|Year : 2015 | Volume
| Issue : 7 | Page : 1-3
Bone and Soft Tissue
|Date of Web Publication||24-Nov-2015|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Bone and Soft Tissue. J Can Res Ther 2015;11, Suppl S3:1-3
Metatstatic Ewings sarcoma of lower alveolus
thD. S. Nihanthy , S. Poojar, S. R. Pallad, K. P. R. Pramod, T. Naveen,
V. Lokesh, I. Khaleel, C. Govardhan
Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India, E-mail: [email protected]
Introduction: Ewings sarcoma was first described by James Ewing, approximately 90% of these tumors have common karyotype translocation (11:12)(q24:q12). Ewings sarcoma is a common round cell tumor affecting children and young adults. Most common in second decade of life, origin is uncertain and most commonly seen in males. It's a very aggressive tumor, with common metastases to the long bones but it's very uncommon to the bones of head and neck. Only 1% of cases are reported with jaw involvement with mandibular predilections. Aims: To report a case of metastatic Ewings sarcoma of lower alveolus. Materials and Methods: A 15 year old boy, diagnosed as Ewings sarcoma of right lower limb, who had received 4 cycles of Neoadjuvant chemotherapy of VAC + IE regimen (vincristine + adriamycin + cyclophosphomide + ifosfomide + etoposide), followed by below the hip amputation and adjuvant chemo radiation six months back, presented with complaints of swelling and pain around the left lower jaw, evaluated and histopathologically proven as Metastatic Ewings of lower alveolus. Treatment: Patient planned on palliative RT, received External beam RT of 30 Gy in 10 fractions on Telecobalt by 2 parallel opposed lateral fields to lower face and neck. During the course of treatment, patient had developed Grade 2 mucositis and was treated symptomatically, EBRT continued without any interruptions in the scheduled fractionation. Results: Patient had tolerated and responded well to RT. There was complete regression of the tumor in the lower alveolus and was symptom free. Conclusion: The treatment of Ewings sarcoma has undergone a drastic change due to integrated therapies with surgery and concurrent chemo radiation. Poor prognostic factors are age less than 10 years, pelvic lesions, metastasis, systemic symptoms, high mitotic rate and large tumour volume. Metastasis to mandible and flat bones are uncommon. There are very few reported cases of metastatic Ewings to head and neck bones and the incidence is very rare. This is a rare case of Metastatic Ewings to lower alveolus treated at our institution.
Primary anaplastic large cell lymphoma of bone: Rare case report
thS. Mittal , Y. Verma, M. Kumar, N. Bansal, A. Khurana, P. Kaur,
A. K. Chauhan
PGIMS, Rohtak, Haryana, India, E-mail: [email protected]
Background: Primary bone involvement may be the presentation in 4-5% of all extranodal NHL. Anaplastic large cell lymphoma (ALCL) represents 2 to 3% of NHL. Only 13 cases of ALCL with primary bone involvement have been described in literature, so far. This case is 14 th overall and 2 nd ALK- case of ALCL with primary involvement of bone/s. Case Report: A 38-year-old Indian woman consulted orthopedic department in our tertiary care center with 7 months history of pain & swelling of right shoulder associated with restricted overhead abduction. Managed symptomatically for couple of months, she had no relief. Six months later, she also noticed a pea-sized painless lump on left lateral aspect of scalp which rapidly increased in size to 5 x 4 cm at presentation. No associated systemic symptom like night sweats, fever, weight loss, lump elsewhere over the body or gynecological complaint was there. MRI of right shoulder region revealed destructive and expansile lesion along distal end of clavicle with surrounding extension of 4.8 Χ 4.5 cm. Bone scan showed an increased uptake in right clavicle's lateral end and left parietal bone of skull. Routine blood counts, biochemical and serologic parameters & bone marrow examination were within normal range. Biopsy from lateral end of clavicle showed poorly differentiated malignant round cell neoplasm. IHC revealed atypical cells positive for Vimentin and LCA. On further analysis they were found to be hematolymphoid malignancy with closest resemblance to CD30 positive and ALK negative anaplastic large cell lymphoma. Clinical examination and imaging studies revealed no evidence of significant lymphadenopathy or hepato-splenomegaly. Treatment and outcome: After explaining all pros and cons of treatment options, patient opted for local radiotherapy for painful shoulder followed by chemotherapy. Six courses of CHOP were planned. Disease responded very well. After 2 weeks of EBRT to shoulder, pain was 90% relieved and mass decreased. Three weeks after first course of chemotherapy, there was no clinical evidence of gross disease at either site. After 3 courses of chemotherapy, FNAC revealed no evidence of disease and patient remains healthy and free of symptoms. Conclusion: High clinical suspicion and early immunopathological diagnosis followed by aggressive treatment approach seems to be the right protocol. Outcome is rewarding with radiotherapy and modern chemotherapy just like in usual cases of lymphoma.
Adult Langerhan's cell histiocytosis with multiple bone invasion: A case report
thR. Bhattacharjee , R. Ghosh, K. Kar, S. Basu
Institue of Post Graduate Medical Education and Research, Kolkata, West Bengal, India, E-mail: [email protected]
Langerhan's cell histiocytosis (LCH) is a rare disease of clonal dendritic cells which usually occurs in children and may affect any organ of the body. The disease is extremely rare in adults. There are no specific guidelines regarding diagnosis and treatment of these patients. The disease may involve multiple sites like bone, skin, pituitary, lungs. Bone involvement may be single or multiple. Various systemic agents have been used in LCH with multiple bone lesions including Methotrexate, Thalidomide and Etoposide along with a Bisphosphonate. Response is evaluated every 2-3 cycles and in case of disease progression an alternate agent is used in place of the drug used in first line. There is no consensus regarding duration of therapy in patients with partial or complete response. Here we report a case of LCH with multiple bone involvement in a 44 year old male. The patient presented to our OPD with toothache and low back pain for 3 years. There were bilateral alveolar non healing ulcers over the mandible. Orthopantomogram (OPG) showed a well defined radiolucent lesion in left mandible at the mental foramina region. Histopathological examination of the alveolar lesion showed sheets of Langerhan's cells with nuclear folds and grooves admixed with eosinophils and plasma cells. Immunohistochemistry revealed that the tumor cells expressed CD1a and S-100 protein confirming the diagnosis of LCH. CT scan face and neck noted soft tissue lesion in the body of mandible in left paramidline location with cortical erosion. Whole body bone scan revealed radiotracer uptake in mandible, pelvic bones and sacroiliac joint. FNAC from the sacroiliac joint revealed LCH invasion. We started systemic chemotherapy with inj. Etoposide 200 mg IV D1-D5 every 28 days. After 3 cycles of chemotherapy repeat CT scan showed diminished size of all the soft tissue and osteolytic lesions. Currently the patient is asymptomatic and we have kept the patient on maintenance Etoposide and zoledronic acid.
Primary diffuse large B cell lymphoma of bone: A report of three cases and review of literature
thR. Ghosh , S. Roy, R. Bhattacharjee, A. G. Dastidar
Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India, E-mail: [email protected]
Background: Primary Bone Lymphoma (PBL) is an uncommon tumor accounting for approximately 4-5% of extra nodal lymphoma and less than 1% of all non-Hodgkin's lymphoma (NHL). Diffuse large-B cell lymphoma (DLBCL) accounts for the majority of cases of PBL. Aims: Owing to its rarity, only a few retrospective series have been published in literature addressing the prognosis and treatment of PBL. We report our experience with three cases of PBL treated with chemotherapy and radiotherapy and review of literature to elucidate the optimal treatment of PBL. Materials and Methods: Case 1: 50 yr old female patient presents with pain, swelling and pathological fracture of left leg. 18 FDG Whole body PET CT Scan reveals intense metabolic activity along with extensive skeletal involvement over left tibia and femur, L5 & D4 vertebra, left popliteal and inguinal lymph nodes. Biopsy from osteolytic lesion of tibia reveals NHL of DLBCL phenotype. Tumor cells are immune positive for CD20 & bcl-6. Bone marrow involvement present. In accordance with the 2013 WHO classification of Bone/Soft Tissue Tumors, patient was classified as multifocal PBL, staged as IVE. Subsequently patient is under treatment with (R-CHOP) chemotherapy alone. After 4 cycles Post treatment work up reveals complete remission. Case 2: 45 yrs old female patient presents with pain and swelling over right leg along with a 1.5 cm sized, hard fixed lymph node over right inguinal region. MRI reveals neoplastic mass in mid shaft of right tibia with muscular compartment extension and pathological fracture. Histopathology confirms NHL of DLBCL phenotype. Tumor cells are immuno positive for CD20 & bcl-6. The bone marrow aspiration find presence of neoplastic involvement, patient was classified as unifocal PBL, staged as IVE. She treated with 6 cycles of R-CHOP regimen followed by IFRT. Case 3: 55 yrs old male patient presents with painless swelling over lower part of right forearm for last 5 months. X-ray wrist joint reveals expansile osteolytic lesion. Biopsy reveals NHL of DLBCL type with immuno reactivity for CD 20. Bone marrow aspiration did not find neoplastic involvement and other staging work up reveals as unifocal PBL, staged as IE. The patient is therefore planned for 6 cycles of R-CHOP chemotherapy plus consolidates radiotherapy up to total dose of 40 Gy in 22 fractions. Conclusion: More prospective studies are necessary for proper staging, understanding behavior and treatment guidelines of PBL cases.
