using PET CT for metastatic work up. Spine and Pelvis has been found to be the commonest sites for such metastases. Metastases distal to knee and elbow joint are rare. Though uncommon, metastases to distal limbs, especially tibia have been reported. However our patient presented primarily with complaints in the leg. The chest symptoms were late and minimal. Thus it is worthwhile not to ignore the subtle symptoms sugessting a primary lung resulting in a secondary bone metastases, along with the possbility of a primary bone tumor while investigating such patients. Conclusion - Skeletal symptoms distal to the knee joint in a known case of lung cancer should be investigated to rule out metastasis.

Te esophageal toxicity with dosimetric parameters in patients of locally advanced non small cell lung cancer treated with radiation and concurrent weekly paclitaxel

Sreya Mallik

PGT, Dept. of Radiotherapy Medical College & Hospital Kolkata. E-mail: [email protected]

Introduction: For patients with inoperable locally advanced non-small cell lung cancer (NSCLC) concurrent chemoradiotherapy (CRT) is standard of care. However the concurrent use of CRT is associated with increased esophageal toxicity. Esophageal toxicity is one of the principal complications which may compromise optimum treatment delivery and often leads to treatment interruption.Aims and Objectives: The aim of this single institutional prospective study was to correlate acute esophageal toxicity (AET) with dose-volume parameters of the esophagus using thoracic irradiation and concurrent paclitaxel in patients of locally advanced NSCLC.Materials and Method: A total of 52 patients with locally advanced inoperable NSCLC (stage IIIA and IIIB) who attended radiotherapy opd of Medical College and Hospital, Kolkata between January 2013 and May 2014 were included in the study. All patients underwent CT simulation with 5 mm slice thickness. Gross tumour volume (GTV), clinical target volume (CTV), planning target volume (PTV) and esophagus, spinal cord, heart, normal lungs were contoured and treatment planning was done in ASHA Treatment Planning software. A mean dose of 61.2 Gy (Range 60-66Gy) in 2Gy per fraction, 5 fractions per week given to all patients in Theratron 780 C Telecobalt Machine along with weekly paclitaxel (60mg/m2) in an outpatient setting for six weeks. Patients were evaluated on a weekly basis during radiation and monthly upto 3 months after completion of radiation to assess the AET.AET was scored according to Radiation Therapy Oncology Group (RTOG)/EORTC criteria. Maximum esophageal toxicity was correlated with clinical and dose volume parameters including age, performance status, mean dose to entire esophagus (MED), volume of esophagus receiving 35 Gy (V35), 40 Gy (V40), 50Gy (V50), 60Gy(V60), 70Gy (V70).Statistical analysis was carried out using standard statistical tests in SPSS software (version 20.0). Results: The majority of the patients developed mild esophagitis; for 26 patients (50%) grade 1 complaint occurred. A total of 16 patients (31%) developed moderate to severe dysphagia (grade≥2) among which 6 patients developed grade 3 AET. No deaths resulted from this complication. For the total study population the mean dose in the esophagus was 31.2 Gy, volume of esophagus was 32.4cc (range 13.5-56.5cc).AET (grade ≥2) significantly correlated with MED, V35, V40, V50. The mean dose of esophagus receiving ≥32 Gy showed statistical significance with respect to AET Grade 2 or worse. A continuously rising risk of acute esophagitis was seen with increasing volumes of irradiated esophagus. Age, stage and performance status had no statistically significant influence on the incidence of acute esophagitis.Conclusion: Both the esophageal volume receiving >35 Gy and the use of concurrent chemotherapy with paclitaxel were the most significant predictive factors for acute esophageal toxicity(grade≥2).

A Study of dose variation due to inhomogeneity: Comparision of different algorithms based planning systems with simulation and Gafchromic film results

Navin Singh, Sudhir Singh, Nirmal Painuly, M.C. Pant

Department of Radiotherapy, K.G. Medical University, Lucknow. E-mail: [email protected]

Introduction: Accurate dosimetry at the interface of two different density media is vital for the success of the treatment using ionising radiation, however, dose measurements at interfaces are generally difficult due to the high dose gradient, the electronic nonequilibrium and the detector finite size. It is therefore important to compare dose measurements obtained experimentally in phantoms involving inhomogeneities with results obtained by simulating the same setup using Monte Carlo codes. Objective: The aim of the present work is (1) To study the variation in absorbed dose at the interface of two different density medium (Tissue phantom and Kailwood) for 15 MV photon beam using Gafcromic film and (2) Compare with different algorithms used in TPS vis-a-vis Monte Carlo code EGSnrc. Materials and Methods: We employed kailwood (Pinus Wallichiana) to mimic the lung. The range of HU for Kailwood obtained using 16 slice Big bore Philips CT simulator (Brillance) varied between -610 to -690, average being -630. Briefly, seven Kailwood plates each measuring 25x25 cm2 of varying thicknesses totaling 13 cm equivalent to the mean thickness of the adult human lung, were sandwiched between 5 cm tissue equivalent material from top and 10 cm below. The physical measurements were performed using the Radiochromic filmEBT2. The field sizes of 1x1, 2x2, 5x5, 10x10 and 15x15cm2 were selected at 100 cm SSD. Dose was prescribed at dmax. Simulations were performed using EGSnrc Monte Carlo code. The dose variation at interface (Proximal and Distal end) was calculated using AAA algorithm and MC based planning systems Results: It is interesting to note the variation between two algorithms, Anisotropic Analytical Algorithm (AAA) and MC based planning system. For small field size of 1x1 cm2 the variation at the proximal surface (Tissue/Lung) obtained using AAA was 17% whereas it was 12% for MC based planning system with respect to the measured/simulated values. At the distal surface (Lung/Tissue) this variation is 15% and 10% for the two systems with respect to measured/simulated values. For field size of 2x2, it comes to 9% by AAA and 7% by MC based planning system at proximal end. For field size of 5x5 and beyond, the difference between the two algorithms become very small and insignificant. The measured values from Gafchromic film were in good agreement with the simulation data (EGSnrc code) for all field sizes. Conclusion: Preliminary results show that at interface there is substantial dose variation especially for small fields and therefore close dose monitoring is required.

Gynaecological Malignancy

A Matched Pair Analysis of locally advanced cervical cancer treated with chemoradiation followed by MR Image based Brachytherapy (MR-IBBT) or CT Image based brachytherapy (CT-IBBT)


Post Graduate Institute of Medical Education and Research, Chandigarh. E-mail: [email protected]

Purpose: To compare the outcomes in patients of cervical cancer treated Magnetic Resonance Image Based Brachytherapy (MR-IBBT) using GEC ESTRO guidelines Versus CT based brachytherapy with Point A based dose prescription. Methods: Twenty-seven patients in each group were matched according to age, clinical stage, histology, tumor diameter, ECOG performance status and baseline hemoglobin. All patients received radical chemo radiation followed by two sessions of HDR intracavitary brachytherapy 9Gy each. A dose of 9Gy was prescribed to HRCTV in the MR-IBBT arm and to point 'A' in the CT-IBBT arm. Organs at risk doses (0.1cc, 1cc, 2cc, and 5cc) and clinical outcome parameters were compared. Results: At a median follow up of 36 months,1 patient (3.7%) in MR-IBBT group and 4 patients (24.8%) in the CT-IBBT arm developed local recurrence (p=0.15). One patient each in both the arms developed distant metastasis. Grade 2 and above rectal toxicity was observed in 2 patients in the CT-IBBT and in 1 patient in the MR-IBBT arm. None of the patients developed grade2-3 bladder toxicity in both the arms. The 3-year DFS in MR-IBBT and CT-IBBT groups were 96.3% and 85.1% and the 3-year OS was 92.5% and 88.8% respectively. Conclusion: In matched-pair analyses, LR, DFS, OS and bladder and rectal toxicities in MR-IBBT were not significantly different from CT-IBBT. However, increased local failures were observed in patients with large residual disease at brachytherapy in the CT-BBT arm. A larger patient data and longer follow up is needed for maturation of the results.

Trans abdominal ultrasound(USG) Vs computer tomography (ct) imaging for conformal intracavitory brachytherapy in carcinoma cervix- A comparative study

Susan Mathews*, Biju Azariah*, Seetha Mohandas*, Jiji V#, P. G. Jayaprakash*

*Dept of Radiation Oncology, # Dept of Imageology, Regional Cancer Centre, Trivandrum. E -mail: [email protected]

Introduction: Brachytherapy is an essential component in the successful treatment of cervical cancer. During the last decade, Image Guided Adaptive Brachytherapy (IGABT) was introduced as a means of tailoring treatment to the targetand adjusting for variations in the individual anatomy.Magnetic resonance imaging (MRI) is consideredas thestandard for IGABT. However routine use of MRI for Cancer Cervix brachytherapy is unrealistic for India and rest of the developing world.In an attempt to provide the benefits of image guidance for our patients, cheaper and commonly available imaging modalities are being tested. At RCC, Trivandrum, we have been practising CT based optimization for Gynaecologic brachytherapy since 2012. The potential utility of Ultrasonography as an alternative to CT basedbrachytherapy planning isbeing explored in this study. Aim: To assess the utility of Ultrasound imaging for Gynaecologic brachytherapy by comparing the ultrasound measurements relevant for brachytherapy with corresponding CT measurements obtained with applicators insitu. Materials and Methods: Trans abdominal Ultrasound imaging was performed after intracavitory applicator placement and the mid sagittal image in the plane of central tandem was acquired. Reference points (anterior and posterior) were defined on the surface of uterus and cervix and the reference distances were measured with respect to the flange and central tandem. These measurements were then compared with those made on the mid sagittal image on planning CT Scan. Results: Twenty five applications were evaluable. The reference distances, both anterior and posterior showed excellent correlation. The mean difference in the observed values for anterior measurements was 0.28cm (min-0cm, max-1.1 cm) and for the posterior measurements was 0.4cm (min-0cm, max-1.6cm). It was observed that the fundal delineation was better with ultrasound imaging. Conclusion: Our observations suggest strong correlation between the two imaging modalities in delineating uterus and cervix. Ultrasound can be considered asa reasonable alternative to CT based brachytherapy planning.

Evaluation and validation of trans-abdominal US based IGRT in cervical cancers: An initial experience

Chira Ranjan Khadanga, Umesh Mahantshetty, Rajesh Kinhikar, R Engineer, S Chopra, SK Shrivastava

Department of Radiation Oncology and Medical Physics, Tata Memorial Centre, Mumbai, India

Background: Radical (Chemo) Radiation therapy is the standard treatment for locally advanced cervical cancers. Radiation therapy is usually a combination of external beam and brachytherapy. In past 2 decades, technological advances in imaging (MR, PET-CT..) and radiation delivery (IMRT, VMAT, IGRT..) have been implemented in routine clinical practice successfully. Image guidance during radiotherapy helps to precisely deliver radiation to the planned target as well as avoiding surrounding normal tissues, thus improving therapeutic ratio. Currently, there are various commercially available IGRT technologies like EPID, CBCT, MVCT etc. are a part of new generation linear accelerators. In the recent past there has been renewed interest in Ultrasound Imaging as an IGRT tool during radiation therapy. This has been successfully implemented for treatment of Prostate Cancers.The advantages of incorporation of US includes easy availability, vast experience in various pelvic tumors (cervix, uterus, prostate etc) and relatively low cost technology. Clarity Based US IGRT system (Elekta Ltd.) is now commercially available as an additional IGRT facility which can be integrated to all Linear Accelerators. With an aim to evaluate and validate Trans abdominal US (TAUS) based IGRT system in the radiotherapeutic (external and brachytherapy) management of Cervical Cancers, we undertook this study which is currently ongoing. Material and Methods: In this ongoing study, patients with histologically proven cervical cancer planned for radical radiation therapy and treated with CBCT based IGRT after obtaining signed informed consent were enrolled. The IGRT process including Clarity system will be presented in detail. After a standard CT Image acquisition in treatment position during simulation, Clarity Based TAUS imaging (after initial calibration) is acquired on the CT couch and transferred to Clarity Automatic fusion and contouring workstation (AFC). Clarity supported NDI (Non-Destructive Inspection) Infrared Camera for alignment and orientation of the TAUS probe assists CT/TAUS fusion. The CT images are transferred to TPS for planning and AFC for CT/TAUS fusion. Contouring of uterus/utero-cervical region and bladder is done on AFC workstation. After finalization of plan on TPS, patient is taken on the treatment unit. As a part of routine IGRT protocol, CBCT of region of interest is taken followed by auto and manual matching for the pelvic nodal region and shifts applied according to the shift protocol. TAUS is performed to acquire the utero-cervical region images after repeat calibration of the infrared camera with respect to the treatment couch using Couch Position Indicator (CPI). These are fused with the simulation session images and contours (CT/TAUS) and shifts noted. These shifts were taken as surrogate for utero-cervical movements and compiled for defining ITV margins. Similarly, for brachytherapy planning, Clarity Imaging was repeated during CT Simulation. The US based planning process for brachytherapy is being defined systematically. Results: In this ongoing study, for TAUS Based IGRT for external beam radiation therapy, we have completed 15 patients. The average shift in various directions are as follows: +X: 4.3±6.7 mm, -X: 3.5±5.5mm; +Z: 9.7±17.9 mm; -Z: 6.6±8.5mm; +Y: 10.7±10.5mm and -Y: 3.2±7.6 mm respectively. Similarly, for CBCT, the average shift in various directions are as follows: +X: 3±3.2 mm, -X: 6.3±3.4mm; +Z: 2.2±2.0 mm; -Z: 4.1±2.4mm; +Y: 3.8±3.0mm and -Y: 3.5±3.8 mm respectively. This interpretation for ITV margins is preliminary. The shift data and its implications for generating ITV margins will be compiled after completion of the planned accrual. Conclusions: TAUS Based Clarity IGRT System in the treatment of cervical cancers is promising. Completion of accrual and systematic compilation and analyses of the shift data is awaited. TAUS Based Brachytherapy Planning Process still needs refinement and validation.

directions TAUS(mean±SD) CBCT (mean±SD)


(Right-Left) +X 4.3±6.7 mm 3±3.2 mm

-X 3.5±5.5mm 6.3±3.4mm

Supero-Inferior +Z 9.7±17.9 mm 2.2±2.0 mm

-Z 6.6±8.5mm 4.1±2.4mm

Antero-Posterior +Y 10.7±10.5mm 3.8±3.0mm

-Y 3.2±7.6 mm 3.5±3.8 mm

Long term clinical outcome and toxicity of intensity modulated versus conventional pelvic radiation therapy for locally advanced cervix carcinoma: Updated results from a prospective randomized study

Ajeet Kumar Gandhi

MD, DNB, Senior Resident, Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India-110029, E-mail: [email protected]

Introduction: Traditionally, whole pelvic radiotherapy with either a 2-field or 4-field technique has been employed for management of locally advanced carcinoma cervix (LACC), but is associated with significant rates of gastrointestinal and hematologic toxicities. Dosimetric studies have shown that intensity modulated radiotherapy (IMRT) can reduce bowel, rectal, bladder, and bone marrow (BM) dose, while early clinical studies have demonstrated lower rates of gastrointestinal (GI), genitourinary (GU), and hematologic toxicity compared with conventional techniques. Yet, prospective studies comparing IMRT to conventional techniques for LACC are lacking. Purpose: We had earlier reported our results of early clinical outcome and acute toxicities in patients with LACC treated with whole pelvic conventional radiotherapy (WP-CRT) versus intensity modulated radiotherapy (WP-IMRT). This study aims to evaluate the chronic gastrointestinal toxicity and long term clinical outcome. Methods and Materials: Between January 2010 and January 2012, 44 patients with International Federation of Gynecology and Obstetrics (FIGO 2009) stage IIB-IIIB squamous cell carcinoma of the cervix were randomized to receive 50.4Gy in 28 fractions delivered via either WP-CRT or WP-IMRT with concurrent weekly cisplatin 40 mg/m2. Late toxicity was graded as per the Radiation Therapy Oncology Group (RTOG) system. Survival was estimated by Kaplan-Meier method and SPSS (version 16) was used for all statistical analysis. Results: Of 44 patients, 22 patients received WP-CRT and 22 received WP-IMRT. In the WP-CRT arm, 13 patients belonged to stage IIB and 9 to stage IIIB; in the IMRT arm 12 patients had stage IIB disease and 10 had stage IIIB disease. Median follow up in the WP-CRT arm was 34.3 months (10.7-47.6 months) and in the WP-IMRT arm was 29.9 months (9.4-46.6 months). Disease free survival and overall survival at 36 months were 83.8% in WP-CRT vs. 66.9 % in WP-IMRT (p=0.32) and 80.6% in WP-CRT vs. 69.2% in WP-IMRT (p=0.25) arms respectively. Patients in the WP-IMRT arm experienced significantly fewer chronic gastrointestinal toxicity (13.6% vs. 50%, p=0.011). In the IMRT arm, the percentage of patients having Grade 1, 2, and 3 chronic GI toxicities were 9%, 4.5% and 0% respectively while for patients in the conventional arm, the rates were 27.3%, 13.63%, and 9.1%. Conclusion: WP-IMRT is associated with significantly less chronic gastrointestinal toxicity compared to WP-CRT and has a comparable long term clinical outcome. We suggest the use of WP-IMRT for definitive management of locally advanced carcinoma cervix.

Dosimetric correlation of rectal dose parameters and rectal distension in patients of locally advanced cervical cancers undergoing three dimensional high dose rate brachytherapy

Irfan Bashir, Sunny Jain, Anil Thakwani, Anshul Bhatnagar, Kundan S. Chufal

Batra Hospital and Medical Research Centre, New Delhi, India.Email- [email protected]

Introduction: Rectal dose defined as a point dose in ICRU 38 is not a good surrogate for actual dose delivered. Image based brachytherapy using CT or MRI allows for volumetric assessment of radiation dose. The possibility of developing rectal complications is best quantified from measuring dose to 2cc (D2cc) of rectum. Aims and Objectives: In this study we investigated the effect of rectal distension on rectal dose parameters in patients of locally advanced cervical cancers undergoing CT based high dose rate brachytherapy and generated a model to predict the increase in D2cc with increasing rectal distension. Materials and Methods: 45 brachytherapy 'planning CT scans' of 15 locally advanced cervical cancer patients between January and October 2013 were reviewed retrospectively. Rectum was contoured from rectosigmoid junction superiorly until the ischial tuberosity inferiorly. The maximum rectal distension was measured as the largest anterior-posterior diameter of the rectum opposite to the applicator from the tip upto the cervical collar. A dose volume histogram was generated and a dosimetric correlation of maximum rectal distension with dose to 2cc (D2cc), dose to 1cc (D1cc), maximum and mean rectal dose was calculated using spss software version 19. Results: The mean maximum rectal distention was 3.11cm (range 2.32-3.77cm). D1cc, D2cc, mean rectal dose and maximum rectal doses were 3.51 Gy, 3.04 Gy, 1.63 Gy and 4.95 Gy per treatment, respectively. Statistical analysis revealed an increase in D2cc (p=0.02) and D1cc (p=0.05) with increasing rectal distension. Further it is possible to predict the increase in D2cc with increasing rectal distension using the linear regression model: "Increase in D2cc in cGy = 17.74+92.22 x Rectal distension in cm". Conclusions: D2cc increases significantly with increasing rectal distension in HDR brachytherapy for cervical cancer patients. Minimizing rectal distension by simple measures like overnight fasting, mild laxatives and enema are likely to minimize potential rectal toxicity. Hence efforts to decrease rectal distention during brachytherapy should be considered.

Epidural analgesia during interstitial brachytherapy for cervical cancer patients

Mohammed Raees Tonse, HasibAG, Firhana Ruzina, Shridhar'

Aim: To find out the efficacy of epidural analgesia in providing continuous pain relief for patients undergoing brachytherapy for cervical cancer. Settings: Teaching hospital. Materials and Methods: A total of 10 cervical cancer patients received continuous infusion of epidural analgesia for 3-4 days of pelvic brachytherapy treatment. Injection bupivacaine 0.125% was given at 5ml/hr continuous infusion till the interstitial brachytherapy implant was removed. Additional top up or systemic analgesic was given for breakthrough pain. Results: 9 out of 10 patients received epidural analgesia. In one patient the epidural catheter was not functioning hence removed and patient was on injection morphine 5mg IV qid. Conclusions: Epidural analgesia is safe and provides satisfactory pain relief during brachytherapy and makes patients stay in hospital more comfortable.

Leptomeningeal carcinomatosis in synchronous presentation with carcinoma of uterine cervix. An exceedingly rare experience

Pranabandhu Das

E-mail: [email protected]

Aims and Objectives: Leptomeningeal carcinomatosis is an exceptionally rare metastatic outcome in gynecological malignancies and more commonly found in ovarian malignancy. It is extremely infrequent in uterine cervical cancer with a very few cases reported so far in the english literature. Materials and Method: A 55 year post-menopausal female presented with bleeding per vaginum and whitish discharge clinically diagnosed to be carcinoma of uterine cervix stage IIB. Biopsy revealed undifferentiated carcinoma. Patient was then started with whole pelvic EBRT during which she developed puffiness of face, headache and giddiness after 28 Gy over 14 fractions. Headache was severe and progressive in nature and unresponsive to medication.On evaluation she was found to have uncontrolled hypertension associated with relative bradycardia. Cardiologist suggested to rule out non cardiac causes of uncontrolled hypertension in suspicion of raised ICP. Patient gradually became irritable and developed neck stiffness.CECT brain revealed diffuse meningeal enhancement and no focal lesion but possibility of carcinomatous meningitis cannot be ruled out. Lumbar puncture was performed and CSF cytology revealed presence of malignant cells consistent with primary cervical malignancy thus establishing the diagnosis of meningeal carcinomatosis. Results: Following diagnosis she was treated with whole brain RT concurrently with intrathecal methotrexate 10 mg per week to achieve symptomatic palliation. She had symptomatic improvement during and immediately following treatment. She died two months after completion of treatment. Conclusion: Treatment of leptomeningeal carcinomatosis in solid tumors is not radical rather intended to achieve judicious local control and effective palliation with improvement of neurological symptoms to prolong survival and provide good quality of life. Standard treatment consists of whole brain RT or craniospinal RT with intrathecal chemotherapy.

Outcome of carcinoma cervix patients treated with radical radiotherapy in rcc - a single institution experience

Geethu Babu, Susan Mathews, Biju Azariah, P. G. Jayaprakash

Department of Radiation Oncology, Regional Cancer Centre, Trivandrum, Kerala, India. E-mail: [email protected]

Aim: This retrospective analysis aims to report on the patterns of care and treatment outcome of cancer cervix patients treated with radical Radiotherapy at Regional Cancer Centre Trivandrum. Materials and Methods: Of the 650 Cancer Cervix patients who registered with us during 2011 - 2012, 350 patients received radical Radiotherapy. All patients had staging investigations followed by External beam radiotherapy and High dose rate Brachytherapy with or without concurrent chemotherapy. Patient profile, stage distribution and patterns of care in terms of -staging investigations and treatment planning techniques were analysed and correlated with outcome. Outcome measures studied include pattern of relapse, sites of failure and toxicity. The Kaplan-Meier method was used to estimate relapse-free-survival and overall survival. Patient and Treatment Characteristics: The age of patients ranged between 31-85 years with a mean of 57 years. 78% patients were post-menopausal. Squamous Carcinoma (90%) was the predominant histology. 8.6% had adenocarcinoma and the rest, poorly differentiated carcinoma (1.4%). All patients had some form of pre-treatment imaging; majority patients had CT Scan (72%). 20% had MRI while 8% patients had USG. Stages IIB and IIIB dominated. Clinical stage distribution was IB1 (14.3%), IB2 (13.1%), IIA (6.3%), IIB (36%), IIIA (1.4%), IIIB (28.9%). All patients had their Radiation treatment planned on Simulator. 60.6% had CT Simulation while 30.4% had X-ray simulation. 68.9% patients received concurrent chemotherapy with CDDP. Results: After a median follow-up of 27 months, 302 patients were available for analyses. 32 patients had died at the time of analysis. 53 patients failed- 36 patients experienced pelvic failure while 26 patients developed distant metastases, 9 patients had both distant and pelvic failures. The 2 year local disease free survival probability was 84.1 and distant disease free survival probability, 91.9. The 2 year overall survival probability was 91.8. There was no significant grade 3/4 acute bladder or rectal toxicity. Conclusion : Excellent outcome even with advanced stages of Carcinoma cervix can be had by proper application of critical treatment factors like adequate radiation tumour dose and volume, use of brachytherapy and administration of concurrent platinum based chemotherapy.

Feasibility and outcome of 20 cases of carcinoma cervix treated with interstitial Brachytherapy with 9Gy/#x2.

Kanhu Charan Patro, E. B Rajmohon

Mahatmagandhi Cancer Hospital and Research Institute, MVP Colony, Sector-7, Viskhapatnam, Andhra Pradesh. E-mail: [email protected]


Aim/Objectives: To evaluate the feasibility and accaptance of interstitial brachytherapy at peripheral centeres at the same time to evaluate the outcome. Material and Methods: After completion of external beam radiotherapy for cervix cancers, all patients were evaluated for accesibilty of intracavitary brachytherapy.Those patients were not suitable for intracavitary brachytherapy because of one of the reasons given 1.vaginal wall involvement, 2.bulky disease [chances of getting not covered by of intracavitary brachytherapy], 3.lateral para involvement, 4.vault recurrance, 5.Higher dose to OAR.Planned for 9Gy in each fraction for 2 fractions at a week interval. Follow up at 3 month after completion and evaluted for response and toxicity. Results: More than 30 cases were planned for this procedure but 20 are evaluated as per follow up.Out of 20 patients 17 patients achieved complete response, and 3 were are found to have residual disease and sent for further treatment for palliative chemotherapy and exenteration surgery.Out of 17 patients 3 are having proctitis [1 having grade IV proctitis and none having cystitis. Conclusions: This procedure is safe and can be accepted as alternative option for those which are not suitable intracavitary brachytherapy.

Prospective randomized study comparing concomitant chemoradiotherapy using weekly cisplatin and paclitaxel vs concomitant chemoradiotherapy using weekly cisplatin in locally advanced carcinoma cervix

Pragyat Thakur

Senior Resident, PGIMER, Chandigarh.

E-mail: [email protected]

Introduction : Despite the use of concurrent chemoradiotherapy with Cisplatin in locally advanced carcinoma cervix, many patients continue to fail in the pelvis (20-25%) and at distant sites (10-20%)1-3, even the Cochrane metaanalysis4 has shown that advantage of concurrent chemoradiotherapy (C-CRT) decreases as the stage increases. To improve upon these results various strategies have been used, one of which is use of combination chemotherapy. Considering this we began a Phase III randomized clinical trial to see the effect of addition of weekly Paclitaxel to the current standard of cisplatin based C-CRT versus the single agent cisplatin based C-CRT. Aims and Objectives: To compare, between the two arms, the local control at 1st follow up and median follow up, DFS and OS at median follow up and toxicities at 1st follow up. Materials and Methods: From 1/7/11 to 31/5/12, 81 Women with newly diagnosed, histopathologically proven carcinoma cervix with FIGO stage IIA to IIIB were randomized to two arms, Cisplatin 40mg/m2/week for 5 weeks was given in single agent Cisplatin (C) arm while Cisplatin 30mg/m2/week and Paclitaxel 50mg/m2/week for 5 weeks were given in Cisplatin and Paclitaxel (CP) arm. External beam radiotherapy (EBRT) was delivered by Theratron Co60 machine by 2 or 4 field techniques, to a total dose of 50Gy/5 weeks/25# with central shielding after 44Gy at 2Gy/# at 5#/week followed by I/C Brachytherapy or Supplement EBRT @ 20Gy/2weeks/10# with 2 cycles of respective chemotherapy. Results: Out of 90 patients evaluated, 81 patients completed treatment. The median age was 50 years (range 27 to 65yrs), 58% patients were of stage IIB while 42% were of stage IIIB. Patients had a maximum follow up of 36 months with a median follow up of 29 months. At 1st follow up response rate was achieved in 98.8% patients, with complete response in 80%, partial response in 18.5% and stable disease in 1.2%. CP arm showed complete response in 84% vs 75.6% in C arm. Major toxicities at 1st follow up were seen in CP arm with Gastrointestinal Grade III (20% vs 7.3%) and IV (12.5% vs 2.4%), and Haematological Grade II (35% vs 12.2%). At last follow up complete response was seen in 73.4% patients while 29.6% patients had progressive disease. CP arm showed disease free survival in 82.5% vs 58.5% in C arm while progressive disease was seen in 17.5% of CP arm vs 41.5% of C arm. Conclusion : This analysis shows trends favoring CP arm, although with increased toxicities which were manageable and reversible.

Socio-demographic profile and mode of treatment in operable carcinoma cervix patients receiving radiotherapy in a tertiary regional cancer center

Padhi Sanjukta, Pujari Lincoln, Routroy Biswa Ranjan, Mekap Himansu Shekhar, Panda Niharika, Senapati S. N.

Department of Radiation Oncology, AHRCC,Cuttack. E-mail: [email protected]

Background : Carcinoma cervix is the second most common female specific malignancy in the world. The same is the scenario in India. In Odisha also carcinoma cervix is the 2nd most common cancer among women (1). Aim of the Study : To study the epidemiological characteristics of patients receiving radiotherapy for various gynaecological malignancy and mode of treatment for operable carcinoma cervix in dept. of radiotherapy AHRCC, Cuttack. Materials and Methods : Retrospective analysis of data collected from the radiation treatment records of department of radiation oncology of patients receiving radiation in curative intent from July 2013 to June 2014 were done. Results: Among 530 patients in total 488 (92%) were of carcinoma cervix, 42 patients were endometrial carcinoma, cancer vulva, vagina and patients with vault recurrence. Maximum number of patients belonged to (41-60) years of age group. There are total 80 patients in below 40 years age group out of which 22 patients(27%) were operable, but only 46 out of 309 (14.8%) presented in operable stage in the age group of (41-60) where maximum number of cases were cancer cervix. Out of Total patients, 111 (21%) were post-op. cases, Among which 84 patients were carcinoma cervix. Among 84 post-op. cases of carcinoma cervix 12 (16.6%) patients, i,e 1 in every 6 patients were operated inappropriately outside our hospital.15 (13.5%) patients presented with vault recurrence. These patients didn't take any adjuvant treatment after surgery. Conclusion: In Odisha bulk of the disease burden is found in 41-60 years of age group. High rate of inappropriate hysterectomy indicates towards need of continued training in diagnosis, strict adherence to diagnostic protocols of cancer cervix and use of newer diagnostic modality in staging of carcinoma cervix.(2)(3). Early detection and strong screening programme can help in detecting the disease in early stage and hence the possibility of increase in number of operable cases.

High dose IMRT for Isolated relapse of ovarian carcinoma

Thomas S. Ram 1 , Anitha Thomas 2 , Ramani M. Kumar 3 , Ebinezer S. Babu 4 , Selvamani B 1 , Abraham Peedicayil 2

1Department of Radiation Oncology,Ida B Scudder Cancer Centre, Christian Medical College, Vellore, 2Department of Gynecology Oncology, Christian Medical College, Vellore, 3Department of Pathology, Christian Medical College, Vellore, 4Department of Medical Physics, Christian Medical College, Vellore. E-mail: [email protected]

Background: Ovarian cancer incidence is going through a changing trend in India. The age-standardized incidence rates (ASR) for ovarian cancer varied from 0.9 to 8.4 per 100,000 person years during the period 2001-06(1). The standard treatment is optimal surgical debulking followed by adjuvant chemotherapy for advanced stage. There are a significant number of patients who are long-term survivors and often present with isolated relapses. Whenever possible surgical debulking of such isolated relapses is desirable. When surgery is not possible the patient is often subjected to salvage chemotherapy which is associated with high systemic morbidity. Whole abdominal radiation therapy had been used in the past as an adjuvant after surgical debulking(2). Due to the associated morbidity and better chemotherapy options it is no longer considered as a treatment option(3). With the technological advancements in radiation therapy by the introduction of precision techniques like IMRT and the apparent radiosensitiveness of ovarian cancers there is a need to revisit radiation as an option in isolated pelvic relapses which are associated with high surgical morbidity. Here we present a case where high dose IMRT was considered for such an isolated pelvic relapse. Case Study: 56-year-old lady was evaluated for lower abdominal pain and found to have complex cyst in the right adnexa. She underwent Total abdominal hysterectomy and left salpingoopherectomy at her hometown where the pathology was reported as dysgerminoma. The histopathology and immunohistochemistry reviewed at our Institution was reported as poorly differentiated carcinoma probably serous. Her CT scan revealed a right adnexal mass in close proximity to the rectum. A biopsy of the mass re-established the diagnosis of poorly differentiated carcinoma. She received three cycles of chemotherapy with Paclitaxel and Carboplatin following which imaging revealed disease regression hence she completed total six cycles of chemotherapy. On follow up she was found to have rising CA 125. PET CT scan done revealed a nodule of size 3.7x2.2 cm in the right pararectal region. The patient refused surgery in view of the associated morbidity. As the pararectal lesion being the only site of PET avid disease she was given the option of IMRT. IGRT was delivered using 7 field IMRT technique and a dose of 60 Gy to the target was delivered in 30 fractions. Following radiation therapy the lesion decreased in size and was surgically excised. The post excision specimen had no tumor. The patient has been on regular follow-up and is now disease free for 24 months. Discussion: Moving strip and whole abdominal IMRT have been already described in literature as adjuvant therapy after optimal debulking(4)(5). We described here a novel technique where high dose (60Gy) IMRT was used to ablate an isolated pelvic relapse which was initially not amenable to surgical debulking. There is not enough literature which supports such an approach to manage isolated relapses using IMRT. However with the encouraging result, the role of ablative radiation therapy to treat isolated pelvic relapse in Ovarian cancer using IMRT or SBRT needs to be evaluated in a prospective clinical trial.

Ovarian carcinoma with axillary nodal recurrence; an unusual metastatic pathway

Bhargav J. B, Selvamani B, Ram T. S

Ida B. Scudder Cancer Centre, Radiation Oncology Unit 1 , Christian Medical College,Vellore. [email protected]

Introduction: Carcinoma ovary is the fourth most common malignancy among women in India with an incidence of 5% and a mortality of 6%. Most patients present with locally advanced disease, where optimal cyto-reductive surgery followed by adjuvant chemotherapy is the standard of care. Ovarian cancer recurrences are predominantly intra abdominal and managed by chemotherapy and if feasible by salvage surgery. Distant metastasis is commonly found in the lung and para-aortic nodes. Metastasis to the axillary nodes is unusual and requires careful evaluation to rule out a co existing breast or a lung primary. We present a case of recurrent ovarian cancer with an isolated axillary nodal metastasis. Case Report: A 47 year old lady presented in 2011 in our institution after suboptimal surgery for a pelvic mass. She was evaluated and diagnosed as stage IIIc Grade 2, papillary serous cystadenocarcinoma of the ovary for which she received six cycles of adjuvant chemotherapy with Carboplatin and Paclitaxel. On follow up she was found to have pelvic and para-aortic nodal recurrence in 2012. She had secondary debulking and then received three cycles of chemotherapy with Liposomal Doxorubicin and refused further chemotherapy. On follow up in April 2014 she had increased CA-125 and PET-CT showed increased uptake in the right axilla and a soft tissue thickening in the left side of vault. Biopsy of the right axillary node revealed metastatic papillary adenocarcinoma, morphologically consistent with ovarian primary. Bilateral mammography and ultrasound of the breasts and axillae ruled out breast primary. Immunohistochemistry showed WT-1 was positive indicating the possibility of an ovarian origin. She was subsequently re challenged with Paclitaxel and Carboplatin. After completion of three cycles there was decrease in CA-125 and SUV uptake in the axilla and the pelvis. She has been planned for three more cycles of the same. Discussion: Ovarian carcinoma primarily metastasizes by either hematogenous, lymphatic, direct or transcoelomic dissemination. Our present knowledge of metastasis may be insufficient to fully explain the pathway of axillary nodal metastasis from an ovarian primary and there is a need to understand novel mechanisms and routes of metastasis. Lymphatic drainage to the axillary node commonly occurs through the lymphatics along Pectoralis major. An unusual pathway describes lymphatic drainage from rectus abdominis, subhepatic and subperitoneal plexuses.This pathway could most likely be postulated to explain the route of axillary node metastasis in this patient. Literature review revealed occurrence of axillary nodal metastasis from a breast primary more frequently than an ovarian primary. Given the rarity of such presentations, a thorough clinical examination and comprehensive imaging of the breasts is warranted to rule out a coexisting breast primary. An excision biopsy of the node for confirmation of the histology is mandatory. Immunohistochemical markers (WT-1, GGCDFP-1 and hormonal markers) often aids in establishing the origin. The treatment options vary widely as this presentation carries a poor prognosis.

Clinico-pathological and radiological prognostic factors in cancer cervix treated with concurrent chemoradiation

Kang M. S, Sahni Kamal Kumar P, Chauhan A. K

Junior Resident III, Professor, Associate Professor, Assistant Professor, Department of Radiotherapy, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly-243202, Uttar Pradesh,


Introduction: Cervical cancer is the fourth most common cancer in women and the fourth most common cause of cancer death world wide (GLOBOCON 2012).In India it is 16% of all cancers (ICMR 2013).Many prognostic factors have been recognized in the outcome of disease in patients with cancer cervix. These have been divided into 1) clinical 2) pathological and 3) radiological prognostic factors. Aims and Objectives: 1. cancer cervix. 2. Clinical prognostic factors will be evaluated in terms of age, stage, haemoglobin level and human papilloma virus infection. 3. Pathological prognostic factors will be evaluated in terms of histopathology, pathology grade, lymph-vascular invasion, mitotic index and necrosis. 4. Radiological prognostic factors will be evaluated in terms of greatest dimension of the disease, parametrial extension, lymph node assessment, presence of hydronephrosis and vascular density of tumour. Material and Methods: Thirty two patients of cancer cervix were selected. Inclusion criteria: 1. Biopsy proven cancer cervix. 2. Age > 18 years 3. Karnofsky performance scale above 70. 4. Stage IA to IV 5. No history of previous malignancy 6. Hepatic, Renal, and Cardiopulmonary functions are adequate. Exclusion Criteria: Metastatic disease. Treatment Planned: All the 32 patients were planned and delivered concurrent chemoradiation with inj. cisplatin 35mg/m 2 and 3- Dimensional Conformal radiotherapy using four field box technique. Radiotherapy dose delivered will be 50 Gy in 25 fractions at 2Gy/day. This will be followed by 3 or 4 applications of intracavitary brachytherapy of 6Gy/fraction each as per departmental protocol. Follow up: The patients will be followed up at least 6 months from day of completion of treatment. Result and Observation: Will be tabulated or graphically reported to draw conclusion. Results: Clinical factors: 1. Age - Older patients fared better in terms of disease free survival than compared to younger patients (Pvalue =0.0036). 2. Stage - Lower is the stage better is the survival (pValue = 0.003). 3. Haemoglobin - fifty seven percent (57%) patients with low haemoglobin (<10g/dl) had recurrence at end of 6 months. This difference was statistically significant (Pvalue=0.00001). 4. HPV - Recurrence was high in the presence of Hpv.This recurrence was statistically significant. (Pvalue = 0.00001). Pathological Factors : 1. Grade of histopathology -. No statistical difference (Pvalue = 0.35) was observed in recurrence according to different grades of histhopathology. 2. Histological subtype - no statistical difference was observed. 3. Lymph-vascular invasion and necrosis - As most cases presented in advanced stages, therefore not much inference could be drawn. 4. Mitotic index - thirty three percent (33%) with high mitotic index presented with disease compared to having low mitotic index (pValue=0.0009). Radiological Factors : 1. Parametrial extension - Recurrence was for patients having disease limited to pelvic wall (32 %) vs greater than pelvic wall (50 %) was statistically significant (p Value = 0.001). 2. Greatest dimension - thirty five percent (35 %) patients having volume of disease greater than 6 cm had disease at end of 6 months.((p Value=.016). 3. Hydronephrosis - 40 % who had hydronephrosis presented with recurrence at end of 6 months after treatment (pValue = 0.0005) was statistically significant. 4. Lymph nodes - There was statistically significant difference (p= 0.01). 5. Vascularity - There was statistically no difference between grades I,II and grade III vascularity groups. Conclusion: Low haemoglobin level (<10g/dl), presence of human papilloma virus infection, Mitotic index (3-5/hpf), parametrial extension upto pelvic wall,presence of pelvic nodes and presence of hydronephrosis were concluded as the independent poor prognostic factors.

Hybrid template in cervical cancer - feasibility study and dosimetric analysis in reducing rectal dose in 50 applications

Manish Chandra

E-mail: [email protected]

Cancer of cervix is a leading cancer of women in India and brachytherapy is an important part of its treatment. One of the major problem faced in India is local control in bulky central disease. This is mainly due to the inadequate/low dose to central disease with conventional 3 channel applicators. to overcome this problem we have been using free hand needles in parametrium for many years. The intention of these needles was dose escalation and lateral delivery of dose. Recently we developed a template to be placed over conventional applicators or reproducible insertion of lateral needles. Other advantage that we got from these needles were to reduce the rectal dose because it was possible to get the desired isodose without increasing the rectal dose. This is our series of consecutive 50 applications of hybrid template. Our study establishes the safety of this procedure and on dosimetric analysis it shows reduction of rectal dose by 20% as compared to standard 3 channel applicator.

Analysis of survival and toxicity profile of radiotherapy in patients of carcinoma cervix of sub himalayan population: A single institution experience

Neha Sehgal 1 , Meenu Gupta 1 , Saurabh Bansal 1 , Vipul Nautiyal 1 , Mushtaq Ahmad 1 , Sunil Saini 2

1 Department of Radiation Oncology, 2 Surgical Oncology, Cancer Research Institute, Swami Rama Himalayan University, Dehradun. E-mail: [email protected]

Introduction: Cervical carcinoma is the most frequent cancers among women in Africa, South America and Asia including India. In carcinoma cervix radiation is a proven therapeutic modality. We conducted a retrospective analysis in order to investigate the patient characteristics, treatment, and toxicities of patients with carcinoma cervix. Aim and Objectives: To analyze the survival outcomes and treatment-related toxicity for patients with cervical cancer treated with radiotherapy. Material and Methods: Data was collected retrospectively from the records of 194 patients with cervical cancer who had been treated with radiotherapy or combined radiotherapy, chemotherapy with or without surgery from January 2010 to December 2012. The primary end point was Overall Survival and toxicity profile. Results: Out of total 194 patients, the median age of the patients at the time of diagnosis was 50yr (range 28-90 years). 175 patients were histologically confirmed as squamous cell carcinoma, 12 adenocarcinoma and 6 patients with other variants. Two (1.03%) patients were diagnosed in FIGO stage IA, Eight (4.12%) patients in FIGO stage IB, Forty-eight (24.7%) patients in FIGO stage IIA, Sixty two 31.9%) patients were in FIGO stage IIB, 7 (3.6%) patients were in FIGO stage IIIA and 47 (24.22%) patients were diagnosed in FIGO stage IIIB. Eleven (5.67%) patients were in FIGO stage 1V A, and Seven (3.6%) patients were in FIGO stage IV B. Out of 194 patients, 148 (76.2 %) were treated with EBRT combined with high dose rate brachytherapy (HDR).Median EBRT dose given was 50Gy followed by Ir192 HDR Brachytherapy [9Gy x 2 sessions or 7 Gy x 3 sessions]. All postoperative patients 53 (27.32%) received 7Gy 2sessions HDR Brachytherapy. Platinum based concurrent chemotherapy regimen was given in 42.7% patients. Median survival was 19 months. The overall survival at 1yr, 2yr and 3yr was 81.4%, 45.8% and 26.8% respectively. The median overall survival in stage IA was 17.5, stage IB 25 months, IIA 22.5 months and in stage IIB it was 20.5 months. For stage IIIA, the median overall survival was 19 months and17 months in IIIB. The median overall survival was 18 and 9 months in stages IVA and IVB respectively. 25 (12.88%) patients experienced RTOG grade 2 acute toxicities out of which 19 (9.7%) patients experienced diarrhea and abdominal cramps. 6 (3.0%) patients experienced moderate dysuria and acute radiation vaginitis. 3 (1.54%) patients developed grade 4 late rectal toxicity with bleeding per rectum and radiation proctitis. Conclusion: Radical radiotherapy provides good survival outcomes with acceptable toxicity. Well planned radiotherapy can efficiently control the disease, especially in this Garhwal region where cancer of cervix is a common malignancy in females. Along with that, education of patients, awareness of clinicians and referral to cancer centre improves survival in these patients.

Series of 3 cases of 18 fdg negative pet ct in locally advanced cancer cervix

Niharika Bisht

E-mail: [email protected]

Introduction: The role of 18-Fluoro deoxy glucose Positron Emission Tomography is well established in evaluation of locally advanced carcinoma cervix.We present a series of 3 cases of histopathologically proven locally advanced Carcinoma cervix(FIGO STAGEII B) in which the primary and nodal disease was found to be non FDG avid. Method and Material: All patients of carcinoma cervix who reported to radiation oncology OPD underwent PET -CT for evaluation of primary and nodal disease. Three patients of histologically confirmed squamous cell carcinoma cervix(locally advanced) were found to be non FDG avid on PET-CT.All patients were managed with external beam radiotherapy(5040cGY/28#) with concurrent chemotherapy(Inj Cisplatin weekly) followed by intra cavitary brachytherapy. Results: A total of 94 patients of carcinoma cervix were treated between Jan 2013-Dec2013 for locally advanced carcinoma cervix at our institute.03 patients were found to have non FDG avid primary and nodal disease.However the primary and nodal disease was picked up on Magnetic Resonance Imaging. Post treatment all three remained asymptomatic and clinically disease free at 12 months of follow up. Discussion: FDG PET CT is considered an imprtant tool for evaluation of primary and nodal disease in carcinaom cervix.Higher uptake in the primary and nodal disease is a poor prognostic marker.Squamous cell carcinoma is more FDG avid as compared to other histologies.Non FDG avid lesions are mostly early stage or adeno carcinoma.Our series brings to focus non FDGavid locally advanced squamous cell carcinoma cervi,detected clinically and on MRI. Conclusion: This series highlights a rare finding of squamous cell locally advanced non FDG avid cervical carcinoma.Follow up imaging with PET-CT and MRI has revealed no residual disease.

Computerized axial tomography scan assisted high dose rate interstitial brachytherapy in gynaecologic malignancies, with inverse planning and simulated annealing; an analysis of 100 martinez universal perineal template applications

Bhattacharyya P. S.*, Mr. Prabhu A. C.**, Rajmohan E. B.**,

Das S**

E-mail: [email protected]

Introduction/Aim and Objectives: Computerized Axial Tomography (CAT) scan assistance during planning Interstitial Brachytherapy (ISBT) with Oncentra based Inverse Planning and Simulated Annealing (IPSA) is used in different Institutes. ISBT has become an integral part for treatment of gynaecologic malignancies. This is an attempt to present the dose schedule used and analyse the outcome and radiation morbidity encountered. Materials and Methods: An institutional prospective analytical study since May, 2012 to June, 2014 was undertaken. A total of 50 cases of FIGO stage IIB to IIIB including 25 post operative cases of Ca. Cervix (42 Ca. Cervix and 8 Ca.Vagina) with 100 ISBT sessions using Martinez Universal Perineal Template (MUPIT) were done. Analysis was done in the month of Sept, 2014. All the patients underwent whole pelvis External Beam Radiation Therapy (EBRT) 4500 cGy in 25 Fractions, followed by midline shielding till total dose of 5040 cGy in 28 fractions @ 180 cGy per fraction, 5 days a week, with weekly Cisplatin 40 mg/m2 prior to ISBT. A gap of 7 to10 days was allowed after completion of EBRT before attempting ISBT. The anatomical relations with Uterus, Bladder, Rectum and Intestines were noted from pre implant CT Scan of the pelvis. Gap of 7-10 days between ISBT applications was allowed and dose ranged from 800-950 cGy per session. The dose to CTV, Urinary Bladder and Rectum is reviewed, with importance to Biological Equivalent Dose (BED). RTOG/ECOG criteria were used to analyse vaginal mucosal/bowel/bladder early and late radiation morbidity. Results: There was only one case of hematuria following implant removal, and one case of rectal wall perforation was noted during the procedure. The mean dose to CTV D90 is 8.74Gy and 0.1cc, 1cc, 2cc of Bladder and Rectum were 8.01Gy, 6.75Gy, 6.29Gy and 7.36Gy, 6.49Gy, 6.02Gy respectably. The BED 8.74Gy for tumour is 85.8Gy (EBRT + 2 sessions of IBT).The mean V100 (91.13%), V150 (15.38%), V200 (6.77%) with homogeneity index of 0.67. With median follow up of 17 months (range 3 -24 months) 3 patients had grade 3 vaginal mucosal toxicity, 5 patients had grade 3 toxicity of bladder and no grade 3/4 rectal toxicity noted. Conclusions: The procedure is well tolerated by the patients. There were no immediate post procedure complications.Total duration of the process from spinal anaesthesia to removal of template is within 3 hours. This study present the dose schedules and fractionation which has less patient distress for lying in bed with the perineal template continuously for two to three days with comparable few toxicity levels.

Comparison between icru reference points and dose volume histogram parameters for bladder and rectum in intracavitary brachytherapy for carcinoma cervix

Ritika Harjani, Janaki M. G., Arul Ponni T. R., Kirthi Koushik T. S, Mohankumar S, Ram C. Alva

Department of Radiotherapy, M S Ramaiah Medical College, Bangalore, E-mail: [email protected]

Introduction: Brachytherapy following external beam radiation plays a key role in the treatment of carcinoma cervix.1 It facilitates delivery of high doses to the primary site with relative sparing of bladder and rectum. Conventionally, point based prescription using orthogonal x-rays and dosimetric reporting as per ICRU 38 recommendations has been practised for many years.2 Since the last decade, it is being replaced by highly accurate image based prescription to the tumor volume. In our department, we have under taken image based planning since 10 months. This study is undertaken to document and compare doses to 2cc of rectum and bladder with conventional standard ICRU38 rectal and bladder points, respectively. Objectives: 1. To compare D 2cc for bladder and rectum with ICRU 38 reference points. 2. To analyse volume of bladder and rectum receiving minimum of ICRU reference point dose. Materials and methods: 20 patients of stage IB2 - IIB who underwent ICBT were the subjects of the study. After insertion of modified Fletcher-Suit applicators, a CT scan with 5 mm slice thickness was performed and images were transferred to the treatment planning system. For dose prescription, Manchester point A was marked. ICRU38 bladder and rectal points were marked using projections of CT images. Also whole volume of bladder, and rectum from 4 cms above anal verge to recto-sigmoid junction were contoured. DVH was computed and parameters namely D2cc bladder, rectum were documented and compared to bladder and rectal point doses while keeping prescription of 6.5Gy at point A. Results: The mean D2cc of rectum and ICRU rectal point doses are 6.74Gy and 6.27Gy respectively (p-0.2). The mean D2cc of bladder and ICRU bladder point doses are 7.81 and 6.885 (p-0.08). Mean D2 cc of rectum and bladder was found to be 1.07 and 1.13 times the doses at ICRU reference points respectively. The mean volume of rectum receiving minimum of ICRU rectal point dose is 4.22cc (+/- 5.1 SD; range 0.4 to 22.7cc) and mean volume of bladder receiving minimum of ICRU bladder point is 6.95cc(+/- 6.9 SD; range 1-25.7cc). Conclusion : ICRU rectal point correlates well with maximal rectal point dose. ICRU bladder dose underestimates the bladder dose, with a trend towards statistical significance.

Osseous metastases in gynecological epithelial malignancies: A retrospective study and review of literature.

Saptarshi Ghosh

GSL Medical College and General Hospital. E-mail: [email protected]

Introduction : Osseous metastasis in gynecological epithelial tumors is an extremely rare phenomenon occurring in less than 1% of these cancers. Objectives: To analyze the clinical characteristics and prognosis in patients with gynecological epithelial cancers with bone metastases. Materials and Methods : This is a single institution retrospective study done with the data available from January 2010 to July 2014. There were a total 16 number of patients with epithelial gynecological malignancies with osseous metastasis. Clinical and pathological data were analyzed along with a follow-up. Results : Out of the 16 gynecological epithelial cancer patients with bone metastases, ten were having cervical cancer, three had ovarian cancer, two had endometrial carcinoma and a one patient had vulvar malignancy. Ten of the patients had squamous cell histology, while the rest had adenocarcinoma. The mean interval from primary diagnosis of cancer to the detection of bone metastases was 30.94 months (range, 1 - 60 months). Solitary bone lesion was present in 6 patients. The most common site of bone metastasis was lumbar vertebra. Extra-osseous metastasis was present in 10 patients. The mean follow-up period was 8.69 months. During the follow-up period 12 out of the 16 patients died. There was significant difference in survival (p = 0.006) between patients with solitary bone metastasis and patients with multiple osseous metastases. Significant survival difference (p = 0.043) was also noted in patients with extra-osseous metastases when compared to the patients without. The overall survival of gynecological epithelial malignancy patients with bone metastases at 17 months was 16.1%. Conclusion : Bone metastasis in gynecological epithelial malignancies is a rare phenomenon, but with grave prognosis. Treatment in these patients should be tailored according to the patient's need. Palliative radiation therapy has a crucial role in pain relief and in prevention of impending fractures. Patients with multiple site metastases benefit from palliative chemotherapy.

Carcinoma cervix with widespread cutaneous/subcutaneous metastasis: A rare case report

Shraddha Raj

Anbarasi Kumaresan Cancer Institute, Adyar, Chennai. E-mail: [email protected]

Background: Cancer of the uterine cervix is one of the leading gynaecological malignancies of developing nations, including India. One of the rare sites of distant metastases in Ca Cervix are skin and subcutaneous tissue constituting only 0.5-2%. Case History: A 45 year old lady presented with menstrual irregularities and other non specific symptoms. After initial work up, she was diagnosed as Carcinoma Cervix, stage IVA. While she was being planned to take up on Radical Concomitant Chemo-Radiotherapy, she developed widespread nodules over various sites over body, which were histopathologically proven as metastatic lesions. She was treated with a palliative intent by radiotherapy and chemotherapy. Discussion and Conclusion : Only a few such cases have been reported in the literature with variable outcomes. These rare presentations should be thoroughly worked up and studied to know more about their biological behaviour.

A retrospective study on systemic recurrence pattern in patients with locally advanced carcinoma cervix and its association with prior pelvic lymph node status: a tertiary medical college experience in Eastern India

Shyam Sharma

Institute of Post Graduate Medical Education & Research, Kolkata. E-mail: [email protected]

Aims: To evaluate the pattern of systemic recurrence in patients with carcinoma cervix after definitive therapy and to determine whether this has any association with prior pelvic lymph node status. Materials and Methods: Hospital records of patients presented with carcinoma cervix from January 2008 to June 2014 were reviewed. Patients who had known pelvic lymph node status, either by Ultra sonography or Computed Tomography Scan of abdomen and pelvis or by post-operative histopathology report and treated with definitive concurrent chemoradiation or surgery with or without radiotherapy or concurrent chemoradiation were included in the study. Patients with para-aortic lymphadenopathy were excluded. We evaluated the percentage of patients developing systemic recurrence with or without loco-regional relapse in this population. Fischer's exact T test by Graph pad Med clac online software was used for statistical significance. Result: Total 2347 cases of cervical carcinoma were registered from January 2008 to June 2014. Surgery was performed in 468 patients. Those who had undergone surgery, pelvic lymph nodes metastasis was present in 142 patients, negative in 232 patients and status was unknown in 94 cases. Concurrent chemoradiation was performed in 1552 patients, among them USG/CT Abdomen and pelvis was available in 676 patients. Para-aortic lymphadenopathy was present in 142 patients who were excluded from the study. Pelvic lymphadenopathy was present in 219 patients and negative in 315 patients. Follow-up records of these 908 patients were evaluated for presence of systemic recurrence with or without local recurrence which was developed in 53 patients after a median interval of 32 months (range 13-47 months). Site-wise distribution of distant metastasis was as follows: lung 23, malignant ascites 7, supra-clavicular lymph node 7, liver 5, bone 5, mediastinal lymph node 4 and brain 2. Out of 361 patients with prior pelvic lymphadenopathy, metastasis developed in 35 patients (9.69%), whereas, out of 547 patients without prior pelvic lymphadenopathy, metastasis developed in 18 patients (3.29%). This difference was found to be statistically significant (p<.0001) by a two tailed Fischer's Exact test. Conclusion: Lung is the most common site of systemic recurrence in patients with carcinoma cervix and those with pelvic lymphadenopathy has a higher probability of developing systemic recurrence than those without pelvic lymphadenopathy. In patients with pelvic lymphadenopathy, apart from concurrent chemoradiation, systemic chemotherapy may be explored further to reduce distant metastasis in future.

Adnexal masses - A diagnostic dilemma

Sindhu N and Chendil V

Bangalore medical college and research institute.