Giant cell tumour of bone with bilateral pulmonary metastasis-
A rare presentation
thS. Gupta , D. Sachan, L. Pandey, N. Sharma, P. Kumar
Sarojini Naidu Medical College, Agra, Uttar Pradesh, India,
E-mail: [email protected]
Background: Giant cell tumor of bone (GCTB) accounts for 5% of primary skeletal tumors. Although it is considered to be a benign lesion, there are apprx 3% incidences of pulmonary metastasis particularly in recurrent cases. Pulmonary metastasis of GCTB may be affected by tumor grading and localization as well as the age, gender and overall health status of the patient. The treatment of the primary GCTB is key to the final outcome of the disease, as intralesional curettage has a significantly higher local recurrence and pulmonary metastasis rate than wide resection. However, even patients with pulmonary metastasis seem to have a good prognosis after timely and appropriate treatment. Objective and Case Summary: The aim of presenting this case is to shows the response of chemotherapy and radiotherapy for lung metastasis in giant cell tumour. We present a case of giant cell tumour of right fibula in a 16-year-old female, who presented to us in april-2014 with post-op local residual as well with bilateral lung metastasis. Patient presented to us with chief complains of pain and swelling in right lower leg and breathlessness and dry cough on exertion. On examination, on lateral aspect of right lower leg just below knee, a diffuse lump present adjacent to scar mark. X-ray chest shows multiple opacity in bilateral lung field suggestive of bilateral lung metastasis. In view of wide spread bilateral lung metastatic lesions patient was kept on chemotherapy followed by radiotherapy to the local site as well as lung bath. Results: Patient is on follow up with good subjective and objective response with no fresh complains. Conclusions: This case is a clear example of how chemotherapy and radiotherapy gave good response for lung metastasis in giant cell tumour of bone.
Evaluation of role of interstitial brachytherapy in soft tissue sarcoma: A single institute experience
thV. Pareek , R. Bhalavat, C. Manish, L. Nellore, K. George, D. Borade, K. Kalariya, N. Kumar
Jupiter Hospital, Thane, Maharashtra, India, E-mail: [email protected]
Background: Soft tissue Sarcomas are rare group of solid tumors comprising of 1% of all solid tumors. The management of soft tissue sarcomas have evolved due to advancements in imaging, histopathology, cytogenetics, and the use of multimodality treatment. The treatment strategies emphasizes on the control of disease locally, sparing of limb function and improvement in the quality of life. High dose brachytherapy has formed a part of the management and has the advantage of providing concentrated dose to tumors and sparing of surrounding normal tissues. In this study we examined the clinical outcome of High dose Brachytherapy for STS at our Hospital through retrospective analysis of the prospective database maintained. Aim: To review the clinical outcome and quality of life in patients with Soft Tissue Sarcoma treated at our centre through High dose rate interstitial brachytherapy. Materials and Methods: Eleven patients with different sites and grades of Soft Tissue Sarcoma underwent surgery and Intraoperative catheter implantations in single plane in biopsy proven Soft tissue sarcoma cases. These patients then underwent High Dose Brachytherapy with Iridium - 192. The patients received average dose of 3.5 Gy per Fraction (Two fractions per day 6 hours apart) with total dose of 35 Gy/10 Fr/5 Days and after completion of treatment were followed up at 1 month and later every 3 monthly for 2 years; Followed by 6 monthly interval. Results: The Patients were followed up for range of 1-42 months (Median 12 months) and overall control rate was 72.72%. The Local recurrence was noted in only one patient (9.09%) and two patients developed distant metastases (18.18%) Conclusions: The results in our study suggested the importance of HDR Brachytherapy in management of Soft Tissue Sarcoma. The local control rate was 72.72%. The dose of 35 Gy over 10 fractions over 5 Days was found to be effective in local control and limb salvage in case of Soft Tissue Sarcoma as practiced at our Centre.
Key words: High dose rate, interstitial brachytherapy, soft tissue sarcoma
Extra-osseous Ewings sarcoma and non hereditary spherocytosis-stroke of God's unusuality
thH. P. Mani , O. P. Singh, H. Ghori, V. Yogi, V. Tiwari
Gandhi Medical College, Bhopal, Madhya Pradesh, India, E-mail: [email protected]
Unusuality makes the field of medicine a real cliffhanger. Hereditary spherocytosis an architectural disorder of RBCs, a synonym for Hemolytic anemia and Extamedullary erythropoeisis has never been reported along with Ewings sarcoma. 24-year-old male, a known case of non hereditary spherocytosis diagnosed and splenectomised three years back, presented with a lump 8 cm Χ 9 cm, over the left inguinal region of two years duration. Past history revealed bleeding episodes from gums and bruises from 14 years of age upto 18 years. His peripheral smear reports showed spherocytes, anisopoikilocytes and osmotic fragility test done showing increased fragility of RBCs, and a diagnosis of nonhereditary spherocytosis was made as none of his family members had a history. Up-to three generations of pedigree had been inquired. His X-Ray Pelvis showed a normal pelvis and hip joint. CT Abdomen Pelvis showed a Large ill defined soft tissue mass lesion in the left inguinal region measuring 7.1 * 5.3 cm, superficially infiltrating the overlying subcutaneous plane and skin. A similar lobulated growth was seen antero-lateral to urinary bladder noted and multiple liver metastatic deposits seen. Biopsy and immunohistochemistry wit MIC-2 and Vimentin tests were Diffusely Positive confirming Ewing's Sarcoma. Ewings Family of tumors comprises Ewing's sarcoma, Extra- osseous Ewing's sarcoma and PNETs (Primitive Neuroectodermal Tumors). The t(11;22)(q24;q12) translocation found in 85% of Ewing's cases results in fusion of portions of the EWSR1 gene on chromosome 22 with portions of FLI1 gene on chromosome 11. Ewing's sarcoma is associated with genes such as ERG on Ch 21q22.3, ETV1 on Ch 7p 21.3, ETV4 on Ch 17q 21.31, EWSR1 on Ch 22q 12.2, FEV on Ch 2q 36 FLI1 on Ch 11q 24.1-q24.3 and FUS on Ch 16p 11.2. Hereditary Spherocytosis -A disorder of the Red Blood cells in its surface architecture due to defect in the vertical relationship between membrane carcass and lipid bilayer, resulting in deficiency of proteins like ANK1 (Ankyrin 1) on Chromosome (ch) 8p 11.2, EPB4 (protein 4.2) on Ch 15q 15, SLC4A (Band 3 Anion transport protien) on Ch 17q 21-q22, SPTA1 (Spectrin alpha chain) on Ch 1q 21 and SPTB (Spectrin beta chain) on Ch 14q 22-q23. Either a random act of God or a chance mutation involving Chromosome 17q21 is responsible for the malady that arose in this patient. Let his history be the onus of proof in future for a causal association.