E-mail: [email protected]

Introduction: Krukenberg's tumour is a rare transcoelomic metastasis to ovaries from most commonly the stomach, followed by breast, colon, appendix and rarely from gallbladder, biliary tract, pancreas, small intestine, cervix, and urinary bladder. Histologically it is signet ring adenocarcinoma with mucinous stroma. Presentation maybe synchronous or rarely primary tumour may not be identified. Prognosis is guarded. Differentiation of these tumours from primary ovarian tumour is difficult by imaging modalities. Case Report: A 52 year old lady presented to surgery OPD with one and half month history of lower abdominal pain. Initial work up revealed heterogenously enhancing solid masses in bilateral adnexal region invading into the rectum with omental deposits with C.A. 125 (333.4U/ml) and CEA (14.10ng/ml) raised significantly. The ascitic fluid was negative for malignant cells. She was referred to us for neoadjuvant chemotherapy(NACT). She received 4 cycles of paclitaxel with carboplatinum, following which there was serial reduction in C.A. 125 levels (195.7U/ml) and imaging showed reduction in size of the bilateral tumour. She underwent cytoreductive procedure (pan hysterectomy) following NACT. Histopathological examination of the specimen showed features suggestive of metastatic adenocarcinomatous deposits in bilateral ovaries (Krukenberg tumour) with ascitic fluid positive for malignant cells. Immunohistochemistry revealed tumour cells positive for CEA and negative for C.A. 125 and CA 19.9. However serum levels of C.A. 125 and CEA continued to be raised. Work-up for primary tumour with upper GI endoscopy and colonoscopy was done which was inconclusive. Palliative chemotherapy - FOLFOX regimen was started after consulting a Medical Oncologist. The main dilemma here is the necessity of histologic confirmation of primary ovarian tumour before starting NACT in a clinically inapparent source of metastasis.

Comparison of dose-volume parameters, tumor response and toxicity in two different schedules of 3D-image based high-dose rate intracavitary brachytherapy using cobalt-60 source in the treatment of locally advanced carcinoma of cervix

Soumadip Panda

E-mail: [email protected]

Introduction: There is no established time, dose, fractionation schedule in High dose rate (HDR)-Intracavitary Brachytherapy (ICBT) for the treatment of locally advanced carcinoma cervix1. At our institution these patients are treated with 3 weekly fractions of 7Gy (7Gyx3#) HDR-ICBT schedule abiding the recommendation of American Brachytherapy Society. Studies based on X-ray based point dosimetry have shown that 2 weekly fractions of 9Gy (9Gyx2#) HDR-ICBT is safe and effective in terms of local control and toxicity and of particular importance in cost-constraint setting.Clinical feasibility of HDR-ICBT using 60Co has been shown previously4. Here, we report a prospective randomized clinical trial comparing dose- volume (DVH) parameters tumor response and toxicity in 7 Gyx3# versus 9 Gyx2# using CT based 3D treatment planning using 60Co HDR remote afterloading device. Aims and Objective : Comparison of DVH parameters, tumor response and and toxicity between the two arms. Materials and Methods: Between January 2013 to March 2014, 60 eligible locally advanced cervical carcinoma patients were randomized into two arms (30 in each arm) to receive either 7Gyx3# (Control: Arm A) or 9Gyx2# (Study:Arm B) after completion of EBRT (50.4Gy/28 fractions in 5.3 weeks) with concurrent weekly cisplatin. During brachytherapy CT scan based contouring and plan optimization was done using 3D treatment planning software. DVH parameters of target i.e. High risk clinical target volume (HRCTV), Intermediate risk clinical target volume (IRCTV) and organ at risk (OAR) i.e. bladder, rectum and sigmoid colon were assessed. Equivalent dose in 2Gray/fraction (EQD2) was calculated summing EBRT and all ICBT doses (considering α/β of tumor and OARs are 10 and 3 respectively). Patients were followed up for tumor response and toxicity. RTOG criteria were used for toxicity scoring. Results: EQD2 D90HRCTV in Arm A (93.99±14.19Gy) and Arm B (100.42±13.75Gy) were comparable (p=0.108). EQD2 D90IRCTV in Arm A and B are 70.36±8.23Gy and 67.49±5.96 Gy respectively (p=0.16).EQD2 D2cc bladder was 83.48±9.63Gy and Arm B was 79.50±5.96Gy (p=0.077). EQD2 D2cc rectum in Arm A was 63.15±4.75Gy and Arm B was 62.56±4.72Gy (p=0.661).EQD2 D2cc sigmoid colon in Arm A was 67.05±5.13Gy and in Arm B was 65.15±5.81Gy (p=0.228). Median follow up time in Arm A was 10 months (range 6 to 18 months) and in Arm B was 11 months (range 5 to 15 onths).Complete response (CR) at last follow up in two arms (Arm A vs. Arm B) was 82.6% vs. 85.7%, partial response (PR) was 8.7% vs. 10.7%, stable disease was 4.3% vs. 0% and progressive disease was 4.3% vs. 3.6%. No grade 3 acute hematological, gastrointestinal, skin or genitourinary toxicity was observed in either arm. Late grade 2 proctitis/proctosigmoiditis was 4.3% in Arm A and 10.7% in Arm B (p=0.617). No late bladder toxicity was noted in either arm. Conclusion: In spite of the small sample size and short follow up duration the study shows that 9Gyx2# is equivalent to 7Gyx3# of HDR-ICBT in terms of DVH parameters, tumor response and toxicity using 60Co HDR source.

A rare incidence of synchronous endometrial and breast carcinoma treated successfully at a tertiary care center: A report with review of literature

Jain Sunny*^, Bashir Irfan*, Bhatnagar Anshul*, Thakwani Anil*, Chufal S Kundan*

*Batra Hospital and Medical Research center, New Delhi. E-mail: [email protected]

Introduction: We report a case of synchronous endometrial and breast cancer in an elderly patient. In view of the rarity of the incidence with very few cases of synchronous endometrial and breast cancer documented in the literature we hereby report a case of dual malignancy treated successfully with acceptable treatment related side effects. Aims and Objective: The aim is to present the case and to give a treatment set up in rare entities of Synchronous Endometrial breast malignancies especially in elder set of patients as there are very few reports documented. Material and Methods: Patient was treated at a tertiary care center under a multidisciplinary team approach. Patient initially underwent radical surgery for breast and endometrium cancer followed by adjuvant radiotherapy by intensity modulated radiotherapy technique to the right breast, and also to pelvis followed by intracavitary high dose rate brachytherapy to the vaginal vault. Results: Patient underwent right breast lumpectomy with sentinel lymph node biopsy and total abdominal hysterectomy with B/L salpingo ophrectomy with infra colic omentectomy with pelvic and para aortic lymphadenectomy. Post op histopathology report revealed- Invasive Ductal Carcinoma, Histological grade I, modified bloom Richardson score of 5, all deep resected margin were free sentinel lymph node was reported to be fibrofatty tissue- pT1bN0M0. On immunohistochemistry tumor was positive for ER (3+ve) and PR (1+) and stained negative for Her2Neu. Post op HPE of uterus specimen revealed- Endometrial Adenocarcinoma, high grade (grade 3) with serous and clear cell components, tumor invading more than half of myometrium (invading 1.7 cm of 2 cm of the myometrium). Following surgery patient was taken up for adjuvant radiotherapy. Patient received 46Gy in 23 fractions over 41/2 weeks @ 2Gy/fraction, 5 fractions/week to the right breast followed by electron boost to the lumpectomy cavity to a total dose of 10Gy in 4 fractions. Simultaneously patient received external beam radiotherapy to pelvis at a dosage schedule of 45Gy in 25 fractions over 5 weeks with 1.8Gy/fraction, 5 fractions/week to whole pelvis followed by intracavitary radiotherapy by HDR technique on Gamma Med Plus delivering 7Gy/fraction x 3 fractions given weekly. Patient was put on Tab Anastrazole 1 mg once a day after completing radiotherapy. Conclusion: Synchronous cancers of the endometrium and breast represent an uncommon event. According to previous literature, coexistence of carcinoma in endometrium and breast are reported in very few cases. With this case we represent the path of managing conͼcordant endometrial and breast cancers especially in elderly patient where the good prognosis and survival potential can be achieved through proper planning and multidisciplinary team approach.

HDR intra-vaginal intra-uterine brachytherapy using conscious sedation and local anesthesia for locally advanced carcinoma cervix: A pain score and dosimetric analysis

Suparna Kanti Pal

Institute of Post Graduate Medical Education & Research, Kolkata.

E-mail: [email protected]

Introduction: Brachytherapy is an integral part of carcinoma cervix. Presently outpatient procedure for IVIU by HDR technique has gained ground. Though General, epidural and spinal anesthesia are most commonly used, the procedure can be also done under conscious sedation along with local anesthesia. This is an attempt to assess the feasibility of the same in terms of pain control. Methodology: 33 patients who had undergone HDR IVIU brachytherapy were included in the study. Pain was assessed with a visual analogue scale of 0 to 10 at the time of insertion of the central tandem, mid-way of packing, at and after removal of applicator and on the next day. Patients were given Tab. Diazepam 5mg orally the night before the procedure. A vaginal pack with 2% lignocaine jelly was used for local anaesthesia 15 min before staring of the procedure. Patients were put under conscious sedation and analgesia with Injection Paracetamol 1000mg IV infusion over 15 mins followed by Inj. Pentazocin 30 mg IM after pre-treating with inj. Metoclopramide 10 mg slow IV infusion. During the procedure the patient received Inj. Midazolam IV short push as adjudged by the operating surgeon. The neucleotron HDR brachytherapy applicator with a 15;central tandem and semi-ovoid or ovoid was used for the procedure. Orthogonal X-rays were taken and planning was done using the PLATO system, with the prescribed dose to point-A being 7Gy. Results: Between May 2014 and August 2014 a total of 33 patients who had undergone 99 procedures were included in the study. The age ranged from 32-74yrs (median 51yrs). The total amount of Midazolam required for the procedure ranged from 0 mg to 8mg (median 4mg). The Median pain score for the entire duration of procedure was 2.5. The median pain score for tandem insertion was 2(0-5), mid packing 5(1-10), at removal of applicator 3(1-5), and after removal was 0.4(0-2).The average discharge time was 20 min post completion of procedure. The average pain score was higher in the first procedure than the later ones (3.5 Vs.2). The pain score obtained after 24 hours was 0.2 (range 0-2). The mean difference of distance between the ovoid and the central tandem was 0.5 cm (range 0-0.8 cm). The mean dose to bladder point was 5.1 Gy and rectal point was 4.8 Gy. Discussion: A meaningful pain control that not only permitted the procedure but also gave the patients an uneventful post procedure period. In most of the patients the obtained geometry as documented by position of the applicators as found in orthogonal X rays and calculated bladder and rectal dose, were found to be satisfactory after optimization. Conclusion: Good pain control with adequate relaxation can be achieved with help of conscious sedation and local anesthesia at time of orthogonal X-ray based HDR brachytherapy.

A prospective comparative trial to study the role of aprepitant in prevention of nausea and vomiting associated with concurrent chemoradiation in carcinoma cervix

Tanmoy Ghosh, Joydeep Basu, Santanu Pal, Shyamsundar Adhikary, Bidyut Mondal, Pratyusha Mukherjee

E-mail: [email protected]

Introduction: Both Cisplatin and pelvic radiotherapy used in concurrent chemoradiation treatment of carcinoma cervix induce significant nausea and vomiting, which may introduce treatment breaks [1,2]. So we have tried to formulate an appropriate combination of anti-emetics for our patients to tackle this nausea and vomiting and thereby reduce the incidences of treatment breaks and prolonged treatment time. Aims and Objectives: This single institutional prospective comparative study was conducted to compare the grades of nausea and vomiting and total treatment time between patients receiving Aprepitant and those not receiving it. Materials and Methods: Between May 2013 and July 2014, 113 patients of loco-regionally advanced carcinoma cervix (stages IIB to IVA) were enrolled. All the patients were initially treated with external beam radiotherapy to whole pelvis using conventional AP - PA pelvic portal in conventional fractionation up to a total dose of 50 Gy in 25 fractions delivered by Telecobalt unit, Theratron 780C. Inj. Cisplatin was given concurrently at a dose of 40 mg/m2 of body surface area every week during radiation for 5 weeks. Patients in the study arm (n=56) received dexamethasone 8mg and granisetron 3mg injections and oral aprepitant 125mg capsule on the day of chemotherapy and 80mg capsule once daily on two subsequent days [3]. Patients in the control arm (n=57) received injection granisetron and dexamethasone in the same doses on the days of chemotherapy. Patients in both arms received oral granisetron 2 mg one hour before EBRT daily [4]. After External beam radiotherapy all patients received intracavitary brachytherapy (HDR 7 Gy per fraction to a total dose of 21 Gy). Patients were followed up weekly to assess grade of nausea and vomiting from the start of treatment to two weeks after completion of chemoradiation using CTCAE criteria version 4.0 [5]. We also kept a note of total time required by the patients in both arms to complete the course of External beam radiotherapy. Data analysis was done by SPSS version 20.0 software. Results: 5 patients discontinued treatment midway due to unknown reasons, 3 from the study arm and 6 from the control arm could not complete 5 weeks of concurrent cisplatin and hence excluded from the study. Incidence of Grade 2 or more nausea in the study arm was 18/49(36.7%) and that in the control arm was 29/50(58.0%) (p-value - 0.034). Incidence of Grade 2 or more vomiting in the study arm was 7/49(14.3%) and that in the control arm was 18/50(36.0%) (p-value - 0.013). Both these differences were statistically significant. There was delay in treatment time among 4/49(8.2%) patients in the study arm and 7/50(14%) patients in the control arm due to nausea and vomiting (p-value - 0.356). Conclusion: Our analysis reveals that carcinoma cervix patients receiving combination of aprepitant, dexamethasone and granisetron have lesser incidence of nausea and vomiting than the patients who did not receive aprepitant and the differences were statistically significant. Though not significant, there is a trend towards increased treatment delay among patients not receiving aprepitant.

Carcinoma cervix with with brain metastasis. A case series

Mishra Tanushree, Routroy B, Mekap H. S, Padhi S, Panda N, Senapati S. N

Department of Radiation Oncology, AH RegionalCancerCentre, Cuttack. E-mail: [email protected]

Introduction: Gynecological Malignancy is the most common malignancy in women in Indian scenario. It usually spreads to locoregional sites. Distant failure does occur to paraaortic lymph node, lungs, liver, bone and skin. Only 0.5 to 1.2% of cases of carcinoma cervix metastases to brain(1). Materials and methods: During a period of one year from july 2013 to july 2014, total 532 patients of carcinoma cervix patients were received treatment in our institution. Out of which four cases received palliative RT to brain for brain metastasis. Out of four patients, two patients with Carcinoma Cervix Stage IIIB, two patients with Ca Cervix post op (Inappropriate Hystrectomy). These patients were offered radical concurrent chemoirradiation after diagnosis. Studies showed carcinoma cervix patients usually presented with brain metastasis after an average period of 4yrs (2). Usual presentation of brain metastasis in studies showed nausea, vomiting and headache.(3) Result: The average time of diagnosis of brain metastasis after initial diagnosis was 3 years. These patients presented with nausea, vomiting and headache due to raised intracranial pressure. All the patients were diagnosed with CT Scan imaging. The site of metastases in all four patients were supratentorial lesions. All the patients received whole brain Radiotherapy in palliative intent. Radiation dose was 30Gy in 10 fractions, 300cGy/fraction, 5 days a week over 2 weeks with best supportive care. Conclusion : Brain metastasis in gynecological malignancies is uncommon in patients with compare to lungs, breast, liver, lymphoma. It usually occur in patient with longer survival. Brain metastasis are more commonly seen with poorly differentiated carcinoma.Usually the mode of spread from gynecological malignancy to brain is hematogenous. Treatment of brain metastasis was either radiation only or surgery with postoperative radiotherapy along with best supportive cares. Physicians should pay more attention to neurological deficit and imaging for early diagnosis. Despite multimodality treatment quality of life and prognosis is poor. Regular follow up of cancer survivors are required to diagnose metastasis and early intervention.

Dosimetric analysis of high dose rate (HDR) intracavitary brachytherapy in carcinoma cervix using Cobalt-60 source

Upendra Nandwana, Narendra K. Rathore, Arvind K. Shukla, P. Sathish Kumar, Sunnia Gupta, Kiran Intodia

Ravindra Nath Tagore Medical College and Associated Group of Hospitals, Udaipur (Correspond). E-mail: [email protected]


Introduction : Brachytherapy is a form of radiotherapy in which cancerous tumor is treated by irradiation from a short distance. The radioactive source is placed directly inside or close to the tumor site. It is the cornerstone for increasing the control rates and improving the survival rate in carcinoma cervix because high doses 75-85Gy cannot be given by EBRT alone. The rapid dose fall rate as we move away from the source leads to decrease toxicity to surrounding normal tissue and delivers maximum dose to the target volume. The most common source used worldwide is Ir-192 due to its high specific activity and rapid dose fall rate. The half-life of Ir-192 being 73.8 days, the source has to be replaced every three to four months. As compared to Ir-192, the half-life of Co-60 source is 5.26 yrs. and is available in miniaturized form and with comparable geometric and Dosimetric properties as Ir-192.It is not required to change the source frequently so it is very logistical and economical in low resources settings like our country to use Co-60 for HDR brachytherapy. Aims and Objectives : To analysis the Dosimetric distribution of doses delivered to point A, bladder and rectal reference points as per ICRU 38 report using Cobalt-60 HDR brachytherapy. Materials and Methods: This study was conducted retrospectively on 100 applications of ICRT in carcinoma cervix patients with stage I to IIIB from June 2012 to June 2013. Brachytherapy is done under general anaesthesia after getting pre-anaesthetic clearance in lithotomy position. A Foley's catheter is inserted into the urinary bladder and the balloon inflated with 7 cc of diluted Urograffin dye to identify the bladder reference points. Fletcher suite applicators are used for brachytherapy in all the patients. The suitable Tandem and Ovoids were placed as per the geometry of the patient. The vagina is packed with gauze to further displace the bladder anteriorly and the rectum posteriorly to minimize the dose to these organs and to immobilize the applicators. An additional rectal marker is placed in rectum to identify the ICRU rectum points. The orthogonal X-rays were taken using C-Arm. The treatment planning was done with BEBIG HDR plus 2.5 treatment planning system. Dose prescription is specified to point A and bladder and rectum reference points were placed as per the ICRU 38 report. The height (dh), width (dw), and thickness (dt) of the pear-shaped reference volume was also measured from the oblique frontal and oblique sagittal planes. The reference volume is approximated by (dh x dw x dt) cm3. Results and Conclusion: The doses to the ICRU bladder and rectum reference points, pear shaped reference volume (dh x dw x dt) cm3 were compared with data from literature and found within limits.


High ligation of inferior mesenteric artery in left colonic and rectal cancers: Lymph node yield and survival benefit

Akhil Kapoor, Jitendra Nangal 1 , Rajendra Bothra 1 , Raj Kumar Nirban, Sitaram Maharia, Harvindra Singh Kumar

Department of Radiation Oncology, 1 Department of Surgical Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Hospital, Bikaner, Rajasthan 334003. E-mail: [email protected]

Background: During surgery for colorectal cancer, the inferior mesenteric artery (IMA) may be ligated either directly at the origin of the IMA from the aorta (high ligation) or at a point just below the origin of the left colic artery (low ligation). The high ligation technique allows en bloc removal of additional nodes at and around the origin of the IMA; however its advantage remains debatable. Methods and Materials: 60 patients of left colonic and rectal cancer undergoing elective curative surgery from January 2007 to December 2008 were selected for this observational study. High or low ligation of the IMA was decided randomly depending on surgeon's choice. The resected lymph nodes were grouped into three levels; along the bowel wall (D1), along IMA below left colic (D2) and along the IMA and its root (D3). Statistical analysis was performed with SPSS version 20.0. Results: D2 level was involved pathologically in 20 (33.3%) and D3 in 6 out of 44 (13.6%) patients. The median nodal yield with high and low ligation were 33 and 25, respectively (p=0.048). 5 year survival for patients with D2 positive nodes was 35 percent while no patient with D3 positive node could survive till five years. Median overall survival for high ligation was 62 months versus 42 months for low ligation (p=0.190). Conclusion: High ligation of the IMA for rectal and left colonic cancers can improve lymph node yield, thus facilitating accurate tumor staging and thus better disease prognostication but the survival benefit is not significant.

Adeno carcinoma rectum extending to the gluteal space through peri anal fistula; A rare case report

Arun Vasudevan 1 , Roshni Sivasevan 1 , Paul Augustine 2 , Shubhanshu Gupta 2 , Anila Ravendran Nair 3 , Lijeesh Lonappan 1

Department of Radiation Oncology 1 ,Surgical Oncology 2 , and Pathology 3 , Regional Cancer Centre Trivandrum, E-mail: [email protected]


Colorectal cancer remains a major health problem worldwide. Carcinoma rectum often presents as painless bleeding per rectum, altered bowel habits, abdominal discomfort, and rarely as intestinal obstruction or bowel perforation. Abdomino perineal resection has been considered the gold standard for surgical resection of distal rectal cancer and includes removal of the primary tumor along with a complete proctectomy, leading to a permanent colostomy (1). This is the case of a seventy one year old male with history of long standing fistula in ano who presented to Regional Cancer Centre Thiruvananthapuram with a gluteal swelling. On examination he was found to have a 15*10 cm indurated mass in the right gluteal region with a 2*2cm ulcer over the summit and a linear non healed scar extending upto the anal verge.A CT scan of the abdomen and pelvis done showed wall thickening of the colonic loops involving the lower rectum,anal canal and extending to right gluteal region with a 12*9.6cm lobulated mass with curvilinear calcification,involving the gluteus maximus muscle, ishiorectal fossa and perineal skin. He was managed by radical Abdomino Perineal Resection.The histopathology reported as mucinous adeno carcinoma involving the anal mucosa and peri anal skin and gluteal muscles. The patient is being planned for adjuvant chemoradiotherapy. So far only one case of adeno carcinoma rectum extending to the gluteal space through peri anal fistula has been reported in the literature.

Assessment of treatment outcome of locally advanced carcinoma rectum patients treated with preoperative chemoradiation: A single institution study.

Roshni Sivasevan, Arun Vasudevan, C. D. Sivanandan, Sajeed A, P. G. Jayaprakash, Lijeesh A. L

Division of Radiation Oncology, Regional Cancer Centre Trivandrum, E-mail: [email protected]

Introduction : Locally advanced rectal cancer is usually treated with preoperative chemoradiation followed by surgery. Patients with no microscopic residual disease after pre op chemo radiotherapy are termed pathologic complete responders. Aims and Objectives : To find the difference in disease free survival and overall survival between the patients who attained pathologic complete response and those with partial response to pre operative chemo-radiotherapy for locally advanced carcinoma rectum and to identify the prognostic factors determining the outcome. Materials and Methods : One hundred and fourteen patients treated at Regional Cancer Centre Trivandrum with preoperative chemo radiotherapy for carcinoma rectum during the period 2008-2012 were included in the study. The median follow up period is 37 months. The patients were followed up until July 2014. Observation and Results: Among the 114 patients included in the analysis,74 were males and 40 were females.The histological subtypes among the patients analysed were Well differentiated adeno(48%),Moderately differentiated adeno(40%),Poorly differentiated adeno(8%) and carcinoma of other hitologies(4%).Six percentage of the patients in our series had history of intestinal obstruction before starting the treatment. The dose of the pre op RT was 45-50.4 Gy given at 1.8-2 Gy per fraction along with concurrent chemotherapy. Ninety four percentage of the patients had tumor down staging after pre op chemo RT. Twenty patients (14%) had a complete response to preop Chemo RT.Eleven patients(12%) among the partial responders had disease reccurence but only one patient (5%) among those who attained complete response had disease reccurence.The three year disease free survival probability is 94% for those with complete response and 87% for those with partial response.The three year overall survival probability is 100% for those with complete response and 89% for those with partial response. Conclusion : The complete responders to preop chemo radiotherapy have definitely a better outcome compared to partial responders with respect to disease free survival and overall survival.

Portal vein tumor thrombus irradiation: A bridge to successful liver transplant

Ashu Abhishek

Associate Consultant Radiation Oncology - Medanta the Medicity, Gurgaon .E-mail: [email protected]

Introduction: Liver transplant remains the treatment of choice for Hepatocellular carcinoma (HCC). Presence of portal vein tumor thrombus (PVTT) is one of the commonest reasons for inoperability and is considered to be associated with poor survival. Such medically inoperable cases are offered alternative treatments like Radio frequency ablation (RFA), Trans arterial chemo-embolization (TACE) and conventional external beam radiotherapy (EBRT). Owing to documentation of poor liver tolerance to radiation from conventional techniques in past, the role of EBRT has not been explored adequately. Stereotactic body radiotherapy (SBRT) is an emerging modality of cancer treatment, promising better outcomes for selected advanced HCC. Methods: We reveiewed 26 of our HCC cases treated for PVTT since April 2011. SBRT planning with breathing motion management(either on linac with Automatic breathing co-ordinator or Cyberknife with Synchrony respiratory tracking) was used in all cases. Plan details, imaging response, transplant status and survival as per last follow up in these cases were reviewed for analysis. Results: Out of 26 cases, 10 were treated till december 2013 (pre 2014 cases) and rest 16 were treated till July 2014 (2014 cases). Adequate follow up was available for pre 2014 cases while most cases of 2014 are still awaiting evaluation. Intent of treatment was curative in 5/10 and palliative in 5/10 cases of pre 2014, while in 2014 cases, 15/16 cases were treated with curative intent. All these cases were with advanced stage (BCLC - C) and Child Pugh A or B. For pre 2014 cases, out of curative cases (5), 2 (40%) underwent successful transplantation and are living a healthy life. 4 out of 5 curative cases are still surviving with follow up ranging from 6 - 18 months post treatment. Necrosis and partial recanalization of vessels were seen at 2-4 months post treatment. Mean survival of 3 out of 10 cases that expired was 11.3 months (range 10-12 months). Treatment was well tolerated and no grade 3 or more toxicity was reported. Even for palliative cases there was adequate pain control. For the 16 cases treated in 2014, 1 case underwent successful transplantation, 10 (63%) are stable and awaiting trasplant evaluation, 5 were detected of systemic metastases on follow up, out of which 4 (25%) expired. Conclusion: In past all advanced HCC cases with PVTT were considered in-operable and referred for palliative or alternative treatments only. In our series, 3/20 curative cases (15 %) underwent successful liver transplant till date with possibility of more to follow among 11/20 curative cases (55%), which are still awaiting response assessment. By making transplant feasible in previously inoperable cases, SBRT significantly promises to improves the outcomes. With encouraging support from evolving literature, utilization of innovative technologies and improvement in radiotherapy skills, SBRT has a potential to become an integral part of multidisciplinary treatment approach towards inoperable HCC, realizing the unmet need of adequate local control.

A retrospective study to compare the response of radical external beam radiotherapy with and without HDR-Brachytherapy in patients of carcinoma middle third esophagus

Jyoti Poddar

E-mail: [email protected]

Aim of the Study: Retrospective analysis of clinical response, disease free survival and quality of life in Carcinoma esophagus patients treated in 2011-2013 by different radiotherapy fractionation schedules with and without HDR-Brachytherapy. Methods and Materials: 60 Patients of histopathologically proven, Carcinoma middle third Esophagus, of median age 53 years, with pre-treatment dysphagia grade II/III, were included in the study in three arms. Patients who were not fit for concurrent chemotherapy because of comorbid conditions were included in the study.

Inclusion criteria

(1) FOR ARM 1 and 2 (2)For ARM 3

Tumour size </= 5cm Tumour size > 5cm

KPS Score > 60 KPS Score <60

Weight > 40 kg Weight < 40 kg and not fit for chemotherapy

Not fit for chemotherapy

Methods: ARM 1:Patients received External Radiotherapy, 60GRAY/30#@ 2GY/# ARM 2: Patients received external radiotherapy 40Gray/20# @2Gy/# followed by response assessment after two to three weeks then Two fractions of Intraluminal brachytherapy(ILRT) (7.5gy each at 1 cm depth). ARM 3: Patients received EBRT 30GRAY/10# @3GY/#,followed by response evaluation after two- three weeks then two fractions of ILRT(7.5gy at 1cm depth). Results and Conclusion: The local control, disease free survival, symptomatic relief was more in the ILRT arm as compared to external beam only arm, with acceptable complications.

Holding out hope: Delayed response to neoadjuvant chemoradiation in locally advanced carcinoma rectum


E-mail: [email protected]

Background: Neoadjuvant chemoradiation (NACTRT) followed by definitive surgery is the established standard of care for locally advanced carcinoma rectum. Radiotherapy to a dose of 50.4 Gray delivered in 28# (or biologically equivalent dose) with concurrent oral capecitabine 850 mg/m2 is the most common neoadjuvant regimen for patients presenting with unresectable disease, and reassessment for surgery is done with an MRI scan 6-8 weeks after completion of NACTRT. Unfortunately the prognosis is considered bleak for poor responders who are still deemed inoperable. Many oncologists advocate waiting upto 12 weeks for a response assessment MRI before declaring the disease unresectable, citing a possibility of delayed tumour response to radiotherapy. But this waiting period may be a lost opportunity for better tumour control. Intensive concurrent chemotherapy with intravenous 5-fluorouracil and oxaliplatin has also been tried. However majority of locally advanced carcinoma rectum patients seen in our institute show poor general condition and nutritional status, and are unlikely to withstand such intensive regimens. Rather than aiming at palliation, we still held out hope for a curative resection in these patients by continuing with chemotherapy post NACTRT. Materials and Methods: Patients with locally advanced carcinoma rectum assessed to have unresectable disease at presentation received neoadjuvant radiation to a dose of 50 Gray in 2 Gray daily fractions with concurrent capecitabine chemotherapy 850 mg/m2. A follow up MRI was done 6 weeks after completion of NACTRT and assessed in a joint gastroenterooncology meeting. Those with persisting unresectable local disease were planned for 4-6 cycles of chemotherapy based on patient's performance status, followed by reassessment imaging for resectability. We analysed the patients who went on to have a successful surgical resection with this extended chemotherapy regimen. Results: 34 patients of locally advanced carcinoma rectum received extended neoadjuvant chemotherapy in last 12 months. At the time of submission of this abstract, 13 patients had undergone successful surgical resection following extended neoadjuvant chemoradiation, with 8 patients further scheduled for reassessment after followup imaging. 9 patients were found to be inoperable in follow up imaging and continued with maintenance chemotherapy. 2 patients were lost to follow-up while 2 patient was taken up for trial resection which was abandoned. Majority of these patients showed good response in both nodal status and tumour size. 3 patients had signet ring morphology in histopathological examination, which has traditionally been associated with grim prognosis. Conclusion: Achieving margin negative resection in these patients is an encouraging starting point for further research in this subset. Whether this continued decrease in primary tumour volume can be attributed to delayed response to radiotherapy or addition of further chemotherapy, or both, is yet to be ascertained. Hence for patients with advanced local disease not yet in palliative stage, further intensive chemotherapy with clinicoradiological follow-up should be done to facilitate successful surgical resection.

Prospective study on quality of life in preoperative and postoperative chemoradiation in carcinoma rectum

Mukul Roy

Jaslok hospital and research centre , Mumbai. E-mail: [email protected]

Background: Colo-rectal cancer is the third most common cancer worldwide and is a major cause of morbidity and mortality throughout the world. Treatment efficacy in oncology should also be judged by effect on quantity and quality of life. Hence Quality of Life [QOL] in rectal cancer patients, who suffer reduced bowel and sexual function is very important. We report our study on QOL in patients receiving preoperative and postoperative chemoradiation in Rectal Cancer using cancer specific instrument, European Organisation for Research and Treatment of Cancer [EORTC] QLQ C-30 and EORTC QLQ CR-29. Analysis was done for the period of August 2009 to April 2012. Materials and Methods : QOL was analysed in 20 preoperative and 18 postoperative locally advanced stage 1(11.1%), 2(16.7%) and 3(80.2%) rectal cancer patients receiving neoadjuvant and adjuvant radiation respectively. EORTC QLQ C-30 comprising of multi item scales and single item measures and EORTC QLQ CR-29 comprising of colorectal cancer specific symptom scales and function scales were analysed. Eligible patients were asked to fill up the questionnaires at the hospital after completion of radiation. Results : This prospective study was carried out in 38 patients over a period of 30 months. The mean age was 41.05 yrs (range: 20-60yrs) in preoperative group and 50.56 yrs in postoperative group (range: 23-74 yrs). There were 16 [80%] males and 4[20%] females in the preoperative arm and 12 [66.7%] males and 6 [33.3%] females in the postoperative arm. In the QLQ C-30, the global quality of life scores representing overall health and quality of life of patients were similar in both the cohorts. In the QLQ CR-29, no significant difference was seen in functional scales in the two cohorts. In the symptom scales, the median score for blood and mucus in preoperative group was found to be 16.67 (range 0 -33.3) and in the postoperative arm it was 0 (range:0-33.3), (p=0.002). The median score for taste alteration in the preoperative arm was 0 (range: 0-66.67) and in the postoperative arm it was 0 (range: 0-33.3) (p=0.047). In addition the median score for flatulence in the preoperative arm was 33.3 (range: 0-66.67) and in the postoperative arm it was 0 (range: 0-33.3) (p=0.0001). The median score for fecal incontinence in the preoperative group was 0 (range: 0-66.67) and in the postoperative arm it was found to be 0 with (range: 0-33.3) (p=0.006). There was no statistically significant difference seen in the other function and symptom scales including sexual function both in men and women. Conclusion : Preoperative chemo-radiation in carcinoma rectum is comparatively associated with inferior Quality of Living.

A retrospective demographic analysis of cancer esophagus patients in a regional cancer institute of North-East India

Partha Pratim Medhi, M. Bhattacharyya, A.K. Kalita, V. Jagtap,

B.B. Borthakur.

2 nd yr PGT, Dr. B. Borooah Cancer Institute, Guwahati E-mail: [email protected]

Introduction: Esophageal cancer rate is particularly high in North East India. As per PBCR, Kamrup Urban District (Guwahati) report 2009-2011, it ranks first among males and second among females -both in incidence and mortality. Even with multimodality treatment survival remains dismal in this group of patients. Aims and Objectives : Retrospective analysis of Cancer Esophagus patients at Dr. B. Borooah Cancer Institute, Guwahati, with regards to Epidemiology, Pattern of Treatment, Follow-up and Response to treatment. Methods: Retrospective data of esophageal cancer patients diagnosed and treated between January 2009 to January 2010 at our institute was evaluated. Patients were stratified according to their age, sex, general condition, level of growth and histopathological types. Number of treatment dropouts and the actual number completing treatment were evaluated and further stratified into the type of treatment received. The average waiting period for radiotherapy was also calculated and the shift of treatment modality from radical to palliative during this period was evaluated. Patients who completed at least 6months follow-up and agreed to undergo UGI Endoscopy or CT Scan or both for response assessment were included in the analysis for follow-up. Results: Out of 431 patients evaluated, 307 (71%) were males, maximum were in the age group 51-60 yrs (34%), squamous carcinoma being dominant histopathology (96%), most in the middle third esophagus (54%) and 49% had good general condition at the time of diagnosis (WHO PS 0-1). Staging was available in 126 cases only of which 85% (107) were Stage III/IV. 367 patients(85%) were planned for radical treatment and rest 64 patients(15%) for palliative. However, only 297(69%) of the above actually started treatment and the rest either did not turn up(27%) or could not be started treatment due to deteriorating general condition(4%). The mean waiting period was found to be 23days (range 7-55 days) and the number of patients who had to be shifted from radical to palliative treatment following the waiting period was 36(8.4%). Among the 297, 51(17%) patients either discontinued or could not complete their treatment. Thus 246 patients, which is 60% of the initially diagnosed patients, completed treatment. 111(45%) received radical RT alone, 41(17%) received concurrent chemoradiation, 13(5%) received neoadjuvant chemotherapy followed by concurrent chemoradiation and 61(25%) received palliative radiotherapy. 20 patients had undergone surgery and received adjuvant treatment- 14(6%) received adjuvant radiation while 6(2%) received adjuvant chemoradiation. On follow-up, 51(28%)were lost to follow-up while 62(33%) had either less than 6 months follow-up or refused to undergo UGI endoscopy or CT Scan for response evaluation. Thus in 72 patients(39%) in whom response evaluation was done till 6 months, the CR rate was 58% with Radical RT, 50% with concurrent chemoradiation, 60% with neoadjuvant chemotherapy followed by concurrent chemoradiation, 75% with adjuvant RT and 100% with adjuvant chemoradiation. Conclusion: Esophageal cancer is a leading cause of mortality in our region. Due to resource limitations most of the patients cannot be staged and are unable to get treatment on time. For improving outcome proper staging and treatment utilization with available resources is needed.

Is neoadjuvant chemoradiation a gold standard for carcinoma rectum? A comprehensive analysis of outcomes and prognostic factors a tertiary care centre from India

Rohit Mahajan

Senior Resident, Department of Radiotherapy and Oncology,

PGIMER,Chandigarh. E-mail: [email protected]

Introduction: The management of rectal cancer has changed over the years with an emphasis on neoadjuvant chemoradiation(NACRT) followed by surgery. Multiple western studies had shown better local control and sphincter preservation with preoperative chemoradiation in carcinoma rectum. However, data from India is lacking. Thus, we conducted the retrospective study in our institution to show the impact of neoadjuvant chemoradiation on sphincter preservation in carcinoma rectum. Aims: Down staging, local control and sphincter preservation in carcinoma rectum. Materials and Methods: The retrospective study was conducted in our institution which enrolled 126 patients with histologically confirmed diagnosis of carcinoma rectum(stage I-III) treated with neoadjuvant chemoradiation followed by surgery from Jan2009-Dec2013. Total dose of 45Gy in 25 fractions over 5weeks was delivered using 3D-CRT technique. All patients received 5-FU/LV weekly with 5-FU 325mg/m2 and LV 30mg/m2 on D1 of every week. 4-8weeks after completion of NACRT, patients were assessed for disease response, sphinchter preservation possibility and resectability of tumour. Pathologic assessment of response was seen in the resected tumours. Impact of different prognostic factors on clinical outcome was analysed. Results: Median age of presentation was 48 years (range 18-77 years). Out of 126 patients, 86 were males and 40 were females. Most of the patients presented with bleeding per rectum (94.4%). Mean duration of symptoms was 9 months. Most of the patients presented with T3 disease (50.8%) followed by T2 (43.6%) and T4 (5.6%). Out of 126 patients, 83(65.9%) had N1 disease and 10(7.9%) had N2 disease. Lymph nodes were not involved in 33(26.2%). Most of our patients presented with stage III disease (73.8%). Mean distance of tumor was 4.2cm from anal verge. All the patients had histologically proven adenocarcinoma with signet ring cell and mucinous variety seen in 9.5% and 7.1% respectively. Most of the patients had moderately differentiated adenocarcinoma (43.7%). Well differentiated and poorly differentiated variety were seen in 6 and 5 patients respectively. With NACRT 82(65.07%) patients out of 126 were down staged and were amenable for surgery. Among 126 patients, 63(50.0%) underwent LAR(low anterior resection) and thus 50% of the patients had sphincter preserved and 53(42.1%) underwent APR(abdomino-perineal resection). Pathological complete response was seen in 14(11.9%) patients. Local control was seen in 60% of the patients. Patients with Hb >12gm//dl and tumours more than 3 cm from anal verge showed better sphincter preservation(p=0.018,p=0.011 respectively). Though grade of the tumour did not have impact on sphincter preservation however survival was improved in low grade tumours. Type of histology, lymph node positivity, pre op CEA did not have any significant impact on outcome. Conclusion: This study represents the largest Indian experience with standard neoadjuvant chemoradiation followed by surgery in rectal cancer. Down staging of tumor, improved local control and increased sphincter preservation was seen in our study. Pretreatment Hemoglobin status, distance from anal verge and grade of the tumour came out to be the important prognostic factors.

Outcome of concurrent chemoradiation in carcinoma anal canal

Arun Sankar S, Seetha Mohandas, Roshni S, Sajeed A, Lijeesh A. L, C. D. Sivanandan

Division of Radiation Oncology, Regional Cancer Centre, Thiruvananthapuram. E-mail: [email protected]

Cancers of the anal region account for 1% to 2% of all large bowel cancers. Majority of these patients (75% to 80%) have squamous cell carcinomas. 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 Objective: To analyze the clinical profile and treatment outcomes of patients with carcinoma anal canal treated at RCC Trivandrum from 01/01/2010 to 31/12/2013. Materials and Methods: Thirty patients with histology proven carcinoma anal canal was treated from 2010 to 2013 at Regional Cancer Centre, Trivandrum. Data was retrieved from case sheets using a structured proforma. Patients were followed up till august 2014. Results: There were twenty six cases of squamous cell carcinoma of which four cases were metastatic at presentation, three cases were malignant melanoma and one was neuroendocrine carcinoma. Male/female ratio is 1.1: 1. Among patients with squamous cell carcinoma seven (31%) patients had stage II, eight (36%) patients had stage IIIA, seven (31%) patients had stage IIIB and four (18%) patients had stage IV disease at presentation. Eleven patients (50%) had palpable inguinal nodes at presentation and seven (31%) patients underwent FNAC, in that four (18%) was positive for malignancy. The twenty two patients with non-metastatic squamous cell carcinoma underwent radical concurrent chemoradiation. All patients received total radiation dose of more than 50 Gray (mean total dose is 54.07 Gray) and 17 (77.27%) patients received concurrent chemotherapy with 5-FU and Mitomycin. All patients could complete planned radiation treatment and 3(17.64%) patients did not receive second cycle of chemotherapy. Locoregional control at first follow up (1 to 2 months) was 31.81%. Complete response at 6 months was 68.18%. Out of seven (31.82%) patients who had residual disease at 6 months, one patient (4%) underwent chemotherapy followed by salvage surgery with abdomino-perineal resection and three (13.63%) patients took chemotherapy. Fifteen (68.18%) patients are alive without disease, four (18.18%) patients are alive with disease and three (13.63%) patients expired due to disease. The median follow up is 20.5 months. The loco regional control at 2 years is 68.18%. The survival probability at 2 years is 86.4%. Conclusion: The most common histology of carcinoma anal canal was squamous cell carcinoma and the most common stage of presentation was stage IIIA. The twenty two patients with non-metastatic squamous cell carcinoma underwent radical concurrent chemo radiation. Fifteen patients (68.18%) achieved loco regional control. The median follow up is 20.5 months. The survival probability at 2 years is 86.4%.

Validation of a palliative radiotherapy regime in carcinoma esophagus in the clinic: evaluation of efficacy, duration and economics

Shirley Lewis, Sarbani Ghosh Laskar, J. P. Agarwal, Shagun Mishra, Shaesta Mehta, Prachi Patil

Tata Memorial Centre, Mumbai. E-mail: [email protected]

Introduction: Palliation of dysphagia is a challenge in advanced esophageal cancer. (1)External beam radiotherapy (EBRT) in combination with intraluminal brachytherapy (ILBT) has shown good and sustained symptom relief. (2) The Phase III International Atomic Energy Agency trial by Rosenblatt et al has shown significant improvement in dysphagia relief experience and symptom scores with addition of ILBT to EBRT.(3) The aim of the present study was to evaluate retrospectively the efficacy ofcombined use of ILBT and EBRT in terms of extent and duration of symptom relief and its economics in terms of need for any other interventions/hospitalizations after palliative RT. Methods: We reviewed the records of all patients with advanced/metastatic carcinoma esophagus who were referred for palliative radiotherapy from January 2008 to April 2014.The medical records of 148 patients were screened and 74 were found eligible for the analysis. All patients received palliative ILBT, two fractions of 8 Gy each followed by EBRT to a dose of 30Gy in 10Fractions (#) or 20Gy in 5#. Patients were assessed for the symptoms scores of dysphagia, odynophagia, regurgitation and chest pain at baseline, after 1stILBT, after 2nd ILBT, 3 months after completion of EBRT and at the time of last contact. Weight was also recorded at baseline, at completion of ILBT and at 3 months after completion of EBRT. Results: For a median follow-up of 6 months (1-42 months), the median OS was 282 days (95% CI 205 -358) with a 1 year OS of 20%. The scores for dysphagiasignificantly improved after completion of Ist ILBT (p= 0.000) and 2nd ILBT (0.000). There was significant improvement in dysphagia scores at 3 months after EBRT compared to ILBT (p=0.02). Though there was improvement in odynophagia regurgitation and pain scores after ILBT and EBRT, it was not statistically significant. In comparison to baseline, there was significant improvement in weight after completion of ILBT (p= 0.001) and at 3 months after completion of EBRT (p= 0.00). The duration of dysphagia relief was a median of 114 days (Mean 163 days, Range 19-1172). At the time of last contact, 41.8% patient had significant improvement or same dysphagia scores compared to after completion of treatment (p=0.02). Thirty one (41.9%) patients required nasogastric (NGT) insertions and 14 (18.9%) needed hospitalization for supportive care after completion of treatment. 24 (32.4%) had grade 4 complications in the form of stricture 20(27%) and fistula 4 (5.4%), 20 of whom required active intervention. Six patients (8.1%) received palliative chemotherapy in view of symptomatic progressive disease. Conclusion: Palliative radiotherapy is an effective alternative for palliation of dysphagia in patients with advanced carcinoma of esophagus. The improvement in symptom scores was evident and sustained. The results of this clinical audit were comparable with those from the trial setting.

The correlation between computerized tomographic (CT) and endo anal ultrasonographic (EAUS) stage with the pathological grading of rectal carcinoma

Kasun Ratnayake

E-mail: [email protected]

Introduction: Colorectal cancer is the 4th commonest malignancy in Sri Lanka among males. Stage of the disease at the time of diagnosis is the single most important predictor of survival in colorectal malignancy and management decisions are mainly dependent on staging. Aims and Objectives: This study aims at identifying the relationship between Computerized Tomographic (CT) and ultrasonographic radiological staging and the pathological grading of rectal neoplasms which led to discordant stage grouping on CT and Endo Anal Ultra Sonographic (EAUS) imaging studies. Materials and Methods: Sequential data was collected from December 2005 to February 2013 from patients treated at the University Surgical Unit of the National Hospital of Sri Lanka who were confirmed to have a rectal neoplasm on colonoscopy. The neoplasms were first staged using CT and subsequently by EAUS with reference to the TNM classification 7. The concordance or the discordance of the group staging between the two investigations were correlated with the pathological grading of the tumour which was reported on the initial colonoscopic biopsy. Results: The histological diagnosis was adenocarcinoma in all 15 patients with full array of investigations. Five (33%) had concordant group staging. The tumour was well differentiated in 4 (80%) of these patients. Ten (66%) patients had discordant group staging of which 9 (90%) were moderate to poorly differentiated tumours and only 1 (10%) was well differentiated. This correlation was statistically significant (Fisher's exact test, p=0.017). Conclusion: Discordance in staging of colorectal neoplasms between CT and EAUS was statistically significant among patients who had moderate to poorly differentiated tumours. Therefore, performing both CT and EAUS for staging is advisable in patients with biopsy diagnosis as moderate to poorly differentiated tumours before taking management decisions.

An Institutional experience of radiotherapy in esophageal cancers: Retrospective analysis

Kothwal Syed Akram

E-mail: [email protected]

Introduction: Esophageal cancer is a highly aggressive neoplasm. It is the 7th most common malignancy. In the Western world, esophageal adenocarcinoma has surpassed in incidence of squamous cell carcinoma. SCC is the most common type of esophageal cancer in the Indian subcontinent, located with a predilection in the distal third. Adenocarcinoma is relatively uncommon and affects more frequently men younger than 40. Aims and Objectives: Retrospective analysis of demographic data and survival in carcinoma esophagus. Materials and Methods : A total of 83 patients with the pathological diagnosis of carcinoma esophagus admitted for radiotherapy (RT) at NIMS, Hyderabad from January 2008 to December 2013 were retrospectively analyzed from treatment and follow up records. Statistical analysis was done by Kaplan Meir Method using SPSS 22 software. Results: The median age was 56 years (range 30 to 84) with M: F ratio of 1.59:1. Histopathologically Squamous cell Ca 88.75% (71/80), Adenocarcinoma 10% (8/80) and Neuro endocrine Ca 1.In SCC Moderately differentiated (57.7%), Poorly differentiated (14%) and Well differentiated (11%). Site wise Upper 1/3rd 11(13.3%), Middle 1/3rd 12(14.5%), Lower 1/3rd 29 (34.9%), Cervical: 1 (1.2%). Out of 83 patients, 57 received treatment with curative intent (Adjuvant: 9, Neoadjuvant: 5, Definitive: 43) and 23 with palliative intent. Median Over all Survival was 16months, Median survival of patients treated with curative intent was 21months and Radical Chemoradiation was 16months. Conclusion: Squamous cell ca was the most common pathology, Lower 1/3 most common location, Most of the patients sent for radiotherapy were in an advanced stage. Recent trials suggests neoadjuvant Chemoradiation may improve survival in carcinoma esophagus.

Evaluation of treatment outcome and comparison of different conformal radiotherapy treatment plans in patients of carcinoma oesophagus (non-cervical) treated by neoadjuvant chemoradiotherapy

Pankaj Kumar 1 , Vinay Kumar 1 , Marimuthu Boopathi 1 , Manmohan Singh Bedi 2 , Sachin Gupta 3 , Sunandan Sharma 2 , Narendra Mohan Gupta 2

1 Department of Radiation Oncology, 2 Surgical Oncology and 3 Medical Oncology, Max Cancer Centre, Max Super Speciality Hospital, Phase-6, Mohali-160055, Punjab, India. E-mail: [email protected]

Introduction: Neoadjuvant Chemoradiotherapy (CRT) is increasingly being used in patients with locally advanced or node positive resectable non-cervical Carcinoma Oesophagus patients and results in around 25-30% pathological complete response (pCR) rate and improved overall survival1,2. Aims and Objectives: To report the pathological response rates and acute toxicity, and dosimetrically evaluate and compare hybrid radiation therapy plans [3-dimensional conformal radiotherapy (3D-CRT) plus Intensity Modulated Radiotherapy (IMRT)] with either complete 3D-CRT or IMRT plans in terms of volume of lung treated to low doses while delivering conformal dose in carcinoma esophagus patients treated by neoadjuvant CRT. Materials and Method: Eighteen patients were included in the study. Treatment protocol consisted of external beam radiotherapy (Hybrid Plan: Phase 1 3D-CRT 30.6 Gy in 17 fractions followed by Phase 2 IMRT: 19.8 Gy in 11 fractions, 5 days per week), and concurrent weekly administration of carboplatin (AUC 2) and paclitaxel (50 mg/m2) for 5 weeks, followed by surgery. The radiotherapy plans were optimized to reduce V5 and V10 lung doses and were compared with conventional full 3D (non-IMRT) plans (Phase 1 Antero-posterior fields; followed by Phase-2: 3-field technique, 1 anterior and 2 posterior oblique sparing spinal cord; to same doses) and full IMRT plans (50.4 Gy in 28 fractions). Dose-volume histograms were evaluated for the planning target volume, ipsilateral, contralateral and total lung and heart doses. Lung volumes V5 (Volume of lung receiving 5 y dose), V10, V20, V30 and mean lung dose (MLD) were cmpared for each plan. Results: Out of 18 patients, 13 patients underwent surgery. Five patients either refused surgery or were found inoperable after CRT, 8 achieved pCR (8/13 patients; 61.5%). The most common major hematological toxicity was leucopenia with neutropenia in 6 (33%) patients and the common non-hematological toxicity was anorexia in 4 (22.2%) patients. Hybrid plans treated significantly smaller lung volumes to low doses than 3D-CRT or IMRT plans and significant reduction was for both ipsilateral and contralateral lung V5, V10, and V20 values and smaller reductions were also found for Mean Lung Dose. The full 3D plans treated much larger extra planning target volumes to prescribed dose levels. Conclusion: Hybrid Conformal radiotherapy plans showed reduction in low dose lung volumes while maintaining the conformality with high response rates.

Synchronous carcinoma of esophagus and bladder: Case report

Sindhu N, Rajesh

Bangalore medical college and research institute.

E-mail: [email protected]

Introduction: Incidence of synchronous multiple tumours associated with carcinoma of esophagus in around 2-5%, likely due to common risk factors like smoking, genetic factors. Ideal sequence of treatment of these tumours needs to be individualized and prognosis is generally poor. Case report : A 70 year old man presented with complaints of progressive dysphagia to solids, associated with pain abdomen and regurgitation of undigested food particles immediately after intake, for which which he was worked up with and Contrast enhanced computerized tomography of thorax, abdomen and pelvis. Upper GI endoscopy showed an ulcerative growth in esophagus starting from 35cm from incisors and scope could not be passed there after. Biopsy of the growth showed infiltrating poorly differentiated squamous cell carcinoma. CECT showed circumferential mural thickening in the distal thoracic esophagus extending into gastro-esophageal junction and incidentally revealed an well defined enhancing polypoidal growth arising from posterolateral wall of urinary bladder. He underwent transurethral biopsy and resection of the polyp which showed invasive low grade urothelial carcinoma (pT1), following which he was planned radiotherapy to esophageal carcinoma. He received a total of 5940 cGy in 33 fractions using Co60 gamma rays in 3 phases to spare the spinal cord. Further follow up is required to assess the response and behavior of both the cancers.


Evaluation of pelvic bony anatomy and implanted gold seed marker based registration for intensity modulated (IMRT) -image-guided radiotherapy (IGRT) for prostate carcinoma with cone beam computed tomography (CBCT): A preliminary experience

Sambit S. Nanda, Madhup Rastogi, Rohini Khurana, M. Shajahan, S. P. Mishra, M. L. B. Bhatt

Department of Radiation Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India. E-mail- [email protected]

Introduction: The success of highly conformal radiation therapy techniques in clinically localized prostate cancer relies on the accuracy of dose delivery on a reproducible TV and OAR. Organ motion has posed a challenge for precise dose delivery to the target volume and sparing OAR and has been an impediment in obtaining better therapeutic outcome. Application of CBCT in Image-Guided Radiotherapy has emerged as a crucial component in precision delivery and optimizing treatment accuracy and minimizing treatment related uncertainties. Aims and Objectives: The purpose of the study is to compare the set up errors acquired with anatomical bony landmarks vis-ΰ-vis gold fiducially inserted in target volume using cone-beam computed tomography (CBCT) for daily localization of prostate cancer. Methods and Materials: The evolutions were conducted From March 2013 to August 2014. 10 patients with localized prostate cancer implanted with 3 gold seeds were planned for Intensity-Modulated-Image-Guided Radiotherapy and were treated on Elekta Infinity equipped with XVI system and Hexapod 6D couch. Daily pretreatment KV -CBCT images were acquired with institutional rectum and bladder protocol. Acquired CBCT images were auto-registered with reference CT images using seed matching module to determine translational errors. Online correction was done in the anterior-posterior (AP), superior-inferior (SI) and left-right (LR) dimensions after data acquisition. Further bony anatomy registration was used to obtain setup errors and was compared with marker registration. Student t- test was used to analyze the data significance among the setup error between the above two acquired data subsets. The study parameters including average age at diagnosis, Individual Gleason score, Pathological staging, pretreatment Serum PSA, Average volume of CTV and OAR were evaluated. Percentage of CTV receiving 95% prescribed dose, Conformity Index and Heterogeneity Index were analyzed. Results: Mean age of patients treated by IG-IMRT at diagnosis was 65 year with mean Gleason's score of 7/10.The average serum PSA value at initial diagnosis was found to be 21.53+ 2.The mean dose of radiation given to low risk patient was 70 Gy and in high risk patient was 78 Gy. The mean translational error in lateral, longitudinal and vertical direction were 0.20+0.38,-0.70+1.006,0.23+0.46 respectively for marker based registration and 0.21+0.39,-0.70+0.45 & 0.27+0.26 for bony anatomy based registration. The longitudinal and vertical results of bony matching and gold seed matching have shown statistically significant difference (p value 0.0001). Conclusion: CBCT with fiducial markers in prostate for treatment verification has a higher level of precision making it the preferred method for verification as compared to bony anatomical registration method. It gives the treating physician the confidence to escalate the dose to prostatewith better tumor control and minimal dose to adjoining normal tissue.