Brain and CNS
Papillary tumour of the pineal region: Treatment outcome of two cases
thA. Arjunan , M. Dhas, B. S. Mathew, A. Mathews, J. Valsalamony,
K. R. Rajeev, M. P. Aparna, K. Ratheesan
Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Background: Papillary tumour of the pineal region (PTPR) is a rare tumour of neuroepithelial origin, first identified as a histologically distinct entity in 2003. The biological behaviour of PTPR is variable and may correspond to WHO grades II or III, but precise histological grading criteria remain to be defined. There are only a few studies on the clinical outcome of PTPR. Materials and Methods: The clinical data on two patients with PTPR treated at our institute was retrospectively reviewed. Results: Case I: A 29-year-old male underwent endoscopic biopsy of pineal gland lesion. Histopathology revealed PTPR WHO grade III, immunoreactive for glial fibrillary acidic protein (GFAP) and cytokeratin (CK), but negative for synaptophysin and p53. MIB-1 labeling index (LI) was 8-10%. Cytological evaluation of CSF and MRI of neuraxis showed no evidence of cerebrospinal dissemination. He was treated with local radiotherapy to a dose of 54 Gy in 30 fractions. MRI Brain done 3 months after radiotherapy revealed stable disease. However patient died 4 months later. Cause of death is not known as he apparently developed acute onset of loss of consciousness and died at home. Case II: A 32-year-old female underwent gross-total resection (GTR) of pineal gland lesion. Histopathology showed PTPR, positive for CK, but negative for GFAP, synaptophysin and epithelial membrane antigen (EMA). MIB-1 was 3-7%. CSF cytology showed no evidence of malignant cells and MRI screening of neuraxis was normal. She was treated with craniospinal radiation (36 Gy with tumour boost upto 54 Gy). She is on regular follow-up with periodic imaging for the last 20 months and has no recurrence at time of analysis. Conclusion: The optimal management of PTPR remains to be determined. Some studies have suggested an indolent behaviour, but local recurrences have been documented in other series. Value of radiotherapy needs to be investigated in future trials.
Stereotactic radiosurgery for brain metastasis: Analysis of outcome
thP. G. Jayaprakash , P. Raju, A. Arjunan, S. Mathews, S. Bhasi,
P. S. George, A. Mathew, B. S. Mathew
Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Background: Treatment options for patients with solitary brain metastasis include surgical resection followed by whole brain radiation therapy (WBRT), WBRT with stereotactic radio-surgery (SRS) boost or SRS alone. Randomized studies have shown similar survival benefits in patients with 1-3 brain metastasis treated with SRS alone compared to SRS plus WBRT. Aim: To assess regional failure (RF) and overall survival (OS) in patients with solitary brain metastasis treated using micro-MLC based SRS. Materials and Methods: 17 patients with solitary brain metastasis were treated with SRS at our institute during the period 1 st January 2012 to 31 st December 2014. Of this, 11 patients received SRS alone. 6 patients who received WBRT followed by SRS boost were excluded from analysis. Of patients who received SRS alone (n = 11), 7 were females and 4 were males. Median age was 57 years (range 42-67 years). Ovary was the commonest primary site (4 patients) followed by breast (3 patients). Other histologies included renal cell carcinoma, small cell lung cancer and carcinoma rectum. 3 patients were classified as Recursive partitioning analysis (RPA) Class I (defined as KPS ≥70, age <65 years with controlled primary and no extra-cranial metastases; 5 patients were RPA Class III (KPS <70) and remaining 3 were RPA Class II. Patients were treated with a frameless radio-surgery system using multiple beams, 6MV photons and micro-MLC based LINAC. Results: The mean prescribed dose was 16.0 Gy (range 10-20 Gy) and the mean PTV dose was 17.8 Gy (range 10.8-21.6 Gy). At a median follow up of 8.03 months (range 1-22 months), 5 patients (45.4%) developed post SRS regional failure (RF). Median time to RF was 7 months. Salvage treatment included WBRT (3 patients) and re-irradiation with SRS (1 patient). 1 patient refused further radiotherapy. 3 patients (27.2%) died due to non CNS causes and 3 patients were alive at time of analysis. Median OS was 8 months. Post SRS overall survival (OS) at 6 months and 12 months were 71.6% and 20.5% respectively. Conclusion: SRS alone represents a feasible option as initial treatment for patients with brain metastases and our experience correlates with the existing literature reports.
Clinical outcome of medullo-blastoma in adults: A single institution experience
thA. Arjunan , V. R. Anjali, B. S. Mathew, P. S. George, Aleyamma Mathew, Anitha Mathews, R. K. Rajeev, K. Ratheesan
Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Background: Adult Medullo-blastoma is a rare tumour. Treatment decisions are mostly based on extrapolations from pediatric protocols. The aim of this study was to review the management and outcome of adult medullo-blastoma patients treated at our institution. Materials and Methods: The clinical data of all patients (≥15 years) with histologically proven medullo-blastoma treated at our centre during 1 st January 2000 to 31 st March 2014 were reviewed retrospectively. Data regarding patient demographics, tumor related factors such as symptoms, location and histopathology, extent of resection (residual disease <1.5 cm2 v/s ≥1.5 cm2), radiotherapy (RT), chemotherapy (CT), disease recurrence and follow up were collected. Patients with ≥1.5 cm2 postoperative residual disease or metastatic disease were categorized as high risk. Overall survival (OS) and progression free survival (PFS) were calculated from date of surgery. Progression was determined as date of first radiologic evidence of disease recurrence/progression. Results: Among the 29 patients identified from the Hospital Registry, there were 21 males and 8 females. Median age at diagnosis was 26 years (range: 15-49 years). Nine patients had high risk disease. All patients received adjuvant RT (34.0-36.0 Gy to neuraxis with posterior fossa boost of 54.0-55.8 Gy). Twelve patients (41%) received concurrent + adjuvant chemotherapy of which 6 were high risk. At a median follow up of 40 months (range, 6-105 months) 5 patients (17%) relapsed. All 5 had high risk disease at presentation. The 2 year PFS and OS were 87.5% and 94.1% respectively. Five year PFS was 76.5% and OS was 83.7%. Conclusion: Adult medullo-blastoma appears to have a comparable prognosis to those in children. Role of chemotherapy and reduction in neuraxis RT dose- especially in average risk patients - needs to be defined.
An international atomic energy agency randomized phase III study of radiation therapy in elderly and/or frail patients with newly diagnosed glioblastoma multiforme (Clinicaltrials.gov Number, NCT1450449)
thWilson Roa , Lucyna Kepka 1 , N. Kumar 2 , Valery Sinaika 3 , Juliana Matiello 4 , DarejanLomidze 5 , Dalenda Hentati 6 , Douglas Guedes de Castro 7 , Katarzyna Dyttus-Cebulok 8 , Suzanne Drodge, Sunita Ghosh,
Branislav Jeremić 9 , Eduardo Rosenblatt 10 , Elena Fidarova 10
University of Alberta, Alberta Health Services-Cancer Control, Edmonton, Canada, 1 Warmia and Mazury Oncology Center, Olsztyn, Poland, 2 PGIMER, Chandigarh, India, 3 N.N. Alexandrov National Cancer Centre of Belarus, Minsk, Belarus, 4 Irmandade da Santa Casa de Misericσrdia de Porto Alegre, Porto Alegre, Brazil, 5 High Technology Medical Center, University Clinic, Tbilisi, Georgia, 6 Institut National de Cancer Salah Azaiz, Ministθre de la Santι Publique, Bab Saadoun, Tunisia, 7 Department of Radiation Oncology Castro DG, AC Camargo Cancer Center, Sγo Paulo, Brazil, 8 Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland, 9 Institute of Lung Diseases, Institutski Put 4, Sremska Kamenica, Serbia, 10 International Atomic Energy Agency Applied Radiation Biology and Radiotherapy Section, Vienna, Austria, E-mail: [email protected]
Background: The optimal radiotherapy regimen for elderly and/or frail patients with newly diagnosed Glioblastoma remains to be established. This study compared two abbreviated radiotherapy regimens on the outcome of these patients. Materials and Methods: Between 2010 and 2013, 98 patients (frail = age ≥50 years and KPS 50-70%; elderly and frail = age ≥65 years and KPS 50-70%; elderly = age ≥65 years and KPS 80-100%) were randomized prospectively to two arms in a 1:1 ratio, stratified by age (<65 and ≥65 years old), KPS and extent of surgical resection. Arm 1 received short course radiotherapy (25 Gy in 5 daily fractions over one week) and Arm 2 received standard radiotherapy (40 Gy in 15 daily fractions over three weeks). Results: The short course radiotherapy was non-inferior to standard radiotherapy. The median overall survival was 7.9 months (95% CI: 6.3-9.6) and 6.4 months (95%CI: 5.1-7.6), respectively (p = 0.988). Median progression-free survival was 4.2 months (95% CI: 2.5-5.9) and 4.2 months (95% CI: 2.6-5.7), respectively (p = 0.716). With a median follow-up of 6.3 months, quality of life between both arms at four weeks post treatment and eight weeks post treatment was not different. Conclusion: There was no difference in the duration of overall survival, progression-free survival and quality of life between patients receiving the two radiotherapy regimens. In view of the reduced treatment time, the short one-week radiotherapy regimen may be recommended as a treatment option for elderly and/or frail patients with newly diagnosed Glioblastoma.