CyberKnife monotherapy for localised carcinoma prostate, an emerging image guided SBRT approach: Our early clinical experience

Aggarwal Mayank, Kumar Pavan, Halder Shikha, Hukku Shelley, Verma Neeraj, E. H. Annex

Department of Radiation Oncology, B.L. Kapur Superspeciality Hospital, Pusa Road, New Delhi - 110005, India. E-mail- [email protected]

Introduction : SBRT with CyberKnife is an emerging approach in the treatment of carcinoma prostate. CyberKnife has robotic maneuverability and prostate motion tracking system, which lowers the Normal Tissue Complication Probability (NTCP) and achieves better Tumor Control Probability (TCP) by targeting higher radiation dose to the prostate and lower dose to surrounding normal tissue. Therapeutic gain can be achieved by delivering high dose per fraction to prostate due to its low α/β ratio when compared with rectum and bladder. Recently published long term data on CyberKnife treatment of prostate cancer by King et.al. shows promising result and is comparable to radical treatment. Aims and Objectives: To evaluate the feasibility of image guided SBRT alone by Cyberknife in selected patients with localized carcinoma prostate. Method: 27 patients with localised Carcinoma Prostate (low to Indermediate risk group and elderly high risk patients with age>70 years) were recruited for Image-guided SBRT alone by CyberKnife from Jan'2013 to July'2014. After proper bladder and bowel preparation, four gold seed fiducial markers were inserted in the prostate under ultrasound guidance followed by treatment planning CT and MRI of Pelvis. Images were imported and fused in Multiplan TPS. Target area, critical normal structures were delineated and treatment planning was done. Patients received total dose of 35 Gy in 5 fractions, 7Gy per fraction. Results: Median age of patients was 73years, Gleasons Score was 7, Pre-treatment PSA was 14.6 ng/ml respectively. There was one patient of Low risk, 14 patients of Intermediate Risk and 12 patients of High risk (Median age of High Risk group: 74 Years). Median follow up was 7 months (Range: 3 months to 19 months ) during which 19 Patients showed complete biochemical response (Median Post-Treatment PSA: 0.22ng/ml), one patient showed partial biochemical remission, four patients are yet to come for first follow up and three patients have lost to follow up. Median PTV volume was 99.37cc, Median V100 of prostate was 95.78% and D95 of prostate was 35.13Gy. Median dose to 3cc volume of penile bulb was 21.47Gy, 15cc of bladder wall received 16.31Gy, 20cc of rectum received 22.04Gy, 20cc of Bowel received 9.75Gy, 10cc of right femoral head received 9.71Gy and left femoral head received 9.84Gy. Median Conformality Index was 1.06 and Homegeniety Index was 1.16. There was only one patient who developed incontinence of urine after one week of therapy, which was recovered in 2 weeks. There was no compliant of hematuria/bleeding PR/impotence in any patient till date. Conclusion: With overall treatment time of 5 days Image-Guided SBRT with Cyberknife is a convenient treatment option for patients with localized Carcinoma Prostate. Constraints for normal structures can be well achieved. Patients tolerates treatment well with reduced toxicity profile. However more patients and longer follow up is required to validate the result.

Scrotal irradiation in prone position

Gangadhar Vajrala M.D., M.P.H. 1 , A. Ananda Giri Babu Ph.D. 2 , Nivalika Rajamoni, M.B.B.S. 3 , Piyush K. Jain, M.D. 4 , Gauthami Netula, M.B.B.S. 5 , Prof. M. Narasimha Rao, M.D. 6

E-mail- [email protected]

Background: The incidence of testicular relapses has declined with the advent of aggressive chemotherapeutic regimen.[1] However, these patients should be treated aggressively since they have been shown to have excellent long-term survival, to an order of 67% at 10 years.[2] Studies documenting description of adjuvant irradiation and its techniques are scanty.[3] Rarely special treatment techniques, using prone set-up with computerized tomography (CT) based planning, have been adopted for scrotal irradiation in special situations.[4] Case Report: A 32 year old male who presented with painless enlargement of scrotum was diagnosed with late isolated testicular recurrence after appropriate investigations. The patient was planned for bilateral testicular irradiation along with systemic therapy as per the current guidelines. After obtaining consent, patient was taken up for testicular irradiation in supine position and was planned accordingly. In view of a large scrotal swelling with bilateral testicular masses along with hydroceles on both sides, the patient was also setup in prone position using belly board platformed up on 15 cm blocks. His penis was plastered to the abdomen and the scrotum was left hanging with the help of belly board. CT scan with 3 mm slices was obtained in both supine and prone positions. Radiotherapy (RT) planning in the prone position was done using slightly angled, wedged lateral fields with half beam block, while AP/PA fields were used for planning in supine position. Bolus on the scrotum of 1 cm thickness was used and both plans were compared.RT plan in prone position was found to have superior dose distribution when compared to that in supine position. Homogeneity index (HI) was 0.087 and 0.133 in prone and supine positions, respectively, while conformity indices (CI) of 98% and 100% isodoses were 1.384 versus 1.110 and 0.988 versus 0.764, respectively. Lower skin dose in both the groins, lower mean and maximum point doses for bladder and rectum were attained in prone setup planning when compared to planning in supine position. After careful evaluation of both plans, patient was re-explained and treated in prone position with a total dose of 26 Grays in 13 fractions, using daily KV-KV image verification and daily portal verification with MV imaging of the actual treatment field. Patient tolerated treatment well with minimal acute skin reaction. Conclusion: Scrotal irradiation in prone position using CT based planning and image verification should be considered in special circumstances in order to obtain superior dose distribution and lower normal structure doses. However, our study findings need validation in larger studies with long-term outcome data.

Dosimetric analysis of external beam radiotherapy plus HDR brachytherapy boost vs. external beam radiotherapy alone (IMRT) in intermediate and high risk prostate cancer: Early results of biologically equivalent dose-volume parameters from a randomized control trial

Manikandan A, Laviraj M. A., Haresh K. P., Sharma D. N., Gupta S, Mallick S, Julka P. K., Rath G. K.

Department of Radiation Oncology, AIIMS, New Delhi, India. E-mail- [email protected]

Introduction: Radical radiation with neo adjuvant, concurrent and adjuvant hormonal therapy is considered the standard for intermediate and high risk prostate. The radiation can be delivered with Intensity modulated radiotherapy (IMRT) alone or in combination with brachytherapy. Aims and Objectives: In this prospective randomized study we compared dose conformity between two modalities HDR Brachytherapy and IMRT to deliver a boost to the prostate after External beam Radiotherapy (EBRT). Materials and Methods: Patients with localized adeno carcinoma of prostate were randomized to receive either IMRT alone or IMRT plus brachytherapy. After randomization all patients received EBRT 45Gy/25#/5 weeks by IMRT in phase I. In phase II patients received either HDR brachytherapy 19Gy/2# (Arm A) or EBRT 29Gy/15#/3weeks (Arm B). In phase II EQD2-DVH parameters were calculated for comparison. EQD2 calculated with a prostate α/β ratio of 1.5 and 3 Gy & α/β ratio of 3Gy for organ at risks. The IMRT planning was done in ADAC Pinnacle version 8.0M and treated with Synergy S. The brachytherapy was planned in Oncentra-brachy version 4.3. Results: We randomized 12 patients to Arm A and Arm B. The median age of the cohort was 68.9 years (Range 60-78). The stage distribution was T2b-T3b. Median Gleason 7 (Range 6-8), Median PSA 32.7ng/ml (Range 4.8-92.3). The median prostate volume was 45.8cc (27.1-60.9). All patients received 45Gy/25#/5 weeks in phase I by IMRT. The HDR BT delivered higher mean doses to PTV compared with IMRT plan. In phase II, the mean EQD2 of 95% of the prostate volume was 48.6Gy in HDR BT whereas 27.2Gy in IMRT. The EQD2 of 33% of rectal volume received mean dose of 6.5Gy and Dmean of rectum was 6.8 Gy with HDR BT. In comparison doses delivered with IMRT were 18.1Gy and 12Gy respectively. EQD2 of Dmean to bladder in HDR BT and IMRT were 4.1Gy and 13.5Gy respectively. Conclusion: HDR BT produced more conformal plan for the boost to the prostate. With brachytherapy the doses to the OAR are lower than IMRT. Dose escalation for prostate tumors is easily achievable with brachytherapy than with IMRT alone. Therefore, brachytherapy might be the preferred modality to achieve further dose escalation.


EQD2 for 95% of PTV (a/b: 1.5Gy) 48.6Gy 27.2Gy

EQD2 for DMEAN to PTV (a/b: 1.5Gy) 47.5Gy 29.5Gy

EQD2 for 95% of PTV (a/b: 3Gy) 39.1Gy 27.5Gy

EQD2 for DMEAN to PTV (a/b: 3Gy) 38.3Gy 29.6Gy

EQD2 for DMEAN to Rectum 6.8Gy 12Gy

EQD2 for 33% of Rectum 6.5Gy 18.1Gy

EQD2 for DMEAN to Bladder 4.1Gy 13.5Gy

EQD2 for 50% of Bladder 2.9Gy 12.6Gy

EQD2 for 1cc of Bladder 15.5Gy 30Gy

Adnexal masses - A diagnostic dilemma.

Sindhu N, Chendil V

Bangalore Medical College and Research Institute.

E-mail- [email protected]

Introduction: Krukenberg's tumour is a rare transcoelomic metastasis to ovaries from most commonly the stomach, followed by breast, colon, appendix and rarely from gallbladder, biliary tract, pancreas, small intestine, cervix, and urinary bladder. Histologically it is signet ring adenocarcinoma with mucinous stroma. Presentation maybe synchronous or rarely primary tumour may not be identified. Prognosis is guarded. Differentiation of these tumours from primary ovarian tumour is difficult by imaging modalities. Case Report: A 52 year old lady presented to surgery OPD with one and half month history of lower abdominal pain. Initial work up revealed heterogenously enhancing solid masses in bilateral adnexal region invading into the rectum with omental deposits with C.A. 125 (333.4U/ml) and CEA(14.10ng/ml) raised significantly. The ascitic fluid was negative for malignant cells. She was referred to us for neoadjuvant chemotherapy(NACT). She received 4 cycles of paclitaxel with carboplatinum, following which there was serial reduction in C.A. 125 levels (195.7U/ml) and imaging showed reduction in size of the bilateral tumour. She underwent cytoreductive procedure (pan hysterectomy) following NACT. Histopathological examination of the specimen showed features suggestive of metastatic adenocarcinomatous deposits in bilateral ovaries (Krukenberg tumour) with ascitic fluid positive for malignant cells. Immunohistochemistry revealed tumour cells positive for CEA and negative for C.A. 125 and CA 19.9. However serum levels of C.A. 125 and CEA continued to be raised. Work-up for primary tumour with upper GI endoscopy and colonoscopy was done which was inconclusive. Palliative chemotherapy - FOLFOX regimen was started after consulting a Medical Oncologist. The main dilemma here is the necessity of histologic confirmation of primary ovarian tumour before starting NACT in a clinically inapparent source of metastasis.

Bone and Soft Tissue tumor

Intensity modulated radiotherapy (IMRT) in pelvic giant cell tumors: A case report

Mohammed Raees Tonse, Hasib A. G, M. S. Vidyasagar

E-mail: [email protected]

Background: Giant cell tumors (GCT) are usually benign tumors representing <5% of all bone tumors. However at times they can be locally aggressive and in some cases malignant transformation or metastatic disease occurs. The majority of these tumors are located on long bones of extremities and is treated by surgery alone. However a small proportion (<10%) occurs in pelvis, spine, or skull base where complete resection is challenging. Primary radiotherapy has been advocated as an alternative treatment in such patients. With evolving radiotherapy techniques such as 3DCRT, IMRT and IGRT it has become feasible to apply higher doses with less toxicity and optimal sparing of critical structures. Case Presentation : We report our experience with IMRT in the treatment of a patient with giant cell tumor arising from the sacrum. Conclusion : IMRT is a feasible option in giant cell tumors not amendable to function preserving surgery. It is possible to achieve high local control rates without severe acute or late side effects and improvement of clinical symptoms.

Primary rhabdomyosarcoma of diaphragm: Report of a paediatric case

Ranti Ghosh 1 , Anirban Halder 1 , Aloke Ghosh Dastidar 1

Department of Radiotherapy, I.P.G.M.E and R and S.S.K.M Hospital, Kolkata. E-mail: [email protected]

Background: Rhabdomyosarcoma is most common soft tissue sarcoma in children.But primary Rhabdomyosarcoma arising from diaphragm is a very rare tumour, only few cases are reported in Literature. Case History: An 8yr old boy presented with severe pain and gradual distension of upper abdomen. X-RAY, ultrasonograpy, CT scan abdomen revealed a giant mass arises from left hemi diaphragm, close to heart. Histopathology examination showed many large, oxyphilic rhabdoid cells between diffusely proliferating spindle-shaped cells and tumour diagnosed as Spindle cell rhabdomyosarcoma of diaphragm, of which location and histological type is very rare. Tumour was inoperable. He is on adjuvant therapy.

Aggressive Fibromatosis in head and neck in a paediatric patient - a case report and review of literature.

S. Lalitha kameshwari M.B.B.S. 1 , Shital kumar Surana M.B.B.S., D.N.B. 1 , Pratap Reddy M.B.B.S., M.D 1

Department of Radiation Oncology, Krishna Institute of Medical Sciences, Hyderabad. E-mail: [email protected]

Introduction: Aggressive fibromatosis, also known as desmoid tumor, is a rare soft tissue tumor often arising from deep-seated musculoaponeurotic structures. The annual incidence is estimated to be around 0.2 - 0.4 per 100,000. Although histologically benign, tumor margins are often poorly defined and tend to interdigitate with the surrounding tissues, and have a high potential for local invasion and recurrence. Head and neck fibromatosis represent around 12-15% of all lesions(1) and tend to be more aggressive and is associated with significant morbidity because of close proximity to the vital vascular and neurological structures. We report the case of a head and neck fibromatosis in a paediatric patient which recurred despite initial complete excision.We also review some commonly accepted therapeutic modalities including radiation in treating these rare tumors. Case Report : A 13yr old girl presented with submandibular swelling of 2 months duration which was excised completely after thorough work up.Post op histopathological examination was consistent with aggressive fibromatosis. Inspite of seemingly complete resection, it recurred with in 8 months and was progressing with observation. After re excision, patient received adjuvant radiation therapy after discussing merits and demerits of various treatment options. Now with 8 months follow up she has stable disease. Conclusion: Wide local excision with negative pathologic margins is the treatment of choice for most desmoid tumors. However adjuvant therapies should be considered in incompletely resected cases, inoperable, or recurrent cases. We suggest that radiation therapy is an important adjuvant modality in recurrent cases and may also be considered as definitive treatment in unresectable disease(2 -5).

Succesful limb preservation in bone and soft tissue tumours of extremities-case series

Khan M. I., Kamble K. M.,Diwan A. K., Mahobia V. K.

Department of Radiotherapy and Oncology, Govt Medical College and Hospital, Nagpur. E-mail: [email protected]

Background: The concept of Preservation of organ(limb) and its function while treating bone and soft tissue tumours of the extremities at current times is still far from reality. To increase the limb-sparing practice in the treatment of locally advanced bone and soft tissue sarcomas of the extremities, preoperative radiotherapy and/or chemotherapy are often used. Limb salvage is a viable alternative to amputation in many cases of advanced sarcoma. The addition of radiation therapy to less than radical surgery has resulted in higher rates of limb preservation and acceptable local control. A multidisciplinary approach will help achieve optimal functional results with less morbidity. Objective: To achieve limb sparing while treating bone and soft tissue tumours of extremities by multidisciplinary approach using chemo radiotherapy along with adequate surgical excision without compromising in local disease control and keeping the functionality of the limb as well. Material and Method: We have treated 2 male patients of osteosarcoma who were in their early 20's and 1 pt of soft tissue sarcoma of knee region again a male in his 30's.The two Osteosarcoma were of stage iiB involving upper end of tibia and of chondroblastic subtype. The histology of soft tissue tumour was Malignant Peripheral Nerve Sheath tumour involving left popliteal region with stage III. Their chief complaint has been pain at the tumour site. All 3 pts were initially treated with neoadjuvant chemotherapy with cisplatin and adriamycin based regimen for 3 cycles 3 weeks apart followed by near radical surgical excision along with graft support wherever necessary. Rest 3 cycles of chemotherapy continued post surgery followed by Radiotherapy. The 2 osteosarcoma pts received 50Gy in 25# where as pt of soft tissue sarcoma received 60Gy in 30# with 5# per week in two fields under cobalt. Two pts has been followed up for 6yrs and one pt has been followed up for 4yrs with repeated x-rays, CT-scan and MRI accordingly. They have been observed for treatment response,any local or systemic recurrences, functionality of the salvaged limb and general well being. Results: All 3 pts tolerated the treatment very well. There were no local recurrences till last follow up. Overall survival and disease free survival at 5yrs was 99%.One pt required fibular graft for resected upper end of tibia. Only complications were from systemic chemotherapy (nausea, vomiting,leucopenia,neutropenia etc) that were also of grade I-II managed with supportive treatment. Conclusion: Limb preservation can be achieved in the locally advanced non metastatic bone and soft tissue tumours of the extremities with the timely intervention of multimodality treatment. Thus it gives moral boost to the patients to lead their lives without getting handicapped functionally as well as occupationally..

Role of adjuvant radiotherapy in myositis ossificans: Case series and literature review

Nivalika Rajamoni M.B.B.S. 1 , Niteen B. More M.D., D.N.B. 1 , Gangadhar Vajrala M.D., M.P.H. 1 , Sunil Apsingi M.S. 2 , Srinivas Kasha M.S. 2

1 Department of Radiation Oncology, Krishna Institute of Medical Sciences, Hyderabad, 2 Department of Orthopedics, Krishna Institute of Medical Sciences, Hyderabad. E-mail: [email protected]

Introduction: Heterotopic ossification of muscle or myositis ossificans (MO) usually occurs either after trauma (fracture, surgery or direct muscular injury) or has a neurogenic origin.(1) This condition most commonly occurs in hip joint as a complication of total hip arthroplasty, occuring in about 16% to 53% of patients.(2) Significant functional deficit is seen in 10% to 20% of MO patients, in the form of pain and decreased range of movement and require active treatment in the form of surgical excision of myositis ossificans mass.(3,4) However this surgery further predisposes the patient to high risk of recurrence of myositis ossificans.(2) Therefore surgical removal should be followed by adjuvant treatments including passive exercises, low-dose radiation, or diphosphonates. The successful use of radiation therapy after heterotopic ossification excision has been well documented. (5, 6) However, it is not popularly practiced due to unknown reasons. Case History: Five patients with symptomatic myositis ossificans of hip joint, following trauma in 4 cases and bearing a neurogenic cause in 1 case, presented with pain and restricted moibility in the affected joint. On evaluation they had large mature myositis mass around the hip joint restricting the joint mobility. Local excision of the lesion was done and adjuvant external beam radiotherapy was given within 24 to 48 hours after surgery. A low dose radiation of 10 Grays in 5 fractions was delivered to the involved area. All patients had significant improved mobility and pain releif after treatment. X-rays were done at initial 4-8 week follow-up, and serially at 3-month intervals after radiotherapy and none of them showed evidence of recurrence at a median follow up of 12 months. Conclusion: Our findings suggest that addition of radiotherapy to surgical excision can improve recurrence-free survival in cases of myositis ossificans. However our study findings need to be validated by long-term studies.

High dose rate interstitial brachytherapy in soft tissue sarcomas: an institutional experience

Rajanigandha Tudu*, Debottam Barman, Arkoprovo Halder,

Kazi S. Manir, Anis Bandyopadhyay, Asit Ranjan Deb

Department of Radiotherapy, Medical College, Kolkata, West Bengal, India. Email id: [email protected]

Introduction: Soft tissue sarcomas are one of the relatively uncommon malignant entitities encountered in our daily practice. Though surgery is the primary modality of treatment of sarcomas, radiation therapy is now considered to be an integral component in its management, for function preservation. Interstitial brachytherapy enables conformal dose distribution to the tumour bed sparing adjacent normal tissues. Therefore, in this study, we retrospectively examine the effects of high dose rate interstitial brachytherapy combined with external beam radiation therapy, in the management of soft tissue sarcomas. Objective : To assess locoregional failure and skin toxicities in patients of soft tissue sarcoma treated with high dose rate (HDR) interstitial brachytherapy combined with external beam radiotherapy. Material and Methods: This is a single institutional retrospective study spanning 4 years from February 2009 to February 2013 comprising a total of 19 patients (18 primary and 1 recurrent) of clinically localized soft tissue sarcomas of extremities who underwent immediate post-operative high dose rate (HDR) interstitial brachytherapy supplemented with external beam radiotherapy (EBRT). The inclusion criteria for HDR and EBRT was high grade sarcomas, tumour more than 5 cm, recurrent sarcomas and positive margins. The interstitial catheters were implanted either intra-operatively or post-operatively by the radiation oncologist. The catheters were placed equidistant either longitudinally or horizontally on the surgical bed with a spacing of 1-1.5 cm in between. Special care was taken to avoid the critical structures. A CT imaging was performed to assess the position and spacing of the catheters and the critical structures near to the tumour bed. Brachytherapy dose ranged from 18-24 Gy in 6 fractions,,twice daily with a gap of 6 hours in between the fractions, over 3 days,given by Gammamed Varian brachytherapy machine with Ir 192. EBRT was given 3 weeks later using telecobalt machine Theratron C in a dose of 45-50 Gy in conventional fractionation with Co60. The follow up period ranged from 18-56 months. The skin toxicities were graded according to the Common terminology criteria for adverse events CTCAE version 4.0. Results: At a median follow up period of 28 months, there was no local failure noted in any of the patients. 2 patients who had implants on the 3rd post-operative day developed wound dehiscence and delayed wound healing. Only 1 patient developed lung metastasis. Skin hyperpigmentation at the margins of irradiated site was noted in 3 patients after the completion of EBRT. No significant skin fibrosis was noted till the time of reporting. Conclusion: HDR interstitial brachytherapy is an effective treatment in combination with EBRT after surgical resection in the management of soft tissue sarcoma, with acceptable complications.

Radiation Physics

Measurement of patient skin doses in x-ray based radiological interventional procedures

Bhupendra Singh Rana, Vivek Gupta, Chirag Kamal, Sanjeev Kumar#, I. S. Sandhu*, Ranjit Singhp., N. Khandelwal

Department of Radiodiagnosis, PGIMER, Chandigarh, #G.G.D.S.D.College, Sector 32, Chandigarh, *Chitkara Institute of Engineering and Technology, Rajpura, Punjab, pDepartment of Radiotherapy, PGIMER, Chandigarh. E-mail: [email protected]

Introduction : Radiological Interventional procedures are associated with substantial amount of radiation doses as compare to Radiography examinations due to long procedure time, continuous fluoroscopy screening time and complexity of the procedures that may lead to high radiation dose to the patients and the dose to the skin is appreciably higher side that may lead to likelihood of radiation induced skin effect/injuries, Radiation induced skin effects are deterministic effect with a threshold of 2 Gray or more. In IR the tissue reaction of concerned is damage to the skin erythema or epilation. The single radiation dose threshold for transient and prolonged erythema are of the order of 2 and 6 Gy respectively and about 3 Gy for temporary epilation. These reaction will occur or not and the degree of their severity can be estimated from entrance skin dose (ESD) delivered to the patient [1]. Radiation injuries have been reported following interventional procedures where skin doses were higher than threshold doses [2, 3]. Studies have been published aimed to measure the skin doses from Interventional Radiological procedures and their potential effect on the patients undergoing theses procedures. [4,5]. Radiochromic films have been extensively used in Interventional radiological procedures for radiation dose measurement [6, 7]. Gafchromic film is placed on the patient skin prior to IR procedure Gafchromic film can be used in dose range of 0.1 Gy to 15 Gy for accurate skin dose measurement using Gafchromic film.Exposed films are read out for dose measurement. Aims and Objectives : Interventional Radiological procedures are conducted using fluoroscopy X-ray machines that give series of continuous radiation exposures to the patients during the procedures. This radiation exposure varies from procedures and mostly depends on the length of the procedures and complexity associated with these procedures.


Measurement of radiation doses to patients during Radiological Interventional procedures.


Identifying the Interventional procedures for which radiation doses are higher that may reach or reaching tissue reactions (skin injuries).

Materials and Methods : Total of 20 patients will be included in the study.Ten consecutive patients will be included in Group A (Diagnostic procedures) and ten consecutive patients will be included in Group B (Therapeutic procedures).These procedures will be performed in Allura XperFD20, M/s Philips Medical System. Patient's age, sex clinical indications will be recorded. Once the patient is enrolled, informed consent will be taken and radio chromic film of appropriate size will be attached over the patient skin. This film will attached over the part that is directly under the X-ray table. Calibration of Gafchromic films is performed by exposing a set of strips of the films to Known air kerma assessed with the calibrated dosimeter in the range of doses from 10 cGy to 6 Gy at 100KVp. Exposed strips will be read after the exposure using Epson flat bed film scanner installed with film QA XR software for calibration of Gafchromic films for X- ray radiation doses.After completion of the procedure, the radiochromic film will be removed from the patient skin and will be transferred in air tight envelope and stored for analyzing irradiated Gafchromic film for radiation dose measurement. Parameters such as angiographic time, fluoroscopic time, Dose Area Product (DAP), mAs will be recorded in each procedure. The analysis of the film for will be done by using Epson 1100 XP flat bed scanner to read reflective density of the exposed film after 24±4 hours using Film QA-XR software. Results and Conclusions : The measured data for patient's skin doses and result will be tabulated, analyzed and compared with published data in the literature. The procedure(s) delivering higher radiation doses to the patient skin will be identified and standardized for the same.

Report on quality assurance of siemens emotion-16 slice ct scanner

*Sivarajan C., *Purnima Hegde.

*Sri Devraj URS University, Kolar. E-mail: [email protected]

Introduction: Various quality assurance protocols on computed tomography (CT) scanner have been described in many literatures. The Atomic Energy Regulatory Board in India also has established standards on technical data to issue authorisation to operate CT scanners in Radiological services. This paper aims to report on quality assurance of CT scanner, newly installed in our institute recently. Aim: To perform the quality assurance of Siemens Emotion CT scanner-16 slice and to report the analysis of results in view to use in patient diagnostic purpose and for Radiotherapy simulation. Material and Methods: CT scanner-16 slice (Siemens -Emotion) with necessary software system for diagnostic purpose has been installed during the year 2012.The quality assurance tests have been carried out with the use of necessary phantoms and dosimeters supplied by the manufacturer. The acquired data provide us a report which emphasize the stringent tolerance limits and will be a base line to maintain standards for future reference.


1. Table Top accuracy movement: Indexing accuracy: ± 0.1mm

2. Alignment of table gantry: 1mm


Scan location light accuracy: Alignment error with respect to laser is 1mm

4. Gantry tilt: + 150 to -150

5. Table position/incrementation: ±0mm

6. Collimation test: maximum alignment error is 1mm

7. Test on X-ray generator: within 1kVp

8. Measurement of mA linearity: Coefficient of linearity = 0.030

9. Measurement of timer linearity: Coefficient of linearity= 0.007

10. Output consistency: 0.0043

11. Low contrast resolution: 4mm

12. High contrast resolution: 1.25mm holes pattern


Radiation dose test: CTDI(Head) =14.42mGy/mAs

CTDI (Body) = 8.07mGy/mAs


Radiation leakage levels in and around the installation: within acceptable limit

Further quality assurance tests on image quality has been conducted using different types of phantoms to test the image quality on CT protocols. Conclusion: The Siemens Emotion CT Scanner-16slice has been tested for basic criteria of quality assurance tests and results are found satisfactory for clinical use. Still further investigations are recommended to improve the image quality in terms of diagnostic purpose for clear reporting procedures. Scanning protocols needs to be individualised to some complex clinical procedure.

Influence of filtered and flatting filter free photon beam of 10 megavolts energy on rapid arc radiotherapy planning for cervix carcinoma

Girigesh Yadav, Lalit Kumar, Kothanda Raman, Manindra Bhushan, Manoj Pal, Manoj Sharma

Medical Physics Division and Radiotherapy department, Rajiv Gandhi Cancer Institute and Research Center, Rohini, New Delhi - 110085, India. E-mail:[email protected]

Introduction: Rapid arc technique is an extension of IMRT technique, can be used for the treatment of deep seated Cervix Cancer tumours, which produced highly conformal dose distribution around the Planning target volume and gives better sparing to nearby organ at risk (OAR's). Aim: Aim of this study is to determine the influence of Filtered and Flatting Filter Free Photon Beam of 10 MV energy on Rapid Arc planning for Ca. Cervix. This study did not consider the contribution of dose deposited by neutrons produce for 10 MV Photons. Material and Methods: CT data sets of eleven patients with carcinoma cervix were used for Rapid arc planning for 10MV_FFB and 10MV_FFFB photon beam energy. RA plans were generated using two ful rotational arcs with gantry angle from 1790 to 1810and from 1810 to 1790, with collimator rotated to 300-450 for clockwise arc and 3050-3300 for counter clockwise arc to decrease Inter-leaf leakage of MLC. All plans were generated to deliver a dose of 50.4Gy in 28 fractions for Planning target volume and ALARA for Organs at risk. All plans were analysed for PTV Coverage, conformity Index, homogeneity index, dose to OAR's, integral dose to normal tissue and total no. of monitor units (MUs) were also studied. p-value less than 0.05 were consider statistically significant. Results: Dose-volume histogram was used to evaluate rapid arc plans for both 10MV_FFB and 10MV_FFFB photon beam. Dosimetric planning results show a comparable PTV coverage for both energies. Results shows volume of PTV receiving prescription dose were 95.10+ 0.09% and 95.09 +0.11%, and volume of PTV receiving a dose of 107% is 0.45+0.96% and 5.25+8.9% for 10MV_FFB and 10MV_FFFB respectively. The homogeneity index (HI) were 1.051+0.007 and 1.066+0.008, Conformity Index(CI) were 1.003+0.019 and 1.012+0.013, Mean Integral dose were 2.65+0.34 and 2.60+0.33(*105Gy.cm3) for 10MV_FFB and 10MV_FFFB respectively. 10MV_FB shows statistically significant (p<0.05) improvement in mean doses to bladder, rectum, bowel and mean total number of MU's and shows remarkable decrease in mean total no. of MU's by 43.7% in comparison to 10MV_FFFB. There is no statistically significant (p>0.05) difference found for Mean dose and Max dose to both femur heads. There is statistically significant (p<0.05) difference found for Conformity Index (CI), Homogeneity Index (HI) for 10MV_FB in comparison to 10MV_FFF beam. 10MV_FFFB shows statistically significant (p<0.05) for mean integral dose to normal tissue (NTID) and delivers 1.65 % less NTID in comparison to 10 MV_FB. Conclusion: 10MV_FB is superior to 10MV_FFFB for rapid arc planning in case of Cervix carcinomas, it offers better target coverage and OAR's sparing, comparable mean Integral dose to normal tissues and 10 MV_FB also produced highly conformal and homogeneous dose distribution in comparison to 10MV_FFFB.

Retrospective dosimetric evaluation of OAR ((Bladder, rectum and Bowel) in CT based 3D treatment planning of intracavitary brachytherapy for carcinoma cervix patients.

Jyoti Bisht*, Vipul Nautiyal*, Meenu Gupta*, Raj Kumar Tyagi#, Saurabh Bansal*, Mushtaq Ahmad*, Sunil Saini*

*Department of Radiotherapy, Cancer Research Institute, HIMS, HIHT University, Dehradun, #Department of Physics, Hemwati Nadan Bahuguna PG College, Khatima, Uttaranchal. E-mail: [email protected]

Aim: The purpose of this study is to compare doses of organs at risk (bladder and rectum) between the representing points defined as in International Commission on Radiation Units and Measurement (ICRU 38) and dose volume histograms (DVHs) from CT based high dose rate intracavitary brachytherapy and dosimetric analysis of small bowel. Methods: 20 patients of carcinoma of cervix were selected. Patients were treated by External beam radiotherapy of 40 Gy with four field box technique followed by 10Gy/5# boost to whole pelvis with midline block followed with two session of 9Gy each with high dose rate intracavitary brachytherapy between June 2013 to Jan 2014. CT guided treatment planning was done and 3D dose distribution is seen according to the reference points described in ICRU38. Bladder, Rectum and colon were delineated in CT slices and doses at the reference points according to ICRU 38 for rectum and bladder and mean doses in volume 2cc and 0.5 cc of OARs were calculated with the help of dose volume histogram (DVHs) and compared. Bowel is delineated till the end of the uterine tandem. EQD2 for each OAR was calculated and compared. Results: The mean doses of D2cc and D0.5cc for bladder are 1.07 and 1.31 times higher and for rectum 1.1 and 1.4 times higher than ICRU38 defined point doses of bladder and rectum. Out of 20 patients five patients are getting D2cc doses near about 7Gy for bowel.

Conclusion: Image based brachytherapy treatment planning gives more authentic doses in the OAR compare to ICRU Point doses and more precaution should be taken for areas of colon which are nearby the uterine tandem due to more frequent high D2 doses in these areas.

Comparison of manual and inverse optimisation techniques in high dose rate intracavitary brachytherapy of cervical cancer: A dosimetric study

Ram Abhinav K

M.S. Ramaiah Medical College. E-mail: [email protected]

Background: Brachytherapy has been a standard component of definitive radiation therapy for cervical cancer.With advent of advanced imaging modalities,there has been a shift from conventional xray based planning to three dimensional planning. Manual optimisation is the one which is widely used across various institutions but it is time consuming and operator dependant. Inverse planning simulated annealing (IPSA) is now available in various brachytherapy planning systems. Similar to external beam radiation, there could be potential improvement in target volume coverage and reduction in planning time with the use of inverse planning. But there is a paucity of studies comparing manual optimisation and IPSA in the treatment of carcinoma cervix with intracavitary brachytherapy and hence this study. Aims and Objectives: To compare dosimetrically, manual optimisation with inverse planning simulated annealing using dose volume histograms (DVH) among patients treated for carcinoma of cervix with intracavitary brachytherapy. Materials and Methods: 15 consecutive patients treated between December 2013 to March 2014 with intracavitary brachytherapy for carcinoma of cervix were selected for this dosimetric study. All patients were initially treated with external beam radiotherapy to a dose 45Gy in 1.8 Gy per fraction followed by intracavitary brachytherapy to a dose of 26Gy in four equally divided fractions over two days. Manual optimisation was done by changing the active dwell weights, by clicking the isodose line and mouse dragging it to the desired location until a satisfactory plan was obtained with respect to target volume coverage and organ at risk (OARs). Inverse planning was done for the same fifteen patients who were treated previously after manual optimisation. Dose constraints were set to OAR's and target volume. IPSA was used to generate an inverse plan, which identifies the combination of dwell times that best conforms to dose constraints of target volumes and OARs. The dose volume histograms (DVH) were analysed for each group and were compared between the two groups using paired t test. The level of significance was set at 0.05. Results: There was a significant improvement in the HRCTV coverage,mean V100 of 88.52% and 83.67% (p=0.03) and homogeneity index 0.42 and 0.39 (p=0.04) for plans generated using IPSA and manual optimisation,respectively.D90 dose also showed a trend towards significance 6.4 Gy and 5.95 Gy (p=0.07). There was no significant increase in the high dose volumes measured as V150,V200 and V300 between the two groups. Conformity index and dose to the OAR's remained similar between two groups. No difference in the volume of tissue covered by 100% (VPD) and 200% (V2PD) of the prescription dose was noted. Planning time for IPSA was around 5 minutes compared to 30-45 minutes in manual optimisation. Conclusion: The use of inverse planning in intracavitary brachytherapy of cervix has shown a significant improvement in the target volume coverage and homogeneity index when compared with manual planning, while volume of high dose region and doses to organ at risk remained similar between the two groups. Planning time also considerably decreased with the use of inverse planning.

Dose enhancement effect of Bismuth nano particle in polymer gel dosimetry

P. Sathiyaraj 1 , Y. Retna Ponmalar 2 , T. Deena 1 , E. JJ. Samuel 1

1 Photonics, Nuclear and Medical Physics division, VIT-University, Vellore, 2 Department of Radiotherapy, Christian Medical College, Vellore, India. Email: [email protected]

Introduction: In the recent years, an extensive research is being carried out on the application of nano particles in the treatment of cancer. Dose enhancement (DE) is an interesting concept and had not been well quantified till date. Many researchers (1-2) have carried out the dose enhancement study in polymer gel dosimeter. Gold is the most preferred nano particle for DE effect because of its higher atomic number (Z=79) as it produces more secondary radiation during interaction and can more easily penetrate the tumor vasculature. Taking the cost effect into consideration, Bismuth nano particle (Bi-NP) has been used in DE study instead of gold nano particle (Au-NP) which is the main concern of many researchers. Bismuth also has an added advantage of having higher atomic number (Z=83), so as the production of secondary radiation is more than gold. Poly acrylamide gelatin tetrakis hydroxyl posponium chloride gel (PAGAT) has been chosen for this study and spectrophotometer has been taken as the analyzing tool. Aim: The extensive vision of this study is to see the dose enhancement in PAGAT using Bi-NP. Objective: The exact focus of this study is to find the dose enhancement of Bi-NP with PAGAT as medium instead of tissue. Materials and Methods: The preparation of Bi-NP from literature (3) and the preparation of PAGAT reported by Brindha et al (4) have been adopted in this study. Bi-NP was impregnated in PAGAT and another gel prepared without Bi-NP. In this study, 0.5mM and 1mM concentration of Bi-NP were used. The prepared gel was transferred in plastic cuvettes and placed overnight in the refrigerator to deform the liquid phase into gel phase. On the next day of preparation, the gel had been irradiated with 60Co source. A setup with the SSD (Source to surface distance) of 80 cm, field size of 10Χ10 cm2and 10 cm back scatter medium (PMMA) has been used. Before irradiation, gel samples were placed in the control console for 1 hr to attain thermal equilibrium. Samples were irradiated up to 21 Gy with an interval of 3 Gy. After irradiation, samples were placed in the refrigerator for 24 hours to obtain complete polymerization. The following day of irradiation, samples were read by spectrophotometer. Data were transferred to personal computer for analysis. Xcom software was used for elemental composition analysis. Results and Discussion: Dose enhancement is measured as the ratio of the absorption of Bi-NP doped gel to non doped gel. The maximum DE of 30.1% was achieved using 0.5Mm of Bi-NP doped PAGAT gel dosimeter. DE was less for 1Mm of Bi-NP particle (10.17%). Less deviation from standard PAGAT composition was observed in the elemental composition of Bi-NP doped gel. Due to the shielding effect (2) of Bi-NP, the DE had been reduced at 1Mm. Bi-NP absorbs the secondary radiation such as auger electron and photoelectrons. Bi-NP is more concentrated in 1Mm, so it acts as a shielding to secondary radiations and not allowing their energy deposition to the gel medium. This study suggests that 0.5mM concentration of Bi-NP is optimum to DE effect. We would like to perform the same study in future with less concentration of Bi-NP. As per our investigation, the shielding effect is present in 0.5 Mm concentration. Further study is required in low concentration to find out optimum concentration of Bi-NP in clinical application.

Study of relationship between target to background ratio and tumor volumes to threshold selection in pet/ct imaging for head and neck tumours

Josia Seli Jose

E-mai- [email protected]

Introduction: F-18 FDG PET is a powerful tool for Radiotherapy planning and staging. To use PET imaging in Radiotherapy planning, a standard and accurate GTV delineation method has to be implemented, which remains as a major issue to date in this field[1]. In this study we tried to find out the correlation of different parameters of PET scan like Target to Background ratio and volume to the suitable threshold selection. Aim: The aim of this study is to find out the correlation between Target to background ratio, threshold and the volume to develop an automatic GTV delineation algorithm based on adaptive threshold method in PET images. Method: A phantom containing 6 spheres of volumes ranging 6ml to 150 ml was made. The selection of the range of sphere volume is according to the usually treating head and neck tumor volumes. The spheres and background were filled with F-18FDG for getting different T/B ratios and the images were analyzed to get a threshold that is in best fit to the filled volume. The thresholds for same volumes in different T/B ratios were taken. All these data were analyzed statistically. Result: Change in threshold was found to be independent of changes in volume within the range 6ml to 150 ml and the threshold was also independent of T/B values. However a weak correlation exists between T/B and threshold which is shown by the Pearson's correlation test and the p-value obtained was p=0.016. From the experiment we observed the threshold varies in the range of 22 to 31 for the volumes ranging from 6 to 150 ml and T/B ratio ranging from 8 to 44. Mean threshold was 27. Conclusion: Threshold calculation for segmentation of large tumors in the range of 6 to 150 ml is independent of volume and almost independent of T/B. When the range of tumor volume is between 6 to 150 ml and the T/B ratio is between 8 to 44, a fixed threshold of 27 which is the mean of thresholds we observed from our experiments can be used for tumor delineation.

Commissioning of electron beams and evaluation of dose profile at photon electron junction

Susan K. Abraham

E-mail: [email protected]

Aim/Objective: To commission the electron beams and to evaluate dose profile at the junction of abutting photon electron beams. Electron beam commissioning is the process of acquiring all beam data like percentage depth dose (PDD), beam profile, and output factors, required for clinical implementation of the linear accelerator. To evaluate the dose profile at the junction of photon electron beams, film dosimetry was performed. Methods and Materials : This study was performed in Clinac 2100 C/D linear accelerator that produces both photon and electron beams. The electron beams data was measured for the different electron energies (4, 6, 9, 12 and 15 MeV) using Radiation Field Analyzer (RFA) (PTW Nucletron). MEPHYSTO mc2 software was used for beam data measurements and the collected data was converted into Eclipse "ASC" file format using PLAMO Eclipse software.Markus PTW parallel plate chamber with a sensitive volume of 0.02 cc was used for measuring the PDD. Beam profiles were measured using 0.125 cc ion chamber (PTW) by moving the chamber in lateral and longitudinal direction for various depths. The output measurement of electron beam was done as per the Technical Report Series 398. A single direct electron field and combination of photon electron fields were generated on phantom in the TPS using the measured beam data. The generated plan was exposed onto the phantom by keeping EBT (gafchromic) film parallel to the central axis of the beam. The measured dose distribution on the film and the calculated dose distribution in the TPS were compared using PTW Verisoft software. Results and Discussion : For electron energies 9 and 12 MeV, the beam data parameters corresponding to each applicator size was imported and the beam data was calculated successfully and then approved. For single direct electron fields, Gamma analysis was performed and the dose to gamma criteria passed with gamma index criteria of 5%/5mm. Comparison of flatness and symmetry, from the beam profile, showed a standard deviation of less than 1%. The slight deviations however found were assumed to be due to certain set up errors in the phantom dosimetry. For combination of photon electron abutting fields, dose variations along the junction were analysed using Verisoft software and regions of over dose and under dose were identified. The deviations were found to be within the acceptable limits with the TPS data. Conclusion: The beam data were collected for electron beams and the data were imported into Eclipse planning system. Using that data several plans were generated and verified using gafchromic films. Based on our results we concluded that these beam data's could be used for treating the patients with electron beams. Based on the dosimetric analysis for abutting fields an optimal distance of separation was recommended for reducing hotspot in the region of photon electron junction with an acceptable under dosage in the region of separation between the photon and electron beam.

Estimation of lung tumor motion using retrospective 4DCT: Experience at Tata Memorial Hospital

Udita Upreti

Department of Medical Physics* and Radiation Oncology#, TMC, Mumbai. E-mail: [email protected]

Introduction: Patient breathing leads to tumor motion in thoracic regions which might have impact in precise delivery of radiotherapy. The quantification and pattern of tumor motion is required for estimating the margins for internal target volume and also useful to decide the gated radiotherapy delivery. Aims and Objective: Present study aims to estimate the motion of lung tumors and its relation to lobar location. Material and Methods: 51 consecutive patients diagnosed with Ca lung were selected for the study. 4DCT scans were acquired for patients (GE Lightspeed16 CT scanner). Breathing patterns were monitored using RPM system (Varian). Patients were instructed and trained to maintain their natural breathing pattern consistently during the 4DCT scan. The 4DCT data was binned (GE AdvantageSim workstation) in 10 respiratory phases and phase errors were quantified. Tumor motion was estimated in each phase. End-expiration phase (50%) was taken as reference. Differences in tumor motion were analyzed for laterality (left vs right lung) and its lobar location. For right lung, motion in upper lobe tumors was compared with middle and lower lobe however for left lung, upper and lower lobe tumor motion was compared. Results: Large phase errors (mean 25.8%, max 44%) and short breathing cycle was observed in 9 patients who were excluded from analysis. Mean±SD population phase error of 42 patients was observed as 8.15±2.54%. Tumor motion was observed in 29 out of 42 patients (69%), however no tumor motion (±1mm) was found in 13/42 (31%) patients. The magnitude of tumor motion was dependent on anatomical location of the tumor. The mean±SD mm (range) motion (≥5mm) in the superior-inferior, antero-posterio and lateral direction was found to be 4.31±5.96 (0-25 mm), 0.42±1.69 (0-12.5 mm) and 0.43±2.85 (0-5 mm) respectively. In superior-inferior direction motion (> 5mm) were observed in 9/42 (21%) patients, medio-lateral motion (≥ 5mm) was observed in 5/42 (12%) patients however anterio-posterior motion (≥ 5mm) was observed only in 2 (4.7%) patients. Overall, least motion was observed in between 40% to 60% phases. Motion of tumor located in lower lobes for both lungs was found larger than upper lobes. Tumors located in lower lobe of right lung shown largest motion (mean 8.82, SD 6.36) compared to lower lobe of left lung (mean 4.38, SD 2.39). Conclusion: From the results of the present study, we conclude that the tumors of upper lobe, tumors attached to the ribs and mediastinum and large volumes tumors do not require 4DCT as part of the assessment of tumor motion for radiotherapy planning. In our Institution where majority of patients present in the locally advanced stage of lung cancer approximately 1/5th (motion>5mm) would require some form of motion management techniques. Gated treatment can be preferred for the tumor motion more than 15mm and between 40% to 60% phases for the tumors located near the diaphragm and middle lobe. The maximum tumor motion was found in superior-inferior direction, as compared to lateral and anterio-posterior direction, and hence differential margins for CTV/PTV could be considered.

Advances in Radiation Treatment

Can daily image guidance be avoided for helical tomotherapy in head and neck cancers? A prospective validation of an offline image guidance protocol (F5 Study)

Animesh Saha

Tata medical center, kolkata. E-mail: [email protected]

Introduction: Daily image guidance is the default practice in Helical Tomotherapy (HT). This can be a time consuming resource-intensive process, which may not be essential in head and neck (H and N) radiotherapy where effective immobilization is possible. We had retrospectively assessed a large dataset of more than 100 patients where on a simulated assessment we found than an offline protocol implementing average shifts from the first 5 fractions enables us to safely avoid daily imaging. Aims and Objective: To prospectively validate that a No-Action-Level (NAL) offline protocol implementing the average shifts derived from the first 5 fractions can be an acceptable alternative to daily imaging for HT for head and neck cancers and to quantify the time and imaging dose that can be saved with this protocol. Material/Methods: 45 H and N cancer patients were planned for recruitment. This initial report is on the first 12 patients recruited with a total of 353 fractions treated. All patients were immobilised with a five clamp thermoplastic head and neck mask. Daily MVCT scan was performed using normal imaging mode covering adequate margin of PTV and always including the base of the skull. The image matching was done by matching the C1/C2 vertebrae for upper neck tumours and by matching the C3/C4 vertebrae for lower neck tumours (larynx, hypopharynx). Average shift of first 5 fractions was calculated and for the subsequent fractions daily imaging was done after setting the patient to the CT isocenter and implementing the average shift daily. For subsequent treatment fractions, we performed imaging to calculate the residual shifts along with residual systematic error (∑) and random error (σ) in each of the three axis i.e, lat(x), long(y), vert(z). We measured the time taken for daily imaging and correction of errors from the 6th fraction onward. Phantom dosimetry for imaging dose was also done. Results: After implementing the average shift from the first 5 fractions, residual errors > 5m occurred only in 1%, 2.7%, 3.1% in x,y and z axes respectively. The residual systematic and random errors found were ∑x,y,z of 0.8, 0.9 and 1mm and σ x,y,z of 1.9, 1.9 and 1.9mm with a required PTV margin in x,y,z axes of 3.5, 3.7 and 3.9mm. The PTV margin for translational vector was 2.5mm. The average time saved per fraction if imaging and matching was avoided was 5.1 min (37% of in-room time). Average imaging dose in central axis of cheese phantom for a 15cm scan length was measured at 3.2 cGy, 1.6cGy and 1.1cGy for fine, normal and course imaging modes, representing reduction of imaging dose by 27-80cGy per treatment course. Conclusion: Initial results suggest that the NAL offline protocol implementing average shifts from the first 5 fractions enables us to safely avoid daily imaging if a PTV margin of ≥ 4mm is used. This results in substantial time saving and reduction of imaging dose.

Successful use of deep inspiratory breath-hold gating technique to reduce the dose to the left anterior descending coronary artery in patients receiving radiotherapy for left-sided breast cancer

Mathangi J, Jayanthi S.Tumsi, Yashashwini, Lokesh, S. Nirmala

Global Cancer Institute, BGS Global Hospital, Bangalore

E-mail: [email protected]

Background: Deep inspiratory breath-hold (DIBH) is a technique aimed at reducing radiation dose to the heart by using hyperinflation of the lungs to distance the heart from the tangential radiotherapy fields. Aim: This study aims to investigate the change in radiation doses to the heart and left anterior descending coronary artery (LAD) with this gating technique. Methods : Thirty patients with left-sided breast cancer were treated with postoperative adjuvant radiotherapy with TrubeamSTx linac, between March 2013 and July 2014, in deep inspiratory breath-hold phase using the RPM gating system. All had two radiotherapy treatment plans: one with respiratory gating, the second a back-up free breathing plan. Using the Varian Eclipse radiotherapy planning system, the heart and LAD were contoured as organs at risk. Mean and maximum doses to the heart and LAD were compared for the gated and free-breathing plans. Correlation between percentage reduction in mean heart dose and percentage reduction in mean LAD dose was assessed, to see whether an improved mean heart dose could be used as a surrogate for improved mean LAD dose. Results: Mean heart dose reduced from 4.27 Gy to 2.41Gy with gating (44% reduction, p<0.01). Maximum heart dose reduced from 53 Gy to 48 Gy (10% reduction, p<0.01). Mean LAD dose reduced from 25.74 Gy to 17.3 Gy (33% reduction, p<0.01). Maximum LAD dose reduced from 52.5Gy to 44.2Gy (16% reduction, p<0.01). Correlation between percentage reduction in mean heart dose and maximum heart dose with gating and percentage reduction in mean and maximum LAD dose with gating showed a strong positive correlation (rs=0.973, p=0.000; rs= 0.767, p=0.000 respectively). Conclusions: This deep inspiratory breath-hold gating technique significantly reduces radiation dose to the heart and LAD, thereby reducing the risk of late radiotherapy-related cardiac toxicity.

Carotid artery dose in glottis cancer: A dosimetric comparison of three radiotherapy techniques

Nanditha Kishore, Vijayanand P. Reddy, Sajal Kakkar, Vinitha Reddy, Kausik Bhattacharya, Revathy and Tamil Selvan

E-mail: [email protected]

Introduction: Various retrospective studies have shown that radiotherapy to neck increases the risk of cerebrovascular events. Given the long term survival of stage I Glottis carcinoma patients, whether reducing the dose to carotid arteries by the new conformal techniques, can henceforth reduce the risk of cerebrovascular events is studied. Aim : To retrospectively compare dose received by carotid arteries in patients of stage I Glottic cancer treated with Radical Radiotherapy using various Radiotherapy Planning Techniques like 3DCRT, IMRT and Volumetric Arc Therapy. Methods and Materials : Simulation CT data sets of 12 patients (ten male and two female) treated with Radical radiotherapy for stage I Glottis Carcinoma from January 2011 to January 2012 were retrieved from the Eclipse Treatment Planning System data base. Patients with recurrent vocal cord carcinoma, past history of CVA/TIA and patients who received radiotherapy to neck previously were excluded. Three plans for each patient were generated in Eclipse TPS version 8.6 with conventional 3DCRT, IMRT and VMAT techniques as per department protocol. After planning the bilateral carotid arteries were contoured in each patient extending from 1cm above to 1cm below the Planning target volume (PTV), to document the dose received by carotids without any efforts to control the dose to carotids. All selected patients received median dose of 66Gy in 30fractions at 2.2Gy per fraction. Mean dose and mean Volume of carotids receiving 50Gy (V50) was calculated in each patient from their respective dose volume histograms. Results : Median age of the study group is 62years (Range 52-76years).Mean dose to carotids in 3DCRT, IMRT and VMAT were 65Gy, 55Gy and 53Gy respectively.Mean V50 of carotids in 3DCRT, IMRT and VMAT were 3.33cc, 2.53cc and 2.25cc respectively. A Repeated-measures Analysis Of Variance (ANOVA) of the results provided statistical estimates of the differences between the following pairs of techniques: 3DCRT vs. IMRT, 3DCRT vs. VMAT, and IMRT vs. VMAT. There is a significant difference (p = 0.02) between the 3 techniques.The unpaired t test shows that 3DCRT technique has significantly higher Mean dose and V50 values than other two groups (with p- 0.01) and there is no significance difference between VMAT and IMRT techniques. Conclusion : Inadvertently, there is a significant reduction in the dose received by the carotid arteries with IMRT and VMAT techniques as compared to 3DCRT, even if they were not considered as organ at risk while planning. Radiotherapy to the neck is known to enhance the risk of cerebrovascular events due to increased incidence of atherosclerosis. Implementation of high precision techniques like IMRT, VMAT may reduce the risk of carotid artery damage without effecting tumor control. Further prospective studies are needed to ascertain whether this dosimetric data translates into any meaningful clinical benefit.

Frameless novalis LINAC based radiosurgery for trigeminal neuralgia- A case report and literature review

Nivalika Rajamoni, M.B.B.S., Niteen B. More, M.D., D.N.B., Lalitha S. Kameshwari, M.B.B.S., Krishnamurthy K, M.Sc., Dip. R.P., Ph.D., P.B.L.D. Prasad., M.Sc., Dip R. P.

Department of Radiation Oncology, Krishna Institute of Medical Sciences, Hyderabad. E-mail: [email protected]

Background: Trigeminal neuralgia (TN) is a disabling pain with a profound impact on quality of life. It has classically been treated using either medical or surgical techniques. For patients with medication-refractory TN, stereotactic radiosurgery (SRS) directed at the affected nerve root has come out as an effective alternative. But the majority of published data deals with frame based Gamma Knife technology(1, 2, 3) and very few reports describe non-invasive frameless systems especially with linear accelerators. (4,5). Purpose: Our objective is to deliver LINAC based Radiosurgery for Trigeminal Neuralgia with submillimeter accuracy using non-invasive frameless system with image guidance using ExacTrac IGRT system. Method: A 59yr old elderly female with no known comorbidities presented with the complaints of constant pain radiating from the right ear down to the angle of the mouth and chin since 4yrs. She was refractory to medical management and had partial response after radiofrequency ablation of the right trigeminal ganglion. Her Barrow Neurological Institute Pain Intensity Score (BNI) at presentation was of grade V (continued severe pain without relief). After thorough evaluation she was taken up for SRS treatment. Initially a specialised thermoplastic SRS immobilization mask was made to the patient head. CT scan was performed using a CT localizer box. Magnetic Resonance Imaging was done using radiotherapy planning protocol. Utilizing Brainlab iPlan TPS software, fusion was performed between CT and MRI images and treatment planning was done. A 6mm cone was used for planning with the isocenter placed at the Root Entry Zone (REZ) of the trigeminal nerve. 50% isodose line was kept tangential to the brainstem. A modified butterfly shaped beam arrangement was planned with 12 arcs. A dose of 76Gy in single fraction was prescribed to the REZ isocenter of the trigeminal nerve. Isocenter stability for Novalis Tx was estimated using the Winston-Lutz test. Patient specific dose delivery quality assurance accuracy was confirmed by film dosimetry. Prior to treatment, a verification cone beam CT was performed and setup reproducibility was verified using ExacTrac 6D Robotic couch. Continuous monitoring of localization accuracy was performed for every arc and treatment was delivered with submillimeter accuracy and less than 0.2 degree rotational deviation. Patient was kept on follow up and pain response was recorded at initial 4-8 week follow-up, and serially at 3-month intervals using BNI pain intensity score. Result: After 1 month Patient had maximal pain relief of BNI- II (occasional pain, requires no medication) and it was maintained thereafter till the present follow up of 12 months. She also had no complications due to treatment. Conclusion: Frameless Novalis LINAC radiosurgery, with appropriate technique and delivery, appears to be a safe and effective alternate for gamma knife radiosurgery for patients with medication-refractory trigeminal neuralgia.

Evaluation of large field IMRT versus RapidArc planning for carcinoma cervix with para-aotic node irradiation

Kothanda Raman S, Girigesh Yadav, Manindra Bhushan, Lalit Kumar, Suresh T

Medical Physics Division and Radiotherapy Department, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi - 110 085, India. Email- [email protected]

Introduction: Intensity Modulated Radiation Therapy (IMRT) and RapidArc techniques are widely used in radiotherapy to treat the patients in order to give more conformal radiation dose to target volumes and less dose to the normal tissues. The objective of this work is to evaluate and compare Large field IMRT and RapidArc planning for Carcinoma Cervix with Para-aotic node irradiation. Material and Methods: In this study, ten patients of Cervix with para-aotic node have been selected with Planning Target Volume length 35+2 cm. All plans were generated in Eclipse (Varian Medical Systems, Palo Alto) Treatment Planning Systems (V.10.0) with Dynamic IMRT and RapidArc technique using 6MV photon energy. In IMRT planning, 7 coplanar field at gantry angle 180°, 130°, 80°, 30°, 230°, 280° and 330° was chosen to get optimal plan and in RapidArc, double arc clockwise (181° -179°) and counter clockwise (179° -181°) were used for planning with collimator rotation of 30°,330° for clockwise and counter clockwise arc respectively. All the plans were generated with single isocenter to avoid junction overdose in double Isocenter. For all the cases the prescribed dose to PTV was same and the plan acceptance criteria are; 95% of the PTV volume should receive 100% prescribed dose. The tolerance doses for the OAR's is also taken in to account. Dose constrains was same for both the techniques. The evaluation criteria used for analysis are; 1) Homogeneity Index(HI) D95%/D5% where D95% is dose to 95% of target volume and D5% is dose to 5% of target volume, 2) Conformity Index(CI):Treated volume enclosed by a given isodose surface(TV)/Planning target volume(PV), 3) Mean Dose to OAR's like bladder, rectum, femoral head, and kidney's 4)Total monitor units delivered. Results and Conclusion: Dose-volume analysis were performed for both IMRT and RapidArc planning. In both the plans, 95% of PTV volume receives prescribed dose and maximum dose are less than 107%. The conformity index are same in both the techniques. The mean Homogeneity index are 1.036 and 1.053 for IMRT and RapidArc plan. The mean (mean + SD) dose of bladder and rectum in IMRT is 44.2+1.55, 42.05+2.52 and RapidArc is 46.66+1.6, 44.2+2.75 respectively. There is no significant difference found in Right Femoral head, Left Femoral head and Kidney doses. It is found that total MU's are more in IMRT compared with RapidArc planning. Hence we conclude that, in the case of cervix with Para-arotic node single isocenter irradiation, IMRT planning in large-field is better compared to RapidArc planning in terms of Homogeneity Index and mean dose of Bladder and Rectum.