A dosimetric comparison between 3D-conformal radiation therapy and intensity modulated radiation therapy in the treatment of posterior fossa boost in medulloblastoma
thM. Gupta , R. Ravikant, V. Nautiyal, J. Bisht, S. Raghuvanshi,
M. Saini, B. P. Kalra, M. Ahmad
Swami Rama Himalayan University, Dehradun, Uttarakhand, India, E-mail: [email protected]
Purpose: To compare 3D conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) in treating posterior fossa boost in children with medulloblastoma; dosimetrically evaluating and comparing both techniques with regard to target coverage and doses to organs at risk (OAR). Materials and Methods: Seven previously irradiated patients of medulloblastoma were retrieved and replanned with both 3DCRT and IMRT techniques. A dosimetric comparison was done by performing two plans for the posterior fossa boost, 3D-CRT and IMRT plans, for the same patient. Prescription dose and normal-tissue constraints were identical for both plans. Target coverage was evaluated with the D95% and D5%. Results: Mean values of PTV 95% and PTV 5% in IMRT were 97.19% and 106.07%, for 3DCRT were 96.57% and 106.33% respectively. The dose homogeneity was better in the IMRT (1.091) as compared to 3DCT (1.100) but was not statistically significant (P = 0.341). Conformity index was comparable in both the plans 3DCRT (0.979) and IMRT (0.976) with p value 0.819. IMRT plan provided reduced mean dose to cochlea relative to the 3DCRT plans with p value 0.032 for right cochlea and 0.020 for left cochlea. IMRT showed no advantage over 3D-CRT in sparing the anterior cranial structures where mean doses to right and left optic nerve were 1.54 Gy and 2.29 Gy for IMRT and 0.48 Gy and 0.53 Gy for 3DCRT respectively. Mean doses to right and left lens were 0.61 Gy and 0.56 Gy for IMRT and 0.16 Gy and 0.09 Gy for 3DCRT respectively Conclusion: IMRT technique was able to improve homogeneity index, spare the cochleae, but 3D-CRT plans were superior in sparing anterior cranial structures, such as the lenses and optic nerves, without compromising the dose to the posterior fossa. 3CRT plan is not inferior to IMRT in treating posterior fossa boost in medulloblastoma and is applicable in countries with limited resources.
Pineoblastoma: A retrospective analysis
thA. Arjunan , M. Dhas, P. Kusumakumary, B. S. Mathew, A. Mathews,
T. Priyakumary, M. Nair, R. Binitha
Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Introduction: Pineoblastoma (PB) is a rare, malignant tumour of pineal region, categorized as supratentorial primitive neuroectodermal tumor (sPNET). Survival rates for PB varies depending on the presence of dissemination at diagnosis, modality of treatment and age at presentation. We retrospectively evaluated the treatment outcomes for PB at our institute. Materials and Methods: The clinical data on eight patients diagnosed with PB since Jan 2009 were reviewed. Data regarding patient demographics, pathological details, treatment details such as extent of resection (gross-total resection [GTR], subtotal resection [STR] or biopsy), radiotherapy (RT), chemotherapy (CT), disease recurrence and follow up were collected. Overall survival (OS) and progression free survival (PFS) were calculated from date of surgery. Progression was determined as date of first radiologic evidence of disease recurrence/progression Results: Of the eight patients identified from our review, four were females and four were males. The median age at diagnosis was 6.5 years (range: 1-52 years). Three patients were ≤ 3 years of age. Surgical intervention included biopsy (n = 6) and STR (n = 2). Four patients had cerebrospinal dissemination at diagnosis. Of the eight patients, two received adjuvant craniospinal RT (CSI) (36.0 Gy to neuraxis with posterior fossa boost of 54.0-55.8 Gy). Three children aged < 3 years received chemotherapy alone and one child aged 5 years received CSI and chemotherapy. Two patients with cerebrospinal dissemination at presentation died before initiation of any treatment. Median follow- up was 8.5 months (range, 1-34 months). Only three patients (37%) were alive at the time of analysis. Of the 5 patients who died due to recurrence/progressive disease, four were children. PFS and OS at 1 year was 66.5% and 37.5% respectively. Conclusion: Poor outcome of younger children compared to older children and adults in our study correlates with existing literature reports. Impact of suboptimal surgical resection on survival needs to be evaluated.
Pineal parenchymal tumours: 5-year experience of a single institution
thA. Arjunan , M. Dhas, B. S. Mathew, A. Mathews, V. Jiji, K. R. Rajeev, K. Ratheesan, P. G. Jayaprakash
Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Background: Parenchymal pineal tumors (PPT) are rare tumors arising from pineal gland. The WHO classification of CNS tumors divides PPT into pineocytoma (PC), pineoblastoma (PB) and PPT with intermediate differentiation (PPTID). There are only a few studies on the clinical outcome of PPT. Materials and Methods: Clinical data of patients with histologically proven PPT treated at our institution since 2009 were reviewed retrospectively. Data regarding patient demographics, pathology, treatment details such as extent of resection (gross-total resection [GTR], subtotal resection [STR] or biopsy), radiotherapy (RT), chemotherapy (CT), disease recurrence and follow up were collected. Overall survival (OS) and progression free survival (PFS) were calculated from date of surgery. Results: 14 patients with PPT were identified from the Hospital Registry (PC = 1 patient, PPTID = 5 and PB = 8). There were 8 males and 6 females. Median age at diagnosis was 18 years (range: 1-52 years). Surgical intervention included GTR (n = 1), STR (n = 3) and biopsy (n = 10). Four patients with PB had cerebrospinal dissemination at diagnosis. Patient with PC did not receive adjuvant radiotherapy. All patients with PPTID (n = 5) were treated with partial brain radiotherapy (54.0 to 57.6 Gy) targeting the primary disease. None of them received craniospinal irradiation (CSI). For PB, postsurgical intervention included: CSI alone (n = 2), chemotherapy alone (n = 3) and CSI + chemotherapy (n = 1). 2 patients with metastatic disease died before initiation of any treatment. At a median follow up of 11.5 months (range 1-53 months), patients with PPTID (n = 5) and PC (n = 1) were alive with no evidence of recurrence. Of the 8 patients with PB, only 3 patients were alive at the time of analysis. 2 year DFS and OS were 83.3% and 61.9% respectively. Conclusion: An accurate histological diagnosis plays a key role in the management of PPT. While local treatment seems to be effective in PC and PPTID, PB requires aggressive multimodality approach.
Treatment of trigeminal neuralgia with cyberknife VSI: A single institution case series report
thT. Divya , P. Prem Kumar, L. Yugandhar Sarma, N. Janardhan,
B. Perumal, S. Jagadeesan
Omega Hospitals, Hyderabad, Telangana, India, E-mail: [email protected]
Background: Trigeminal Neuralgia (TN), also known as Suicide disease, is a neuropathic disorder characterized by episodes of intense, agonizing pain in the face originating from the V th nerve. The most acceptable theory of causation is focal demyelination of V th nerve root by vascular compression. Traditionally, it has been treated by medical and surgical techniques. In patients with refractory TN, SRS directed at the affected nerve root is an effective alternative. Though majority of the published data has been on Gammaknife Radiosurgery which is frame based, some data also favours the effectiveness of Cyberknife in the management of TN. Objective: To report our preliminary, single institution experience in treating refractory TN, by frameless Cyberknife Robotic Radiosurgery and to assess its effectiveness as an alternative treatment option. Materials and Methods: A total of 5 patients with refractory, U/L TN were treated with CK-SRS between October 2013 and December 2014. Using super-imposed CT and MRI-FIESTA images, the retrogasserian cisternal component of trigeminal nerve (a length of 6 mm, 3 mm anterior to REZ) was delineated. Plan was done on Multi-Plan TPS version 4.6, for a dose of 60 Gy in single fraction to 80% isodose line, aiming to achieve minimal dose to critical structures. The dose was then delivered with sub-millimeter accuracy using Cyberknife VSI (Accuray, Inc., Sunnyvale, CA, USA). After treatment, patients were followed regularly, at monthly intervals for the first 3 months and at 3 monthly intervals subsequently. They were evaluated for the level of pain control (BNI scale), time to pain relief, facial hypoesthesia and time to pain recurrence. Results: The median age of the patients treated was 60 yrs (F >M) and have a median follow-up period of 19 months. All 5 patients achieved a successful treatment outcome. The BNI pain score before treatment was V in 3 and IV in 2 patients. In all 5 patients, the BNI pain score came down to I or II after treatment with the time to pain relief being 4 hrs-20 days. Only 1 patient developed non progressive facial hypoesthesia, 5 months after treatment. No recurrence was observed till the last follow-up among 3 patients and are completely off the medication. But in 2 patients, BNI score went up to III-IV, 4 & 6 months following SRS respectively, necessitating additional treatment. Conclusion: The frameless Cyberknife Robotic SRS allows optimal pain relief and is a viable treatment option for patients with refractory TN.