Cranio-spinal irradiation in medulloblastoma with three-isocenter IMRT planning: An analysis based on dosimetric indices

Pooja Gupta, Shajahan, Rohini Khurana, Madhup Rastogi, S. P. Mishra, M. L. B. Bhatt

Department of Radiation Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh. E-mail: [email protected]

Introduction: Cranio-spinal irradiation is an established treatment method for primary tumors like Medulloblastoma. Achieving appropriate doses to entire neuraxis during CSI planning has always been a challenge. Emerging radiotherapy techniques, such as three-dimensional conformal radiotherapy (3DCRT) and intensity modulated radiation therapy (IMRT) provide option beyond conventional technique such as feathering junction technique used in CSI treatment. IMRT technology can offer better conformity Index (CI) and homogeneity index (HI) than traditional multi-field 3DCRT in complex target areas. Inverse treatment planning with IMRT reduces the difficulty of planning and implementation as well. These two advantages are particularly important in CSI. Reducing the complexity of treatment plans and shortening treatment time will make the treatment more reliable and improve the overall treatment quality. For this purpose, we have developed a simplified IMRT technique called three-isocenter overlap-junction (TIOJ) IMRT. The goal is to simplify the implementation of the treatment plan, ensure satisfactory CI and HI, and reduce the time needed for planning and implementing CSI treatment. We present here the Dosimetric indices of CSI planning using TIOJ IMRT technique. Aims and Objectives: To evaluate TIOJ IMRT technique for Cranio-spinal irradiation (CSI) treatment in Medulloblastoma. Material and Methods: Image and planning data of three retrospective patients of Medulloblastoma during the period October 2012 to august 2014 treated with CSI were recovered and the prescription was 36 Gy in 20 fractions. Treatment plan was created with new technique called three-isocenter-overlapped-junction (TIOJ) IMRT technique. The study was conducted using the parameters of heterogeneity index (HI), conformity index (CI), and doses to the organs at risk (OARs). IMRT plans for all patients were generated using Mosaic treatment planning system Elekta Medical Systems. A 6MV linear accelerator equipped with multileaf collimator (MLC) was used to implement the treatment plan. Patient are on regular follow-up to assess long term toxicity. Result: Retrospective analysis of three patient of Medulloblastoma were reviewed. Mean CI and HI were found to be 0.993 ±.005 and 0.0406 ±.02 for PTV-Brain and 0.992 ±.005, 0.0295 ±.02 for PTV-Spine respectively. In case of PTV-Brain, maximum dose to Right and Left eye was 33.6 ± 2.08 and 32.8 ± 4.70, RT and LT Lens 7.38 ± 1.25 and 7.23 ± 0.80, both optic nerves 34.5 ± 1.5, 33.4 ±.98 and parotids (mean dose) was 5.39 ±.26 and 5.39 ±.17 for RT and LT side respectively. In case of PTV-Spine, maximum dose to right kidney and left kidney was 18.6 ± 3.78 and 19.3 ± 2.8. Maximum dose to Liver was 22.38 ± 5.90. Conclusion: Treatment planning Dosimetric indices for CSI irradiation were evaluated for three patients. TIOJ IMRT is an effective technique for CSI and in achieving good dose distribution.

Efficacy of external beam radiotherapy for the management of refractory plantar fasciitis: A prospective study

Yashpal Verma

Medical Officer, Department of Radiotherapy, Pt. B.D.Sharma University of Health Sciences, Rohtak (India). E-mail: [email protected]

Purpose: To evaluate the efficacy of external beam radiotherapy for the management of refractory plantar fasciitis and to assess radiation induced side effects, including malignancy. Material and Method: The study was carried out in Department of Radiotherapy, PGIMS, Rohtak (India), on 36 diagnosed cases (56 heels) of plantar fasciitis. These diagnosed patients of plantar fasciitis having pain, refractory to medical treatment, were accrued for and given external beam radiation therapy (EBRT) during 2005-08. The dose of EBRT was 6 Gy in 6 fractions over 2 weeks (1Gy per fraction, 3 fractions per week), given on Telecobalt. Assessment was made for response - at completion of radiotherapy, after six months and one year following radiotherapy. Response was evaluated using Objective (Calcaneodynia) pain score and Subjective (Von pennewitz) pain score. Acute skin reactions were noted at completion of radiotherapy. Late event as radiation induced malignancy was noted after at least 6 years following treatment. Results: Six months following EBRT, complete/excellent response (CR) was observed in 62.5% heels, both by objective and subjective scores. Partial/good response (PR) was 16.1% on objective score and 23.3% on subjective score, minor/fair response (MR) was 12.5% and 7.1% and no/poor response (NR) was 8.9% and 7.1% respectively. One year after radiotherapy, Calcaneodynia objective score revealed CR, PR, MR and NR respectively were 80.4%, 7.1%, 8.9% and 3.6%. No progressive disease was found in any of the heels treated with radiotherapy during treatment or follow-up. No significant acute skin reaction was observed. None of the patients has reported with radiation induced or second malignancy so far. Conclusion: External beam radiotherapy offers very good treatment option for management of plantar fasciitis pain refractory to medical treatment. EBRT may be offered to patients, particularly older, without the historical fear of radiation induced malignancy. Though, equally effective in young patients, conclusive words regarding risk of long term side effects still need longer follow up.

Pallative Care

Comparison of single versus multiple fractions for palliative treatment of painful bone metastasis: First study from North West India

Akhil Kapoor, Mukesh Kumar Singhal, Saroj Kumari, Ramesh Purohit, Kamlesh Kumar Harsh, Harvindra Singh Kumar

Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Hospital, Bikaner, Rajasthan - 334 003. E-mail: [email protected]

Background: Bone metastasis is a usual cause of pain in advanced cancer. Conventional radiation schedules require larger hospital stay and thus, are unsuitable for patients with poor general condition. This prospective observational study aims to analyze the pain relieving efficacy of different radiation fractionation schedules- 8 Gy administered in a single fraction and 30 Gy in 10 fractions. Materials and Methods: 250 consecutive patients of bone metastasis were evaluated for the study with 63 patients being excluded due to non fulfilment of inclusion criteria. The response of radiotherapy leading to pain relief as per visual analog scale was recorded at the end of treatment, 8 days, 15 days and one month follow up visit. Results: 62% of patients received single fraction while the rest received 10 fractions. In 10 fraction group, overall response was present in 60%. Stable pain was present in 23% of the patients while 9% patients had progressive pain. At 1 month of completion of treatment, 9% patients lost follow up. In single fraction arm, overall response was seen in 58%, stable pain in 27% and progressive pain in 7% of the patients. 6% cases lost follow-up. Conclusions: Single fraction treatment for bony metastasis is at least as effective to relieve bony pain and also convenient to both the patient and the caregiver.

Analysis of patterns of palliative radiotherapy in North West India: A regional cancer center experience

Akhil Kapoor, Mukesh Kumar Singhal, Satya Narayan, Ramesh Purohit, Puneet Kumar Bagri, Harvindra Singh Kumar

Department of Radiation Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Hospital, Bikaner, Rajasthan - 334 003. E-mail: [email protected]

Background: Palliative radiotherapy (PRT) is the eventual requirement in 30-50% of all cancer patients. PRT is primarily aimed to relieve the pain, and prevent/treat collapse or fracture in case of bone metastasis, to reduce oedema in patients with cranial metastasis and to control distressing symptoms of rapid primary growth. An audit of the PRT planned in a busy cancer center can help in the characterisation of the requirements of the patients and the formulation of institutional policies accordingly. Methods and Materials: 516 patients who received PRT in our regional cancer center from January 2012 to December 2012 and whose complete records were available for analysis were selected for this retrospective study. Medical records and radiotherapy files were analysed to obtain data of sociodemographic parameters, prescription of PRT and follow-up. The descriptive statistics were evaluated in terms of frequencies and percentages to allow comparisons. Results: 73% patients were male; the median age of the patients receiving PRT was 62 years (range 13-83). 48% (n=248) patients received PRT at the primary site while rest (52%) were given PRT at the metastatic site. The most common indication of PRT was pain (56.8% of the cases), followed by cytostatic (19.8%) and raised ICT (12.4%). The median dose prescribed was 30 Gy (range 8 Gy to 36 Gy) delivered in one to 12 fractions over the duration of one to 18 days. The overall response rate was about 43% at 2 weeks of completion of PRT; the median follow-up of the patients was 154 days (range 9 days to 256 days). The long term symptom relief at median follow up was 8%. Conclusions: Good clinical judgement and expertise is required in prescribing correct fractionation schedule to achieve effective symptom palliation with lowest possible cost and inconvenience to the patients and relatives. Hypofractionated radiotherapy is a feasible treatment option in patients with advanced incurable disease to achieve effective palliation.

Squamous cell carcinoma Skin with metastasis to Mastoid: A rare case report

Routroy Biswaranjan, Mekap Himanshu Sekhar, Pujari Lincoln, Padhi Sanjukta, S. N. Senapati

Department of Radiation Oncology, A. H. Regional Cancer Center, Cuttack. E-mail: [email protected]

Case report: Squamous cell carcinoma is the second most common form of skin cancer (1). It is most frequently seen on sun-exposed areas, such as the head, neck, and back of the hands. Sunlight induced squamous cell carcinoma of the skin is common and produces low incidence of metastases. The biologic behaviour of invasive SCC depends on depth of invasion, degree of differentiation, site of lesion, immune status of patient. Metastasis is more likely from carcinomas related to other antecedent lesions (burns, scars, chronic ulcers, arsenical dermatosis, x-ray injury) or of unknown etiology (2). Organs prone to metastasis include regional lymph nodes, liver, lungs, and bone (3). The incidence is very low in Squamous cell carcinoma of skin cancer constituting about 1-2% in Indian scenario. Here we report a rare case of squamous cell carcinoma dorsum of foot metastasis to mastoid bone. A 45 year male patient presented in Oncology OPD, with history of swelling and discharge in left post auricular region, inability to close left eye and drooping of left angle of mouth. He had previously developed an ulceroproliferative lesion on dorsum of right foot since 6 months back and was diagnosed as invasive squamous cell carcinoma of skin and he had undergone surgery twice for local recurrence. Preoperative Post op. histopathology shows Invasive squamous cell carcinoma well differentiated T2 N0 M0, stage II. In CT scan neck irregular enhancing soft tissue attenuation mass noted over left mastoid, occipital bone, with destruction of left mastoid air cells. Trucut biopsy from left mastoid swelling metastatic invasive squamous cell carcinoma moderately differentiated. He was planned for palliative EBRT to mastoid followed by chemotherapy.

Nodular hidradenoma of left temporal region - A Rare Sweat Gland Tumor

Chandrima Banerjee

Institute of Post Graduate Medical Education and Research and SSKM Hospital. E-mail: [email protected]

Introduction: Nodular Hidradenoma is a rare, skin-appendageal tumor mostly of benign nature. It usually presents as slowly enlarging, solitary, freely movable, solid or cystic swelling. It is known to occur in 20-50 years age group with a female preponderance. Case Report: We herein report a case of nodular hidradenoma in an elderly male. Our patient a 63 years old male presented with an asymptomatic solitary mass lesion in the left temporal region of 6 months duration. It was gradual in onset and slowly progressive in size according to the patient. It was a reddish brown nodule of size approximately 3.5 x 2 cm at the time of presentation. On examination, no regional lymphadenopathy was detected and general physical and systemic examination was normal. Patient underwent an excisional biopsy. On gross histopathological examination - a well circumscribed intradermal benign tumor with both solid and cystic components was present. On microscopic examination the solid component consisted of two types of cells- numerous polyhedral cells and few clear cells without nuclear atypia. It was consistent with benign nodular hidradenoma. As the findings were benign, the patient was not given post-operative adjuvant treatment and has been under follow-up. Presently the patient is disease free during his last follow up at 19 months. Conclusion : Thus, we report here a case of Nodular Hidradenoma of left temporal region which is an uncommon benign epithelial tumor of eccrine sweat gland. It can occur anywhere in the body but the most common site is the head. It most commonly occurring in the age group of 20 - 50 years, twice more common in women than in men. This case report is to create awareness that though uncommon, it can also occur in elderly males and should be kept in mind while evaluating a patient presenting with such clinical features.

Radiotherapy Treatment gaps: incidence and causes.

Adnan Calcuttawala, Vedang Murthy, Jaiprakash Agarwal, Sarbani Ghosh Laskar, Ashwini Budrukkar, Tejpal Gupta

Introduction: Tumor growth occurs even during radiotherapy. Some tumors grow at an accelerated rate after a few fractions. There is compelling evidence available to prove that treatment interruptions result in poor local control rates especially in rapidly proliferating tumors. There is a necessity to develop a protocol in every radiotherapy department to prevent delay in overall treatment time by preventing the causes that lead to treatment gaps. To achieve this, a departmental audit had to be conducted to determine the incidence, the associated factors and the causes of treatment gaps in order to prioritize and channelize resources appropriately. Aims and Objectives: To determine the incidence of treatment gaps and the various factors associated with it, in patients with cancers of the head and neck region treated with curative intent in the year 2013 at Tata Memorial Hospital. Materials and Methods: Data for the radiotherapy treatment gaps and their causes were collected from the electronic record system, the radiation oncology information system and the personal case files and RT records as well. Various patient related and treatment related factors were correlated with the delay in overall treatment time mainly using the chi square test. Results: 761 patients were treated with a curative intent in the head and neck disease management group in the year 2013. 703 patients completed at least 90% of the planned treatment. Out of these 571 patients have faced a delay in their treatment corresponding to 81.2% and a mere 18.8% were concluded within the planned overall treatment time. Factors that correlated with significant treatment delay (≥4 days) were gender (female vs male 53.3% vs 43.6%) and technique (conformal vs conventional 66% vs 42.4%). Conclusion: Occurrence of treatment gaps is very frequent in our setup, gender and treatment technique being significant factors associated with the same. To our surprise conventional technique is associated with a lesser frequency of gaps in treatment as compared to conformal techniques. Causes for the treatment gaps are being looked into and will be completed soon.

Retrospective analysis of thymoma: Clinical experience from a South Indian tertiary care cancer hospital

Jacob John

E-mail- [email protected]

Introduction: Thymoma is a rare, slow growing tumor in the upper mediastinum. The current clinical practice recommendations for the management of are largely based on the retrospective data. We present the retrospective analyses of cases of stages II-IV thymoma treated in Regional Cancer Centre (RCC), Thiruvananthapuram from 2002 to 2010. Aims: To evaluate the clinical outcome of thymoma cases treated in our institution including Loco-regional control and Overall survival. Materials and Methods: Those patients registered and treated in RCC, Trivandrum will be included in this retrospective analysis. Details of clinical presentation, various treatments received and follow-up events will be analyzed. Discussion: There were 18 cases of thymoma stage II to IV, of which only 13 patients were evaluable. Median age of presentation was 41years and Male to Female ratio was 1.6:1. Six patients (46%) had Myasthenia gravis at presentation. Seven cases (53%) were of stage II, 3 cases (23%) of stage III and 3 cases (23%) were of stage IV at presentation. Eleven patients (84%) underwent surgery of which 3 patients received neo-adjuvant chemotherapy (NACT) with CAP regimen. 5 patients (45%) underwent complete excision of the tumor, 3 had partial debulking and 3 had only biopsy performed. Five patients had R0 (45%) resections, four had R1 resections and two patients had margin status unknown. Those patients who underwent neo-adjuvant chemotherapy had only incomplete resection. Eleven patients received postoperative radiotherapy, including one patient who was stage IV at presentation and received NACT. Median survival was 42.9 and 33.5months respectively for those who underwent complete and partial resections. The mean radiotherapy dose was 47.45Gy (range 36Gy to 50.4Gy in 1.8-2Gy per fraction).Majority of the patients received whole mediastinal radiotherapy with two dimensional techniques. Seven patients received ≥50Gy. All patients completed the radiotherapy without interruptions. Grade II esophagitis was the most common acute radiotherapy related toxicity. There were no grade III or IV acute toxicities. Six patients received postoperative chemotherapy as-well. Regimens include CAP (Cyclophosphamide, Adriamycin and Cisplatin) and Adriamycin + Ifosfamide. The mean number of cycles received was 4.3. Salvage regimens included Ifosfamide + Etoposide/Carboplatin (second line), Cisplatin + Etoposide/Cyclophosphamide(third line). The median PFS after second line chemotherapy was 6.77 months. Four patients had loco-regional recurrence after completion of multimodality treatments. One patient had distant metastatic relapse and 2 patients had asymptomatic residual lesion in the mediastinum. The mean time to loco-regional recurrence was 27.13 months (range 17.5-48.33). Median overall survival for stages II, III and IV was 42.9, 35.4 and 27.8 months respectively. At a median follow up period of 35 months, there were three disease related deaths. Conclusion: Masaoka stage and extent of surgical resection are the most important factors predicting survival. Although, NACT facilitates resection, it may not increase the chances of an R0 resection. Postoperative radiotherapy may improve loco-regional control and dose of ≥50Gy has better outcomes.

Prevention of nausea and vomiting in cancer patients undergoing chemo and radiotherapy: An investigational study

Mohammed Raees Tonse, Rithin Ravi, Saira Pais, Dipika Jayachander, Hasib A. G., M. S. Vidyasagar, M. S. Baliga

Father Muller Medical College, Mangalore - 575002, Karnataka, India. E-mail: [email protected]

Chemotherapy and Radiotherapy-induced nausea and vomiting remains both a feared side effect of cancer treatment and a primary focus of many supportive care initiatives/guidelines. It is associated with severe morbidity and causes significant deterioration in quality of life of the cancer patients. The emetogenic potential of the chemotherapeutic agents, repeated chemotherapy cycles, the radiation dose, the site of tumor, and patient risk factors like female gender, younger age, alcohol consumption and history of motion sickness are the major risk factors. A combination of dexamethasone, serotonin receptor antagonists and H2 blockers has been used with success in the prevention of chemotherapy induced nausea and vomiting from both moderately and highly emetogenic chemotherapy. The present study addresses the experience of our hospital in the reduction of chemotherapy and radiotherapy induced nausea and vomiting among cancer patients.

Retinoblastoma: A Retrospective Analysis pertaining to clinical characteristics and changing trend in the management of 141 patients (between 1983-2013) from GMCH, Nagpur

Kabre R. S., Kamble K. M., Diwan A. K., Mahobia V. K. Department of Radiation Therapy and Oncology, Govt Medical College and Hospital, Nagpur.

E-mail: [email protected]

Introduction: Retinoblastoma is most common intraocular tumour of childhood. It is a malignant tumor that originates from developing retina. Diagnosis is based on clinical signs and symptoms and is usually made in children under the age of five years. Nagpur cancer registry has shown incidence of Retinoblastoma as 0.1/100,000 population. A Retrospective analysis from 1983 to 2013 was done where total 173 patients of Retinoblastoma were registered but the records of 141 patients (162 eyes) were available for analysis. Aim: To evaluate Clinical profile, Management, Treatment and Follow up for Retinoblastoma patients at GMCH,Nagpur. Methods: The retrospective study is done by reviewing clinical records of 141 retinoblastoma patients (162 eyes). Personal, clinical and disease profile, as well as treatments and their results along with complications and outcome is analysed and being presented. Results: Of 141 patients, 81 (57.45%) presented in age group of 1-3 years. 81 (57.45%) males and 60 (42.55%) were females. 114 patients (80.85%) had unilateral, while 24 (17.02%) had bilateral and 3 (2.12%) had trilateral retinoblastoma. Most common presenting symptom was proptosis/swelling of eyes seen in 81 (57.45%) patients, followed by 36(25.53%) showing white eye/leukocoria. calcification as presenting sign was seen in 45(31.92%) patients. Family history for retinoblastoma was present only in 2 (1.41%) patients. 36 (25.53%) patients showed optic nerve and soft tissue involvement. Extracranial in 26(18.44%) and intracaranial involvement was present in 16(11.34%). surgery was done in 75(53.19%) patients in which 65(86.67%) underwent enucleation and 9(12%) were exentrated and 1(1.33%) patient underwent craniotomy. 139 eyes could be staged, as per International Classification of Retinoblastoma and Reese Ellsworth Classification, of which 85(61.15%) were in group E, 24(17.27%) in group D, 14(10.07%) in group C, 13 (9.35%) in group B while 3 (2.15%) in group A. 103(73.05%) were treated by EBRT. Adjuvant or neoadjuvant chemotherapy was received only by 46(32.62%) patients, majority being in latter half. Mean follow up of all patients was 112 days. Post op or post RT recurrence was seen in 54(38.29%). Majority of patients were lost for follow up, with disease 64(45.39%), followed by 43(30.49%) without disease, 16(11.34%) patients lost with disease status being unknown, and 18 (12.76%) patients died with disease. Conclusions: This study shows that retinoblastoma is characterised by late diagnosis and advanced stage at presentation. Most common age for presentation was between 1-3 years with unilateral disease being most common. Male preponderance was noted. EBRT was the mainstay of treatment, chemotherapy as an adjuvant treatment was added in latter half. Poor follow up of patients was noted as a major problem.

Benign reactive lymphoid hyperplasia of orbits: A case presentation

Vijay Kumar Kontham

Apollo gleneagles hospitals, Kolkata. E-mail: [email protected]

A 40 year old lady with known history of hypothyroidism for the last 8 years and on medication. Presented with swelling and pain of both eyes, this was there for last 6 years. There was not much progression in size for the first 4 years but, since last 2 years there was rapid increase in size of both orbits. Clinical presentation was proptosis and pain in both eyes. Vision was normal and no signs of extraocular muscle dysfunction. MRI suggested bilateral diffuse infiltrative lesions enveloping the globes and extra and intraconal compartments, moderate enlargement of extraocular muscles with fat plane obliteration, possibility of lymphoproliferative lesion. Biopsy taken from right lacrimal gland came out to be lymphoid hyperplasia not conclusive of lymphoproliferative disorder. IHC was positive for CD3, CD43, CD20, CD79a, CD5, CD25,Ki 67 increased, Cyclin D1 and Bcl2 negative. Whole body PET-CT revealed uptake in bilateral retro-orbital mass and in multiple sub cm nodes in various sites of unknown significance. Patient was started on radiotherapy by IMRT technique, dose delivered was 25.2Gy in 14 fractions over 3 weeks to each orbit. Follow up after 1 month revealed excellent response with no pain.

Urological cancers in Manipur- a single centre study

F. S. Desai. M.D.

Consultant pathologist and Head, Histocytolaboratory, Dr. N. Jitendra Singh. (MS, MCh. Urology), Assistant professor, JNIMS

Urological cancers are composed of cancers of the kidney, adrenal gland, upper urinary tract, urinary bladder, urethra, Prostate, testis, penis. Cancer spectrum in a region is dependent upon various genetic, environmental, dietary and social factors. The present study was therefore conducted to analyze the frequency, clinical presentation and the histopathological Types of the various Urological cancers diagnosed in our center. In a retrospective study, 43 urological cancer cases were found in histopathology records from June 2012 to June 2014, Among which adult Renal carcinoma were (6.9%), Upper urinary tract carcinoma (13.9%) with M:F ratio (0.2:1), Urinary bladder carcinoma (48.8%) with M:F Ratio (1.3:1), Urethral carcinoma (2.3%), prostatic carcinoma (25.5%), Testis (2.3%), Penis (2.3%). Urothelial carcinoma of urinary bladder and prostatic carcinoma were found to be common malignancies in male while urinary bladder cancer was found to be the most common malignancy in females. Most common histopathological types were High grade urothelial carcinoma in urinary bladder and adenocarcinoma in prostate.

IGRT estimation of setup errors -First Time RCC Institutional experience in North East India

Fahim A. Hassan 1 , Vikas Jagtap 1 , A. K. Kalita 1 , M. Bhattacharjee 1 , S.Goswami 1 , Manoj Kalita 2

Department of Radiation Oncology; Dr.B.Borooah Cancer Institute, Population based Cancer Registry; Dr.B.Borooah Cancer Institute. E-mail: [email protected]

Background : Estimation of setup errors is necessary for any radiotherapy treatment planning and ensuring proper coverage of tumour and hence prescribing the adequate CTV to PTV margin. The aim of this study was to estimate the setup errors using IGRT i.e. cone beam CT (CBCT) using Elekta Synergy treatment unit for different tumour sites and prescribing the optimum margin in radiation therapy. Method : 14 sets of data of patients were analysed retrospectively from the IGRT console of the treatment unit, out of which 11 patients had Head and Neck tumours and 3 patients with brain tumours. Anterior-posterior(y),cranio-caudal(z)and medial-lateral(x) deviations were collected from each patient. CTV-PTV margins were computed using ICRU 62, and Van Herk's formula. Results: The mean displacements in medio-lateral(ML),anterior-posterior(AP) and superior-inferior(SI) direction was -1.07mm(+5.4mm to -5.5mm),0.12mm(+8.1mm to -3.9mm) and -1.98mm(+3.8mm to -6.7mm) respectively for Head and Neck tumours. Similarly for brain tumours translational displacements in medio-lateral (ML), anterior-posterior (AP) and superior-inferior (SI) direction was.56mm (-1mm to 2mm).,76mm (-3.8mm to 5.2mm) and.32mm (-1.1mm to 2.3mm) respectively. The population systemic error (Σ) in ML, AP and SI direction was 2.1mm, 1.3mm and 1.7mm respectively and the population random error (σ) in the corresponding direction was 2.5mm, 2.3mm and 2.5mm respectively for head and neck tumours. Similarly for brain tumours the population systemic error (Σ) in ML, AP and SI direction was 0.4mm, 1.2mm and 1.2mm respectively. The population random error (σ) in the corresponding direction was 3.1mm, 2.8mm and 1.2mm respectively. Using Van Herk's formula the CTV-PTV margin in the ML, AP and SI direction were 7.08mm, 4.9mm and 6.25mm for head and neck tumours. For brain tumours the CTV-PTV margin in the ML, AP and SI direction were 3.2mm, 5mm and 4mm respectively. Using the ICRU recommendation the CTV-PTV margin in the ML, AP and SI direction was 3.28mm, 2.68mm and 3.13mm respectively for head and neck tumours. For brain tumours the CTV-PTV margin in the ML, AP and SI direction were 3.1mm, 3.1mm and 1.7mm respectively. Conclusion: The present study reveals a required PTV margin of 7-8mm for head and neck tumours and 5mm for brain tumours as calculated from Van Herk's formula. The setup error measured with kv cone beam CT using elekta synergy in our institute was greater as compared with published reports in literature. This may be the result of intratreatment weight loss, changes in tumour volume during the course of treatment thereby affecting the setup accuracy with reference to the planning CT. Analysis of institution's specific setup errors using CBCT or other volumetric imaging is encouraged for determining PTV margins, because setup errors vary according to immobilization system used and patient tumour characteristics and general condition.

Assessment of pre-treatment and post treatment serum copper status in cancer patients

H. Lakhipyari Devi, Arpita Das Th. I. Devi, M. A. Singh

Department of Biochemistry, RIMS, Imphal, E-mail: [email protected]


Introduction: Microelement metabolic disorder constitute important field of cancer studies useful and has proved to be very useful in the diagnosis, staging and prognosis of cancer. Aims and Objectives: To assess pre-treatment and post-treatment serum copper level in patients with different types of malignancies. Materials and Methods: A case-control study was conducted in the Department of Biochemistry, RIMS, Imphal from January 2013 to July 2014 including 50 patients aged 10-80 yrs already diagnosed as solid tumours of different parts of body clinically staged and confirmed by histopathological examination as cases and 50 age and sex matched healthy subjects were taken as control. Serum copper level was estimated by calorimetric Di-Br-PARSA method. Results: The mean ± SD value of copper was significantly increased among malignant cases (221.19±66.20) compare to controls (121.85± 5.54) (p<0.001). Post treatment serum copper level for different types of malignancies like GIT (160.45±36.28), Nasopharyngeal carcinoma(158.88±26.41), Hepatobiliary cancer(180.18 ±14.65), Breast cancer(174.4±16.39), Cervical cancer(162.45±17.65), Prostate cancer (152.00±14.42), Lung cancer(174.67±42.90) and Misc(154.53±15.13) exhibited a significant decrease (p<0.05) irrespective of site and type of treatment compared to pre treatment 190.18±53.73, 181.13±22.37, 259.45. ±44.84, 206.00±36.47, 199.36± 34.06, 175.00±11.27, 247.67±130.43 and 177.67±22.68 respectively. Conclusion: The study indicates serum copper level increases in malignant cases which declined significantly after treatment. Serum copper might be a valuable biochemical index and biomarker in diagnosis of cancer and disease progression.