A case of pineal germinoma
thT. Pounikar , S. Rawat, M. K. Advait
Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India, E-mail: [email protected]
Background: A 5 year child presented with complaints of headache and vomiting of two month duration, she initially went to neurosurgeon. MRI done revealed a solid neoplastic region of 2 * 1.5 cm and routine with resultant supratentorial hydrocephalus with mild periventricular ooze. She underwent right sided occipital craniotomy and the post op hpr revealed pineal germinoma her blood levels of beta-hcg was 6.6, alpha feto protein was 290. the child was started on chemotherapy with BEP, she received five cycles of the same chemo and then she was shifted to cisplatin and vinblastin received three cycles of the same her blood levels of beta hcg and alpha feto protein was found to be normal. She was started on irradiation. She received craniospinal irradiation of 22 Gy and a total of 45 Gy to brain and is now under regular follow up with no fresh neurological complaints. Conclusion: Theories of on the development of germinoma suggest an embryonic event that shows the aberrant migration of germ cells to the diencephalon. Before starting the treatment the malignancy should be accurately staged, our patient was considered for craniospinal radiation in view of te large tumor and its multicentricity. Variety of tumors arises from pineal region those that arises from the pineal gland are called pineoblastoma. Germinomatousa tumors are more common than the non germinomatous ones. There is no conventional method of treatment to be followed. The treatment modalities include surgery, chemotherapy, and radiation. The most common type of germinomatous tumors are germinoma but other types of tumors like embryonal and yolk sac tumors can also occur the pineal gland tumors have also a tendency to spread via CSF, so craniospinal irradiation form a part of the treatment. The intracranial tumors germinomas mostly radio sensitive and have an excellent prognosis whereas the non germinomatous ones have a poor prognosis the chance of recurrence after irradiation in a pineal germinoma is 40%, for recurrent tumors a second look surgery or chemotherapy is the best modality. Pure germinomas have good prognosis, and a low recurrence rate. Clinical remission is defined by normalization of tumor markers and the absence of tumor. It is rare for another type of germ cell tumor to develop after successful eradication of pineal germinoma, if whole brain irradiation is performed after going through various sources such a case has not been reported in this age group which make it a rare one.
Primary meningeal melanocytoma of the cerebellopontine angle: A rare tumor in an unusual location
thS. Dikkala , G. Nethula, S. Surana, P. R. Thammineni
Krishna Institute of Medical Sciences, Secunderabad, Telangana, India, E-mail: [email protected]
Background: Primary meningeal melanocytomas were first described by Limas and Tio in 1972. These are rare benign tumors arising from the leptomeninges with no site predilection in the neuraxis. To the best of our knowledge less than 200 cases have been reported. Complete surgical resection can be curative for most cases. Although described as benign, incomplete resection of these tumours had only a 42% 5-year survival rate. 5 year survival rates are 100% if incomplete resection is followed by radiation therapy. There are also reports that described transition of melanocytoma to a primary malignant melanoma. Case Presentation: A 25 year old female presented with a history of headache and decreased hearing in right ear of 2 months duration. An MRI of brain revealed a 21 x 24 x 25 mm mass lesion along the posterior surface of right petrous bone which appears hyperintense on T1, and hypointense on T2 and FLAIR sequences. The lesion showed homogeneous enhancement on post contrast study. She underwent retromastoid suboccipital craniotomy and near total excision of the tumor. Per operatively an extra axial black coloured, vascular mass was seen adherent to superior petrosal vein and brainstem. Microscopy of the specimen showed perivascular arrangement of the tumor cells containing finely granular brownish black pigment granules in cytoplasm. Nuclei were vesicular with prominent nucleoli. Mitotic activity was 10-12/10 HPF. No necrosis or invasion into CNS parenchyma was seen. These features were consistent with melanocytoma. Post operatively patient was planned for external beam radiation therapy in view of high mitotic activity. Radiation was delivered using VMAT-Rapidarc under image guidance. A dose of 50.4 Gy was delivered in 28 fractions @ 180 cGy per fraction. Discussion: Herein we report a rare case of primary cerebellopontine angle meningeal melanocytoma (PCPAM). Primary meningeal melanocytoma is a rare, benign tumor but it can behave aggressively and relapse after subtotal resection. So it mandates external beam radiation therapy after incomplete surgery.
Retrospective analysis of paediatric ependymoma: A single institution experience
thA. Arjunan , P. Kusumakumary, T. Priyakumary, R. Binitha, M. Nair,
P. S. George, C. P. Rari Rahman, K. Ratheesan
Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Background: Ependymomas are rare tumors and constitute approximately 10% of all primary intracranial tumours in children and 25% of all spinal cord tumours. Despite improvements in the treatment of paediatric brain tumours, survival rates for children with intracranial ependymoma are generally poor. We retrospectively evaluated the treatment outcomes for ependymoma at our institute. Materials and Methods: We retrospectively reviewed the clinical data of all children (≤17 years) with ependymoma treated at our institution between 1 st January 2000 to 31 st December 2014. Data regarding patient demographics, pathological details, treatment details such as extent of resection (gross-total resection [GTR], subtotal resection [STR] or biopsy), radiotherapy (RT), chemotherapy (CT), disease recurrence and follow up were collected. Overall survival (OS) and progression free survival (PFS) were calculated from date of surgery. Progression was determined as date of first radiologic evidence of disease recurrence/progression. Results: Of the 28 patients identified from our review, 7 were females and 21 were males. The median age at diagnosis was 6.4 years (range: 1-16 years). Eleven patients (39.2%) were ≤3 years of age. 25 patients had intracranial ependymoma (16 supratentorial and 9 infratentorial) and the remaining 3 patients had spinal ependymoma. 3 patients had features of leptomeningeal dissemination (supratentorial tumours [n = 2] and infratentorial [n = 1]). All the patients had surgical excision. GTR (n = 14), STR (n = 13) and biopsy (n = 1). 4 patients were lost to follow up after surgery. 2 children aged ≤3 years of age are undergoing chemotherapy with vincristine/etoposide based regimes at the time of analysis. 4 children received chemotherapy till the age of 3 years followed by radiotherapy. Patients with leptomeningeal dissemination (n = 3) received craniospinal irradiation. 15 patients with localized disease received adjuvant radiotherapy alone targeting the gross tumour volume (GTV) with adequate margins (dose 54.0 to 59.4 Gy in conventional fractionation). At a median follow up of 24 months (range, 4-70 months), 5 patients developed progressive disease and 2 patients died. The 2 years PFS and OS were 83.3% and 87.5% respectively. Conclusion: Survival rates for children with ependymoma in this study were comparable to published literature reports. Longer follow up is required to further assess patterns of failure.