Primitive neuroectodermal tumor kidney

K. L. Jayakumar, Naseeba K. T.

Department of Radiotherapy and Oncology, Medical College Trivandrum, Kerala. E-mail: [email protected]

Background : Primitive neuroectodemal tumor, first described by Stout in 1918, composed of small uniform round cells, characterized by translocation resulting in fusion transcript of EWS gene and ETS-related family of oncogenes. Renal PNET a member of Ewing's sarcoma family is rare, first described by Mor-et-al in 1975. Most publications are case reports, with largest case series included 79 patients described by Parham-et-al in 2001.We report a case of sixteen year old boy with rPNET and review of literature. Case report : 16 year old boy admitted with history of abdominal pain for 3 months, and one episode of hematuria. Clinical, baseline hematological and urine examinations were within normal limits. Abdominal USG showed ; renal mass of 6.3 x 5.2cm in lower half. CT abdomen showed well defined mass lesion in mid and lower pole of ; kidney measure 6 x 5cm with heterogeneous peripheral enhancement and central non enhancing necrotic areas. Patient diagnosed as renal carcinoma and radical nephrectomy done. Macroscopically, grayish-white ill circumscribed mass 6x5.2x4.5cm with necrotic area in lower pole of kidney extending close to renal pelvis seen. Renal vessels, renal sinus and ureter were normal. Microscopically small uniform cells arranged in sheets with indistinct cell borders, scanty eosinophilic/clear cytoplasm, with few pseudo rosette formations. Perinephric infiltration seen. Immunohistochemistry showed diffuse positivity with CD99 (MIC-2 gene product), focal faint positivity with Chromogranin, negative for cytokeratin, LCA, desmin and myogenin. Cytogenetic study is under process. CECT thorax, bone scan and bone marrow study were normal. Patient started on chemotherapy with VAC alternating with IE regimen (Vincristine, Adriamycin,Cyclophosphamide, Ifosfamide,etoposide). Discussion : rPNET behaves more aggressively than PNET of other sites. Commonly seen in Children and young adults, 25-50% presents with metastatic disease with 5-year DFS of 45-55%. Median relapse free survival is 2years. Response to therapy is poor. Clinically and radiologically rPNET is similar to other renal tumors and diagnosis depends on pathologic characteristics and biomarkers. rPNET is characterized by small uniform round cells. IHC showing CD99 is crucial in the diagnosis and seen in more than 90%. Neural markers like neuron-specific-enolase, chromogranin-A, synaptophysin, S-100 may be positive. Cytogenetic analyses reveal reciprocal translocation t(11:22) (q24:q12) in 85% patients. Treatment is surgical resection followed by chemotherapy +/- radiotherapy. The role of radiotherapy is not clear, but it may be advocated in locally advanced disease and involvement of Gerota's fascia. Myeloablative chemoradiotherapy followed by autologous bone marrow rescue also considered. Conclusion: rPNET is a distinct entity with a poor survival, despite combined modality treatment. Immunohistochemistry for CD99 and cytogenetic studies are essential in diagnosis. This case report emphasis the awareness of this rare tumor.

Clinical study of induction chemotherapy followed by concurrent chemoradiation in locally advanced carcinoma cervix

Sheet Saikat, Bose Chaitali, Parida Sailendra, Panda Niharika, Padhi Sanjukta, Senapati Surendranath

Department of Radiotherapy, AHRCC, Cuttack. E- mail: [email protected]

Introduction: Cancer of the uterine cervix is the second most common cancer among women worldwide. Incidence is particularly high in developing countries. It is the commonest malignancy in females in India comprising around one third of all cancers cases. Aims and Objectives : 1) To see the response rate to neoadjuvant chemotherapy with Paclitaxel and Carboplatin followed by concurrent chemoradiation Vs chemoradiation only in locally advanced carcinoma cervix. 2) To compare the toxicity of the neoadjuvant chemotherapy followed by concurrent chemoradiation with patients who received only chemoradiation. Methods and Materials : 44 histopathologically confirmed locally advanced Carcinoma Cervix patients were divide into two arms. In ARM-A 22 patients were taken and they received external beam RT of 50Gy in 25 fractions followed by HDR intracavitary brachytherapy 7Gy/# in 3 fractions. During EBRT patients received concurrent weekly Cisplatin 30mg/m 2 . 22 patients in Arm -B received 3 cycles of neoadjuvant chemotherapy with Paclitaxel (175 mg/m 2 ) and Carboplatin as per the Calverts formula AUC-6 (3 weekly regimen).Two weeks after completion of neoadjuvant chemotherapy, patients were subjected to chemoradiation followed by HDR Intracavitary brachytherapy 7Gy/# in 3 fractions. Response to treatment was assessed after completion of EBRT, 6 weeks after completion of treatment and at 3months interval thereafter for 1 year. Response was assessed clinically. Results: Response is better in Patients receiving neoadjuvant chemotherapy followed by chemoradiation arm than only chemoradiation arm i.e. 81.81% vs 63.63%, 6wks after completion of radiotherapy. During the follow up at 3 months 86.66% patients in ARM-B were surviving without disease but only 59.09% patients in ARM-A were surviving without disease. Mainly Gr II anemia was observed in the two arms. More than half of the patients in both the arms developed Gr II and Gr III skin reactions. Gr II nausea and vomiting was noted in majority patients in ARM-B those who received neoadjuvant chemotherapy. Mild degree of peripheral neuropathy was observed in patients receiving neoadjuvant chemotherapy. Only 4 patient out of 22 patients in ARM-B developed febrile neutropenia which can be well managed without any difficulties. The observed acute and late toxicities were not found to be statistically significant in the two arms. Conclusion: According to our study, neoadjuvant chemotherapy with Paclitaxel and Carboplatin has got a definite beneficial role in the treatment of locally advanced carcinoma cervix patients. The side effects of the chemotherapeutic agents occurring during the period of neoadjuvant treatment are only mild and can easily be managed in a hospital. However, due to the small sample size and limited period of follow up, no definite conclusion could be drawn regarding the Disease free survival in these patients. Further follow up, is required to have more information regarding disease free survival and overall survival advantage .

Radiation as a tool inLarge B Cell Non-Hodgkin's Lymphoma of Left thigh- A rare case report

Subathira Balasundaram, Rathnadevi Ramadas, Janos Stumpf, Raja Thirumalairaj, Karthikeyan Perumal

Introduction: Nearly 25% of non-Hodgkin lymphomas (NHLs) arise in extranodal locations 1 .NHL is rarely encountered in soft tissue 2 . This study describes a rare case of chemo-resistant large B cellNHLof skeletal muscle, characterized by voluminous swelling in the thigh which responded well to radiotherapy. Observation: A 62 year old gentleman presented with swelling in the left thigh 2.5 years ago. His past history was significant for NHL left axillary region a year beforeand treated with radiotherapy. Excision biopsy of the left thighlesion was consistent with large B cell lymphoma. He was treated with sequential 6 cycles of chemotherapy - R-CHOP regimen followed by radiotherapy of 40 Gy in 20 fractions elsewhere. Follow-up imaging studies of left thigh showed multiple masses in the soft tissues of left thigh in 6 months duration.He was treated by salvage chemotherapy with Rituximab and Bendamustine regimen and was changed to R-ESHAP regimen (Ristova, Etoposide,Solumedrol, Cisplatin, Cytosar) after one cycle due to clinical evidence of refractoriness. Radiotherapy was given after 3 rd cycle of salvage chemotherapy to a total dose of 39.6 Gy in 22#) to left leg lesion by 3 Dimensional Conformal Radiotherapy (3D-CRT) technique -by Left Anterior Oblique and Right Posterior Oblique portals were used.Follow-up PET-CT after 2 months of radiation showed interval new soft tissue deposit in the medial and posterior compartment of the left thigh just above the knee joint, left rectus abdominis muscle, increase in the metabolic activity of the intermuscular deposit in the medial compartment of the left upper thigh and interval resolution of metabolic activity of the soft tissue deposit in the medial and posterior compartment of the left thigh.The lesions in left upper thigh (medial compartment) were treated by 50 Gy and that above the left knee joint by 45 Gy delivered in 25 fractions by 6 field IMRT technique. The patient had been relapse free in 18months of follow-up. Discussion: In this patient recurrent NHL showed partial response and refractoriness to various chemotherapy regimens and good response to active management with radiotherapy and no evidence of disease after 18 months of follow-up. Conclusion: NHL involvement of skeletal muscle is rare. Most of the published literature describe the diagnostic methodology, surgery or chemotherapy used as treatment.This is the first case report describing the durable response with radiation without in-field recurrence in chemo-resistant Large B cell NHL skeletal muscle.

Effects of care burdens among family caregivers of cancer patients on their quality of life

R. Durga Prasad,CO-AUTHOURS: S.Shanmuga Kumar [HOD],

N. V. Kalaiarasi Vishal Manik, Ramya, Jayasree

E-mail: [email protected]

Introduction: Family caregivers play a central role in managing all aspects of the patient's care.The responsibility of caring for the cancer patient at home is down to the patient's spouse, parents, children, relatives, or friends. The decrease in the caregiver's quality of life influences the quality of care and thus the QOL of the patient. Aim: The aim was to evaluate the effects of caring burdens among family caregivers of cancer patients on their quality of life and to determine the effect descriptive characteristics and care related properties have on their quality of life. Materials and Method: Sample included 200 family caregivers in the dept.of radiotherapy MMC and RGGGH.Data were collected using a questionnaire that included socio-demographic variables, the burden interview[MODIFIED ZARIT] and caregiver quality of life index cancer scale[CQOLC]. Pearson correlation analysis was used to analyze the relationship between care burden and quality of life. Results: The mean score of Burden Interview of caregivers was 36.65±11.21 and their mean score of Caregiver Quality of Life Index-Cancer was 81.40±17.3. The Caregiver Quality of Life Index sub-scale scores of caregivers were 21.18±5.3 for "burden," 14.96±4.8 for "disruptiveness," 12.31±3.9 for "positive adaptation," and 5.69±3.0 for "financial difficulties". Conclusion : Results of this study concluded that factors that had an effect on the quality of life were being under 35 years of age, being between 36 and 50years, having a low income, being the spouse and parent of the patient, and the patient having their own room (p<0.05).: In this study there was a negative relationship between caring burdens and the quality of life (p<0.001); according to Pearson correlation analysis. It is recommended that caregivers are given support by being offered training about providing care.

DEFAUlters in head and neck irradiation patients and its causES - A Tertiary regional cancer center experience

Pujari Lincoln, Padhi Sanjukta, Routray BiswaRanjan, Bose Chaitali, Pattanayak Lucy, Panda Niharika, Senapati.S.N.

Department of Radiation Oncology, AHRCC, Cuttack. E-mail: [email protected]

Background: WHO defines adherence as the extent to which a person's behaviour corresponds with agreed recommendations from a health care provider (1).Strict adherence and timely completion of the EBRT schedule is one of the most important prognostic factors in survival of head and neck cancer patients(2). Aim of the Study: To study the socio demographic profile of patients receiving radiotherapy to head and neck, to identify the patients who default in treatment, the pattern of defaults and its causes for possible intervention. Methods and Materials: We did a retrospective epidemiological analysis of the patient data available in the treatment record of the patients in department of radiotherapy, AHRCC, Cuttack. We enrolled patients who had started taking EBRT for head and neck cancers with curative intent from January 2013 to December 2013 and stopped the EBRT prematurely. Unplanned treatment breaks in the treatment was not taken into consideration. Only completion of the treatment after receiving the desired dose and fractions was taken into consideration. Results: Total 123 out of 635 i.e. 1 in 5(19.37%) patients defaulted in treatment and didn't complete the EBRT. 104 out of 457(22.75%) male and 19 out of 178 (10.67%) female patients defaulted in treatment. 79 out of total 123 patients approx. 2 in every 3(64.23%) who defaulted stopped taking treatment within 15#s i.e. halfway in the treatment. 12 out of total 123 patients (10%) stopped taking treatment just at the 22nd/23rd #.defaulter rates in patients from nearby districts and faraway places are similar in the range of 17 -25%. Conclusion: Radiation induced acute toxicity is not the only cause of patients not completing the treatment. Socioeconomic status and distance plays minimal role as a cause of patients stopping taking EBRT.Proper counselling of the patients while starting radiotherapy treatment and timely management of any radiation toxicity can improve compliance immensely and so as treatment outcome.

Stratified random sampling design to evaluate the appropriateness of radiation therapy prescription for patients with bone metastases

Manpreet Singh Tiwana

E-mail: [email protected]

Introduction: Despite the abundant evidence there is a considerable worldwide variability in RT prescription for patients with bone metastases (BM). We wanted to test through this stratified sample design the validity of radiation therapy prescription in patients with BM in British Columbia (BC) Cancer Agency, which is a publicly-funded service with no direct costs to patients, and provides all RT services within the province. Methods: The BCCA's Cancer Agency Information System was used to identify all patients during 2007 through 2011 who received palliative RT for bone metastases. The BCCA RT database contains RT information, including site of RT, date of RT, dose, and fractionation. RT fractionation was classified into two categories: single fraction (SF) or multiple fractions (MF). C hart review and audit was done by an independent Radiation Oncologist for all the prescribed RT courses within sample, n.Concordance was recorded between the given RT fractionation schedule and the audited plan, along with estimates of the confidence interval and standard error. Sample size was calculated with three parameters: Margin of error- +/-4%,Confidence Interval (C.I.,Z-score)- 95% confidence interval with a Z-score of 1.96, and Standard of deviation (StdDev)- 0.5 as the expected variance in this design.The following stratifying variables were selected for the sample design:BCCA centers, and Primary tumour sites- Breast, Lung, Gastro-Intestinal (GI), Prostate and OthersThe statistical analysis was done on Microsoft Excel Office 2010; of Windows; version 7. Following notations were utilized: N = the total population size; Nh = the population size in stratum h;n =the total sample size; nh = the total of the observations in stratum h; Sh =Variance within each stratum,h; t= total for Nh Sh across all the strata; p= sample proportion. The following equations were used- Calculation of sample size was done as per, n = (95% C.I.,Z-score)΂ - StdDev*(1-StdDev)/(margin of error)΂, Proportional allocation in each stratum, nh = (Nh/N) n, Optimal allocation in each stratum, nh= n (Nh Sh)/t, Standard error of proportion,SE = sqrt[ p * (1 - p)/N ],95% Confidence interval, C.I. Result : A total of 16,898 RT courses were included the study period from 2007 till 2011.Primary tumours arising from prostate, breast and lung were more commonly treated (19-23%).The most commonly irradiated skeletal sites was spine (42.2%) followed by pelvis (28.6%).The sample size for the analysis was 636.Twenty five strata were created in reference to the primary tumour site and BCCA center. Proportional allocation was selected for final analysis. After rounding off to minimum sample size within each stratum to 10, the absolute proposed allocation stratified random sample size, n was 636.The 95% CI concordance rates for the RT fractionation in the sample analysis ranged from 0.75-0.98, point estimates across BCCA- 0.86-0.94, and standard error-0.021-0,022. Conclusions : Stratified random sampling technique gave useful and precise estimates for RT prescription in patients with BM across the province. It does have inherent limitations with smaller strata, and added complexity with introducing other more relevant stratifying variables. Cautious interpretation and careful implementation is thus recommended when applying the stratified random sampling technique to similar research.

Primary cutaneous anaplastic large cell lymphoma- A case report

Pooja Iyer*, Chendil V**

Dept of Radiotherapy,BMCRI. E-mail: [email protected]

Introduction : Primary cutaneous anaplastic large-cell lymphoma is part of the spectrum of CD30+ lymphoproliferative cutaneous processes, characterized by single or multifocal nodules that ulcerate, are autoregressive and recurrent. Extracutaneous dissemination may occur, especially to regional lymph nodes. Histology shows a diffuse, non-epidermotropic infiltrate, anaplastic large lymphoid cells of immunohistochemistry CD30+, CD4+, EMA-/+, ALK-, CD15- and TIA1-/+. Prognosis is good and does not depend on lymphatic invasion. Radiotherapy, removal of the lesion and/or low-dose methotrexate are the treatments of choice. Case report : A 30 years old woman presented with 9 months history of non resolving plaques over the skin of right thigh. They were multiple, with ulceration, largest measuring 6x6cm, which was exophytic, associated with bleeding. No significant inguinal lymphadenopathy could be detected, and patient was otherwise asymptomatic. It was initially addressed with wide local excision at a local hospital. She developed recurrence at the same site and underwent local debridement. Histopathology revealed malignant tumor of right thigh. With differential diagnosis of epitheloid angiosarcoma and amelonotic melanoma further IHC studies were done with which a diagnosis of Primary Cutaneous Anaplastic Large cell Lymphoma with positive LCA, CD30, CD4, CD8, EMA,ALK NEGATIVE was made. Patient defaulted treatment and presented 2 months later, with a local recurrence associated with fever and night sweats. Bone marrow aspiration and biopsy suggested no tumor infiltration. In view of presence of B symptoms and aggressive recurrent disease, chemotherapy was planned. She received 4 cycles of CHOP in a dose dense fashion along with G-CSF support. Partial response was obtained with 3 cycles, however, following which there was progressive disease. Metronomic Methotrexate has been started as second line chemotherapy and patient continues to show stable disease. Conclusion : Lymphoma can present as a cutaneous lesion, and unless proper histopathology followed by appropriate IHC markers are not done, the diagnosis can be missed. Lymphoma should be considered in the differential diagnosis for patients presenting with sarcomatoid type of lesions.

Study of conformity and homogenity indices for various brain tumors treated with stereotactic radiosurgery using Gamma Knife

Ranjit Singh 1,2 , Arun S. Oinam 1 , K. K. Mukherjee 3 , Sanjeev Kumar 4 , D. Mehta 2 , J. Shahi 2 , B. Singh 5

1 Department of Radiotherapy, PGIMER,Chandigarh, 2 Department of Physics, Panjab University, Chandigarh, 3 Department of Neurosurgery, PGIMER,Chandigarh, 4 Department of Physics, G.G.D.S.D. College, Chandigarh, 5 Department of Nuclear Medicine, PGIMER,Chandigarh. E-mail: [email protected]

Introduction : Conformity index (CI) and homogeneity Index (HI) provides information about confinement and uniformity of the dose distribution to the tumor volume, respectively. Various formulae have been reported for these indices in the literature. However, there is scarcity of the experimental data related to brain tumors and authentication of these formulas. The present study involves treatment of various brain tumors with stereotactic radiosurgery using Gamma Knife and reports comparison of conformity and homogeneity indices evaluated using different formulae available in the literature. Method and Material : The present case study consisted of 60 patients diagnosed with Meningioma, Acoustic Schnomma and Arterivenous malfunction treated during the period from November, 2010 to April, 2014. The data information for the tumors of these patients were obtained using magnetic resonance imaging (MRI) and showed volume size ranging 0.2-30 c.c. The patients were treated on Gamma Knife PerfexionTM (Elekta, Leksell, UK) installed at PGIMER, Chandigarh. It has 192 60Co sources arranged in 8 sectors with each sector containing 24 sources. Collimators of 4 mm, 8 mm and 16 mm are available with the provision of changing the size of collimator independently for each sector. The database information and planning was generated using the clinically implemented Leksell GammaPlan; (version 8) computer-based treatment planning system. Within each target, dose is calculated in a cubic calculation grid with 31 Χ 31 Χ 31 sample points. A high degree of conformity is required in stereotactic radiosurgery (SRS) treatment plans to minimize damage to the tissues that surround the target area. In clinical practice, this conformity is evaluated using a combination of dose-volume histograms (DVHs) and visual inspection of dose distribution in and around the target volume. In the present study, a number of plan quality matrics have been generated to facilitate comparison and to evaluate compliance with clinical trial protocols. The quality metrics evaluated are those proposed by the radiation therapy oncology group (RTOG), conformity index (CIRTOG), quality of coverage (Q) and homogeneity index (HI). The other recently defined conformity index defined by Paddick (CIPaddick) and Lomax and Scheib's modified index (CILomax) were evaluated for comparison. Various homogeneity indices considered in literature are HI=D5/D95, HI=Dmax/Dmin, HI=(D2-D98)*100/Dp, HI=(D5-D95)*100/Dp and HI=Dmax/Dp. The patients were divided into different groups, based on specific tumors, prescribed dose and target volume. Mean HI of each group will be analyzed to find the correlation between these factors and HI after including more number of patients. Results and Conclusions : The statistical analysis of CI and HI of 60 patients deduced from the present measurements show that CILomax exhibits minimum standard deviation for the Meningioma, Acoustic Schnomma and Arterivenous malfunction patients. On the other hand the Homogeneity Indices calculated using the formulae, HI=Dmax/Dp shows minimum variation in experimental results. In addition, we could not conclude regarding the correlation between the prescribed dose and target volume from the present set of 60 patients and more data is required for such information.

Evaluation of hypothyroidism in locally advanced head and neck malignancies treated with concurrent chemordiotherapy.

Gampa S. C., Singh D. P., Kumar P., Chauhan A. K.

Junior Resident, Professor and Head, Associate Professor, Assistant Professor, Department Of Radiotherapy, SRMS IMS.

Introduction: Head and Neck cancer is the 5 th most common malignancy worldwide.The thyroid gland with its central location in the neck will hence invariably be included in the radiation field.The tolerance dose of the thyroid gland has not been definitively determined 1 , and some investigators suggest that the percentage of thyroid volume receiving 30 Gy (V30) is a possible predictor of hypothyroidism . Aims And Objectives: The aim of the present study is to evaluate changes in thyroid function (incidence of hypothyroidism) in patients with head and neck cancer treated with chemo radiation (chemotherapy and external beam radiotherapy (EBRT)) in terms of factors relate to 1. Patient related- Age, Sex. 2. Tumor related- site, stage, grade. 3. Treatment related- chemotherapy (cisplatinvs paclitaxel), radiotherapy dose. Materials and Methods: For the present study previously untreated 50 patients locally advanced head and neck malignancies will be selected. Patient selection: Inclusion Criteria: 1. Previously untreated patients, 2. Age >18 years. 3. KPS>70, Normal Haemogram, Normal Renal Function Tests, Normal Liver function tests, Normal ECHO and Normal Thyroid function test. Exclusion Criteria: 1. Patients having thyroid metastases, a positive thyroid diseases, or thyroid surgery.2. 50 patients will be randomized into two groups of 25 each as following: 3. Group-I (25 patients) with concurrent cisplatin 35mg/m 2 given every week (total 7 cycles weekly). 4. Group-II (25 patients) concurrent low dose paclitaxel 35mg/m 2 given. Assessment for Thyroid Function: Blood samples will be analyzed for T 3 (0.60-1.81 ng/ml), T 4 (1.9-13.3 ΅g/ml) and TSH(0.35-5.50 ΅IL/ml) a. before EBRT (BT), b. mid way of EBRT (MT) (36 Gy tumor dose), c. at completion of EBRT (CT) (60-70 Gy tumor dose) d.during subsequently follow up after 6 months. Follow up: The patient will be followed up atleast for period of 6 months from day of completion of treatment. Results : Occurrence of hypothyroidism in comparison with age, sex, site, stage grade and chemotherapy-

• Age group was 51-60yrs in one patient (2%)

• Patient gender male in one patient (2%)

• Site was at tonsil in one patient (2%)

• Stage was stage III in one patient (2%)

• Grade I in one patient (2%)

• Chemotherapy was Paclitaxel in one patient (2%).

Conclusion: 1. Radiation induced hypothyroidism is seen as a late complication. 2. Long termfollowup is required.3. Within 6 months of followup, no literature says the occurrence of radiation induced hypothyroidism.4. Minimum 2 years followup is required. 5. In our 50 cases after 6 months of followup, only one case(2%) developed radiation induced subclinical hypothyroidism. 6. The incidence is anywhere between 3% - 40% and it increases with time, with a peak incidence seen at 2-3 years. 7. In our study we have recognized hypothyroidism as early after 6months following radiotherapy. 8. Hence, Thyroid function tests should be made routine and must be started from as early as 6 months.

A series of patients with multiple primary malignancies at a tertiary care centre of India

Shraddha Raj

Anbarasi Kumaresan Cancer Institute, Adyar, Chennai. E-mail: [email protected]

Introduction: The rising trend in the incidence of cancer is matter of global concern. But, there are patients having more than one malignancy in their lifetime. These may be 'synchronous' or 'metachronous'. In our clinical practice, we came across a few such cases, which we have compiled to present in this article. Aims and Objectives: To study • the pattern of occurrence of synchronous/metachronous malignancies at a tertiary cancer care centre,• its correlation with the probable cause, • the impact of regular follow up on early diagnosis of the second malignancy. Materials and Methods : Among the follow up patients at our centre, we studied seven patients who presented in the year 2013-14. During follow up, these patients developed symptoms, for which they were worked up and were subsequently diagnosed to have a second primary malignant lesion and then were treated accordingly. Out of seven patients, four had dual primaries within the aero-digestive tract. One patient developed malignancy of the nasal ala, years after achieving cure for carcinoma endometrium. Another patient had sarcoma of vagina, after more than a decade of successful treatment of carcinoma of the cervix. And,one patient reported to us with her third malignancy in the form of Cancer Cervix, seven years after treatment of Ca Breast and Ca urinary bladder. Observations: Two thirds of the total patients were cases of head and neck malignancy, who subsequently developed metachronous second primary cancer of lungs. This occurrence, once again highlights the strong concept of field cancerization and the need to follow up such patients more meticulously. The appearance of multiple primary and absolutely unrelated malignancies together in one patient emphasize the fact that various environmental and genetic factors probably contribute to the development of a second or third malignancy de novo in the same patient. The carcinogenic potential of radiation is also brought up in one case where the patient has developed vaginal sarcoma decades after achieving cure for cancer of uterine cervix, treated by Radical Radiotherapy. Conclusion: Thorough follow up of all cancer patients is extremely important to look for the signs of a second malignancy, apart from its importance to know the disease status, metastasis, recurrence and quality of life. Various known and unknown causes exist for the development of one or more than one malignancies. Patient education also plays crucial role in at-risk cases.

Primary mediastinal germ cell tumors-assessment of treatment outcome-a single institution experience

Roshni S 1 , Soorej Balan Kaliyath 1 ,C. D. Sivanandan 1 , Sajeed A 1 , Preethi Sara George 2 , Lijeesh A. L. 1

1 Department of Radiation Oncology, 2Division of Epidemiology and Biostatistics. E-mail: [email protected]

Introduction : Germ-cell tumours usually arise from the testis. However, in small percentage of the cases, they also occur outside of the testis as a primary site without evidence of testicular primary tumour. This infrequent entity often appears in the body midline, predominantly in mediastinum and retroperitoneum. Mediastinal germ-cell tumours (MGCT) representing only 3 to 10% of tumors originating in the mediastinum, and are included in the differential diagnosis of any mediastinal tumour of unknown origin. Aim and Objective: To analyse the clinical profile and treatment outcomes of Primary Mediastinal GCT's treated at Regional Cancer Centre (RCC), Trivandrum, during the time period of five years and to identify the various factors influencing the outcome. Materials and Methods : 15 patients treated at RCC Trivandrum for Primary Mediastinal GCT's from 2005 to 2010 are included in the study. The patients were followed up until September 2014. The median follow up is 59.2 months. Observation and Results : Among the patients analysed, all were males. The median age was 24.93 years (range 15-42 years). The most common presenting symptom was Dyspnea(60%), Chest Pain(20%), Cough (13.3%), SVCO (6.7%). Two patients(13.3%) had Pulmonary Metastases at presentation. Most common first-line chemotherapy received was Bleomycin+Etoposide+Cisplatin (66%) followed by Etoposide+Cisplatin (26.7%) and Carboplatin(6.7%).One patient developed Bleomycin toxicity(?). Following chemotherapy 93.3% patients had marker response, with 40% (n=6) patients having residual disease following completion of chemotherapy. Further 4 patients underwent surgical resection for residual disease,with 2 patients having pathological evidence of persistent viable tumor. The five-year Overall survival (OS)was 93.3% and Progression-free survival (PFS) was 60.6% with median PFS 55 months. Conclusions: Primary mediastinal germ cell tumor is rare with a dominant frequency in young male patients.15 patients were included in the study. After a median follow up of 59.2 months, 5-year survival rate was 93.3%.The 5-year PFS was 60.6 % with median PFS 55 months.


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