Cyberknife radiosurgery for benign intracranial lesions
thV. Singhal , S. Halder, S. Hukku, P. Mehrotra, N. Vaid, E. H. Annex, S. Kaushik
Dr. B. L. Kapoor Memorial Hospital, New Delhi, India, E-mail: [email protected]
Background: Management paradigm for benign intracranial lesions has largely shifted away from aggressive surgical resection to radiosurgery. Cyberknife robotic radiosurgery being precise frameless outpatient procedure, effective in treatment of these lesions. Aim: To study efficacy and safety of cyberknife Radiosurgery in benign intracranial lesions. Materials and Methods: We retrieved all cases of benign intracranial lesions in last 3 years (October-2012 to April-2015) registered in our department, from our computer database and documented their diagnosis, age, treatment volumes, dose, fractionation, conformity index, doses to organs at risk, pre-treatment and followup clinical/MRI findings & analyse data using SPSS. Results: Between Oct-2012 to April-2015 we registered 125 cases of benign intracranial lesions (39 = Schwannomas, 37 = meningiomas, 17 = AVM, 10 = Pituitary adenomas, 4 = Trigeminal neuralgias, 4 = Glomus tumour, 3 = benign nerve sheath tumours, 2 = craniopharyngiomas, 1 = Hemangiopericytoma, 2 = Hemangioblastoma, 1 = Cavernous sinus malformation, 1 = Pontine cavernoma, 1 = occipital hemangioma, 2 = Penial gland tumours, and 1 = Neurocytoma). Median age of presentation was 46 years (09 yrs to 81 yrs). Prescribed dose ranges from 12 Gy to 25 Gy in 1 to 5 fractions to median isodose of 80%. Median tumour volume was 8.96 cc (0155 cc to 133.195 cc). Median of tumour volumes receiving 100 percentage of dose was 94.49%. Median conformity index was 1.14. Median D-max for organs at risk are-brain stem = 16.27; right cochlea = 3.12; left cochlea = 3.44; right optic nerve = 1.24; left optic nerve = 1.57; optic chiasm = 3.147. Median followup was 14 months (mean = 15.79 m). Out of 125 patients 32 lost to followup (74.4%). 88 of 93 patients were alive (OS = 94.62%). 81 patients had no apparent complaints with MRI findings showing no interval changes/decrease in size of lesion (PFS=87.09%). 07 patients were symptomatic with progression on MRI. Five patients expired (?disease/morbidity). Conclusion: Cyberknife radiosurgery is safe and effective modality for treating benign intracranial lesions. High dose precision, optimal coverage, short treatment time and minimal dose to organs at risk offers favourable risk-to-benefit profile. Longer follow-up is always desirable.
Cavernous sinus metastasis from carcinoma buccal mucosa:
A rare presentation
thB. Azariah , R. Kumar, C. Kainickal, M. Rafi, G. Babu, K. Ramadas
Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Oral tumors mostly present as localized disease and tend to remain localized until late in the course of their development. Around 20% of the patients develop distant metastasis and might eventually die of their disease. Most common sites of metastasis are lung, followed by bone, and liver. Brain metastasis from squamous cell carcinoma of oral cavity is very rare. In the following case study, we present a patient who developed cavernous sinus metastasis while on treatment for carcinoma right buccal mucosa. This 55 year old female patient presented to us as a case of cT4a N2b M0 carcinoma right buccal mucosa [in virtue of bone involvement]. She was treated with Neo adjuvant chemotherapy with cisplatin and 5-fluorouracil for two cycles, followed by surgery (Wide excision + Right hemi mandibulectomy + Right MRND + Pectoralis major myocutaneous flap reconstruction). Her surgical pathology showed a residual tumor of 2.5 x 2 cm. All of the 18 nodes sampled were negative for metastasis. All surgical margins were negative, and there was no lympho vascular or perineural invasion. However segment of bone which was removed showed tumor infiltration. She was started on post-operative radiotherapy to the tumor bed and ipsilateral neck. After 5 fractions of radiation, she was admitted with generalized weakness, poor oral intake and hyponatremia. While on admission she was found to have right lateral rectus palsy and diplopia. MRI evaluation showed T1 iso/hypo intense lesion in the right cavernous sinus encasing internal carotid artery [approximate size 15 x 12 mm], suggestive of a metastatic deposit. Her general health and the site of the deposit was not satisfactory to proceed with histological confirmation and further evaluation. The adjuvant radiotherapy was stopped and she was then started on radiotherapy to skull base. She was treated with palliative radiotherapy with 20 Gy in five fractions to the skull base and was discharged with symptomatic improvement. This is the first case report of this kind reported in the literature. This could either be a metastatic deposit in cavernous sinus or it could also be a deposit due to perineural spread along the mandibular nerve. Though metastasis to cavernous sinus from a carcinoma buccal mucosa is extremely rare, proper clinical examination and the suspicion of remote possibilities might be extremely helpful while managing our patients.
Audit of gliomas at a tertiary centre: A retrospective analysis
thR. Mishra , H. Mishra, I. Jaiswal, R. Khurana, S. Sapru, R. Hadi,
M. Rastogi, K. Sahni
Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Background: CNS tumours constitute 1-2% of all malignancies with a wide spectrum of disease presentation, treatment options and its outcome. Malignant gliomas account for 35%-45% of all primary brain tumours and their incidence has increased in elderly in last two decades. Aim: To analyse patient characteristics, clinic-pathological characteristics, treatment offered and outcomes of glioma patients enrolled in our centre in last 3 years. Materials and Methods: Data collection done for all glioma patients who were registered in the radiotherapy OPD between October 2012-July 15. Results: Total number of patients of primary CNS neoplasm were 202. Out of these, 152 (80%) were gliomas, 93% histologically proven and 7% radiologically diagnosed. Headache was most common presenting symptom (51%). Median KPS at presentation was 70. Pre-operative MRI only was done in 80% patients, CT scan only in 21%. Disease location was supra-tentorial in 93% patients and infra-tentorial in 7%. Disease was lateralised right side in 55% and left side in 45% patients. Fifty-six percent patients underwent gross total resection, 37% sub-total resection and 7% were inoperable. Grade IV (GBM) histology was present in 57%, Grade III in 24%, Grade II in 15% and Grade I in 4%. Median time between surgery and RT start was 36 days. 96% patients received planned RT dose. Median RT dose for low grade was 54 Gy and for high grade was 60 Gy. Among GBM patients, 75% received concurrent as well as six cycles of adjuvant Temozolamide (TMZ), 10% received only concurrent TMZ and 15% patients had adjuvant RT alone. Almost all patients complained of somnolence, alopecia & grade I skin toxicity. Fifty percent of patients required steroids to control symptoms developed during RT. Median follow-up time was 9 months and 40% had a follow up MRI. Till the time of analysis, 53% patients had stable disease, 20% had complete response, 9% died and 18% were lost to follow-up. Conclusion: GBM was most common histopathology. Incidence was more common in males (M:F = 3:1). Headache was most common presenting symptom. Supra-tentorial region was most common site. Age, KPS, grade, extent of surgery and compliance to RT determined the outcome.
Demographic profile of patients receiving palliative radiotherapy to brain: An institutional review
thT. Mishra , S. Mishra, L. Pattanayak, S. Padhi, N. Panda, S. Senapati
A.H. Regional Cancer Center, Cuttack, Odisha, India, E-mail: [email protected]
Background: Brain metastases are a common manifestation of systemic cancer affecting 20-40% of all cancer patients. Aggressive management of brain metastases is effective in both symptom palliation and prolonging the life. Radiotherapy has a major role to play in the management of brain metastases. Aim: To correlate clinicopathological variables of patients presenting with brain metastases with primaries and mode of presentation with literature review. Materials and Methods: A retrospective analysis of 94 patients who have received palliative radiotherapy to brain metastases from January 2014 to june 2015 at dept of radiotherapy, AHRCC, Cuttack, has been analysed with respect to gender, age, site of primary. Patients were treated with palliative whole brain radiotherapy to a dose of 30 Gy in 10 fractions over two weeks. Diagnosis was done in most cases with computed tomography scan and by MRI scan in some cases. Results: Out of 94 patients, a female preponderance 62.7% was seen compared to males (37.3%). 30.8% patients were in age group 31-45 yrs and 66% of patients belonged to age group >45 yrs. Considering site of primary malignancy producing brain mets, carcinoma lung was most common (43.6%) followed by carcinoma breast (29.7%). 11% of patients presented with upfront brain mets i.e., without receiving any treatment to the primary site of malignancy. 19% cases presented with metastases at other sites along with brain. Out of 94 patients, 82%presented with supratentorial lesion and rest 18%presented with infratentorial lesion. 76% patients presented with multiple metastasis whereas 24% presented with single metastasis. The former group received only WBRT. Among patients with single mets, 9 patients underwent surgery and received RT;whereas 14 patients received only RT. Patients who underwent surgery plus WBRT had fewer local recurrences, improved survival (40 weeks versus 24 weeks in case of RT alone) and better Karnofsky performance status (KPS) than patients who received WBRT alone. Survival in patients with multiple metastases was 18 weeks. Conclusion: From this study we can infer that carcinoma lung followed by carcinoma breast are the most common sites of primary malignancies developing brain mets which is in well accordance with literature. Females show a higher incidence than males. A larger patient pool and a longer followup can derive more robust associations and survival benefit.
Ophthalmic metastasis from an extraocular primary malignancy
thB. Rotroy , C. Bose, D. Samanta, S. Padhi, S. Senapati
A.H. Regional Cancer Center, Cuttack, Odisha, India, E-mail: [email protected]
Background: Ophthalmic metastasis from an extraocular primary malignancy is a rare clinical entity consisting 2% to 3% of patient with malignancy. Orbital metastasis is defined as one that occurs within the space between the eyeball and bony orbit. It usually occurs due to direct extension or perineuronal invasion of nasopharyngeal and ethmoidsinous carcinoma. Most of the ophthalmic metastasis are due to primary carcinoma of breast (38-40%), lung (20-29%) and gastrointestinal tract (12%). Aims and Objectives: Here we report four cases of orbital metastasis presented in upfront and during follow up period. Three different primary cases metastasis to orbit, time and mode of presentation with literature review. Materials and Methods: Four patients of ophthalmic metastasis who attended the department of radiotherapy during period from January 2014 to April 2015 were analysed with respect to their age, site of primary, interval between the primary and appearance of metastatic disease. All patients treated with radiotherapy and chemotherapy. This case series is been reported due to its rarity. Results: Out of four patients of ophthalmic metastasis two patients were male and two were female having age of presentation between 40-50 years. Considering site of primary, two patients had carcinoma buccalmucosa, one carcinoma breast and another was from carcinoma lung. Out of four patients one presented with upfront metastasis and rest of the three patients presented with metastasis ranging from nine months to three years. Out of four patients three were presented with multiple metastasis i.e., to bone and liver whereas only one presented with single metastasis. All the patients received radiotherapy to eye followed by chemotherapy in palliative intent and hormone therapy according to their primary disease. After completion of treatment, all patients have experienced partial improvement in vision. Two patients are in regular follow up and one is lost to follow up. Another patient died due to progression of his disease. Conclusion: Although ophthalmic metastasis is rare, any patient with ocular symptoms with history of malignancy should be evaluated for this metastasis. A thorough metastatic work up should be done as most patients with orbital metastasis may have other non-orbital metastasis. Metastasis to orbit remains a poor prognostic factor, and prompt diagnosis and treatment is essential to preserve the visual function and improve the quality of life.
Efficacy of fractionated stereotactic radiosurgery for re-radiation as salvage therapy in recurrent glioblastoma
thA. Gulia , A. K. Anand, C. Garg, A. K. Bansal, P. Kumar, C. K. Patro
Max Cancer Center, Max Superspeciality Hospital, New Delhi, India, E-mail: [email protected]
Background: Various therapeutic approaches have been tried in recurrent Glioblastoma. We evaluated Fractionated Stereotactic Radiosurgery (FSRS) in inoperable cases, to deliver ablative doses of radiation to the tumor while minimizing dose to the previously irradiated surrounding normal tissues. Aim: To evaluate treatment outcome in recurrent Glioblastomas with FSRS. Materials and Methods: We retrospectively analyzed 37 recurrent Glioblastoma patients treated with salvage FSRS from January 2009 to December 2013. KPS at the time of recurrence was more than 70 and the lesion was considered inoperable. Results: Mean initial KPS and KPS at the time of recurrence were 90 and 80 respectively. Mean age of patients was 54.3 years. The median time to recurrence was 14months. The median dose delivered by FSRS was 30 Gy in 6 fractions. The mean volume of reradiated target was 20.7 cc. At a median follow up of 25 months, the median OS after initial diagnosis was 23.5 months and after re-radiation it was 7 months (1-34 months). Two patients were still alive at 5 and 11 months post FSRS. 6 and 12 months OS after recurrence was 53% and 25% respectively. 2, 3, 4 years OS after initial therapy [RT+Temozolamide (TMZ) ] and subsequent FSRS was 47%, 21.6% and 11.8% respectively. Conclusion: Treatment options in patients with recurrent Glioblastoma are limited. With the advent of stereotactic radiotherapy, delivery of high ablative dose of radiation is possible while saving surrounding normal tissues. This strategy has yielded good results, as has been observed in the present study and can be an effective alternative to other salvage therapies like surgery and chemotherapy.
Prospective study of neurocognitive function, performance status, quality of life and local control in patients with 1-3 newly diagnosed brain metastases treated with stereotactic radio surgery alone
thVijay Anand Reddy
Apollo Cancer Hospial, Hyderabad, Telangana, India, E-mail: [email protected]
Background: Whole Brain Radiotherapy or Stereotactic Radio Surgery alone in newly diagnosed 1-3 brain metastases is a subject of debate. Neurocognitive function, Performance status, QOL and local control were prospectively measured in patients receiving SRS alone for 1-3 brain metastases in the study at Apollo Cancer Hospital, Hyderabad. Materials and Methods: Patients with ECOG scale less than 2, age less than 70 yrs, brain metastases of maximum size less than 4 cm and 1-3 brain metastases are accrued into study. At the time of final analyses seventeen patients (9 male and 9 female) with 22 brain metastatic lesions who received SRS alone with dose ranging from 30 Gy (5 fractions) to 18 Gy (1 fraction) with a median dose of 18 Gy (1 fraction) were analyzed. Results: The median follow up is 9 months (3 months-20 months). At the baseline, 10 of the 17 (58.8%) patients had impairment of one or more tests of neurocognitive function. The domains most frequently affected at baseline were Motor dexterity, learning, memory and executive function. The mean standard deviation MMSE value was 27.88 3.3 in the SRS group at baseline which was improved to 30.3 0 at last follow up. An improvement in MMSE of 3 points was observed in 59% of the patients after the initial brain treatment. Preservation of full score of 30 was observed in 41% of the patients. Performance status evaluation shows that in total at the 6 months follow up 13 patients (76%) were alive and out of them 12 patients (92.3%) are having a ECOG score of less than or equal to 2. Among the 5 patients who had a pretreatment score of 3, an improvement in performance status was observed in 4 patients (P = 0.04). In the organ-specific BN20 module, a significant improvement in future uncertainty (p < 0.0001), visual dysfunction (p < 0.01), motor dysfunction (p = 0.001) and headache (p = 0.03) is observed. Serial MRI scans showed that four out of 13 (30%) has complete response, 2 of 13 (15.3%) of patients had partial response. In total 11 of 13 (84%) patients had achieved local control at the time of evaluation. Conclusion: This final analysis shows encouraging results for SRS alone in limited brain metastases in terms of improvement and preservation of neurocognitive function, Performance status, Quality of life and in achieving acceptable local control. The results of this study show better local control rate and Quality of life compared to similar studies done previously on SRS in limited brain metastases.
Role of whole brain radiotherapy plus stereotactic radiosurgical boost versus whole brain radiotherapy alone in the management of one to three brain metastases
thS. Singh , A. Sarin, S. Bhatnagar 1 , S. Sharma 2
Command Hospital (SC), Pune, Maharashtra, 1 Army Hospital (R&R), New Delhi, 2 Command Hospital (CC), Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Background: Brain metastases are a major cause of mortality & morbidity in cancer patients and are traditionally seen as a terminal event in the natural course of disease. Whole Brain Radiotherapy (WBRT) has remained the most commonly used treatment for multiple metastases with no change in dose or delivery technique until very recently. Though it provides symptomatic relief, the effects have a low durability and local failure is common. Stereotactic Radiosurgery (SRS) techniques such as Gamma Knife have been shown to be as effective as Surgery in control of limited (1 to 3) mets and as effective as WBRT in control of multiple mets. In this study, we have compared use of WBRT alone versus WBRT plus SRS boost for management of 1 to 3 brain metastases. Aim: To study the role of SRS boost after WBRT in patients of 1-3 brain metastases. Objectives: (1) To compare the survival of patients with 1 to 3 brain metastases treated with WBRT with vs without SRS boost. (2) To compare duration of functional independence and normal neurocognitive function (NNF) post treatment in the patients belonging to the two groups. Materials and Methods: The study was carried out from 01 Jan 2011 to 30 Jun 2013 at a tertiary Oncology centre. 26 patients with 1 to 3 brain metastases were included and underwent complete work up including MRI of brain. Exclusion criteria included a KPS < 70%, age >70 yrs or <18 years, brain mets > 3 cm in size or located <5 mm from optic chiasm, history of prior treatment of brain metastases or a MMSE score <24. All patients received WBRT to a dose of 30 Gy in 10 fractions over 2 weeks. Half the patients (13 in number) were also given an SRS boost of 16 to 20 Gy by Gamma Knife technique. All patients were followed up at 12 weekly intervals for a period of 9 months and assessed for survival, FI (KPS>60%) and NNF (MMSE score>24). Results: At 9 months the median survival in the SRS boost group was 27 weeks compared to 22 weeks in the no boost group. Mean duration of functional independence & Normal neurocognitive function was 24 and 12 weeks in the boost and non boost arms respectively. The difference between two groups was not statistically significant. Conclusions: Though results are not significant, a definite trend towards improvement in median survival, functional independence and neurocognitive function in patients who received an SRS boost after WBRT is seen. Use of SRS is a viable option but appropriate patient selection is advised.
Encouraging experience with helical tomotherapy based re-irradiation in recurrent brain tumours: A combined retrospective and prospective patient analysis of survival and quality of life
thP. Gupta , T. Gupta, J. Sastri, S. Churi, R. Jalali
Tata Memorial Centre, Mumbai, Maharashtra, India, E-mail: [email protected]
Background: To report our experience including survival and preliminary QoL data in patients with confirmed recurrent CNS tumours treated with re-irradiation using helical Tomotherapy (HT) based image guided IMRT. Methods: Between 2009 to 2015, 34 patients with at least 1 month post re-irradiation follow up were analysed. Patient cohort includes 15 patients enrolled in an ongoing prospective study examining QoL and activities of daily living (ADL), as well 19 patients who underwent CNS re-irradiation over last seven years. Recurrence was confirmed by histological examination after a re operation in patients and/or with detailed imaging including biological MRI parameters and final consensus in a joint neuro-oncology multidisciplinary meeting. Thin slice planning MRI fusion was used to aid target volume delineation. All patients were treated with IMRT under daily image guidance with 6 MV using HT with 1.8-2 Gy/fraction to total of 45-55 Gy. QoL was assessed with EORTC QLQ-30 and validated BN -20 questionnaires, and ADL scored using Barthel ADL Index. Results: 28 patients were treated with re-irradiation for a recurrent glioma (16 upfront and 12 transformed high-grade from an original low-grade histology), 5 medulloblastoma and 2 atypical meningiomas. Mean KPS at the time of re-irradiation was 80. RT dose was 50-55 Gy for low-grade tumours or 60 Gy for a high-grade glioma (HGG) at the time of primary treatment. Planned re-irradiation dose depended on tumour histology, target volume and gap from previous RT. 15% received re-irradiation at 1-3 years, 32% at 3-5 years, 44% at 5-10 years and 8% at more than 10 years after primary RT. Mean overall survival for recurrent medulloblastoma was 24 months, and 32 months and 18 months for recurrent grade III and grade IV glial tumours respectively. 20/34 patients are alive and on regular follow-up presently. Of the prospective cohort, 12/15and 11/15 patients did not show a clinically significant decline in QoL and ADL respectively at 1 month post RT. 14/15 patients completed planned re-irradiation without any treatment break. Conclusion: Clinical experience of CNS re-irradiation with modern IG-IMRT using HT in recurrent glial and other CNS tumours has been encouraging in terms of tolerance, and providing reasonable survival and palliation. Detailed QoL and ADL assessment will be provided at the time of presentation.
The role of hybrid 3DCRT and VMAT in craniospinal irradiation in children
thA. Chandran , S. Prem
Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, E-mail: [email protected]
Background: The complexity of radiation treatment planning in cranio-spinal irradiation using 3DCRT and better conformity achieved using VMAT led us to devising a hybrid treatment protocol for the same. Aim: To report the treatment of cranio-spinal irradiation (CSI) with hybrid 3D-CRT and volumetric modulated arc therapy in children. Materials and Methods: Five patients from our institutions were treated with CSI using hybrid VMAT and 3DCRT technology. Patient age varied between 9 and 10 years. The lengths of the planning target volumes (PTV) and dose prescriptions ranged from 52.2 to 69.95 cm, and from 23.4 to 36 Gy, respectively. Different arc arrangements were used, with two isocentres, from two modulated arcs. All patients were treated in the supine position. Doses to PTV, organs at risk and non-target tissue, imaging strategy and pre-treatment quality assurance are reported. Results: The mean conformity index was 1.2. Mean doses to the lenses, lungs, heart, and kidneys were, respectively7.74, 8.1, 16.6 and 9.22 Gy keeping those values acceptably low. Mean non-target tissue dose was 21.0 3.8% (5.6 1.8 Gy, range: 3.0-8.1 Gy). Mean monitor units was 758. Conclusions: VMAT techniques achieved highly conformal treatment plans for CSI. Beam-on time was short, and VMAT plans were satisfactorily delivered to all patients.
Dose constraint model to predict neuroendocrine dysfunction in young patients with benign and low grade brain tumours treated with high precision conformal radiotherapy
thM. Maitre , T. Gupta, J. Swamidas, J. Sastri, U. Krishna 1 , D. Dutta 2 , N. Shah 3 , R. Jalali
Tata Memorial Centre, 3 King Edward Memorial Hospital, Mumbai, Maharashtra, 1 Kidwai Cancer Institute, Bengaluru, Karnataka, 2 Apollo Cancer Institute, Chennai, Tamil Nadu, India, E-mail: [email protected]
Background: Dose threshold to hypothalamic-pituitary axis (HPA) to predict neuroendocrine dysfunction is poorly defined. We report a possible dose constraint model for HPA, based on a prospective study of high-precision conformal radiotherapy to residual/recurrent brain tumours. Materials and Methods: HPA was meticulously contoured in 46 patients (median 13 years; 32 males, 14 females) with low-grade brain tumours treated with stereo tactic conformal RT (SCRT). Dose volume histograms were studied in patients with or without endocrine deficits at 2 and 3 year follow up. Results: Dosimetric correlation with 2-3 year clinical data showed post RT endocrine dysfunction (new deficit or additional deficit over preexisting one) in 10/20 patients, of which 80% had HPA within 2 cm of PTV. GH axis was the most commonly impaired (70%), followed by steroid axis (30%), pubertal axis (20%) and thyroid axis (10%). Average Dmax and Dmin to HPA were 39.7 Gy and 26.8 Gy respectively. Average V95, V50 and V30 were 40%, 59% and 73% respectively. For patients who did not develop post RT endocrine dysfunction, only 50% patients had HPA within 2 cm of their PTV. Average Dmax and Dmin for this group were 26.5 Gy and 17 Gy respectively. Average V95, V50 and V30 too were lower, being 20%, 20% and 49% respectively in patients with no post RT endocrine dysfunction. Detailed analysis is ongoing to see the possible doses to the entire or partial HPA at different dose levels and a linear regression model will be employed to correlate the doses with already available endocrine function data at 2 and 3 years follow up. Conclusion: There seems to be a direct dose relationship with endocrine dysfunction at post RT follow-up. A detailed analysis with HPA as a conformal avoidance model to minimise neuroendocrine deficits will be presented.
Hypofractionated stereotactic radiotherapy for AVM: A single center experience
thP. Gopu , J. K. Ramireddy, S. Patricia, B. Rajesh, S. John
Christian Medical College, Vellore, Tamil Nadu, India, E-mail: [email protected]
Background: Arteriovenous malformations (AVMs) are congenital vascular lesions that are associated with high morbidity and mortality if left untreated. There are several options for treatment including stereotactic radiosurgery. Safe and effective single-fraction radiotherapy for patients with large AVMs has been considered difficult. Aim: The aim of this study is to find the outcome and side effects of patients treated with hypofractionated stereotactic radiotherapy (HFSRT). Materials and Methods: Hypofractionated Stereotactic Radiotherapy was carried out for patients who had AVMs more than 4 cm and or lesions close to critical organs. From September 2008 to December 2014, 24 patients have undergone HFSRT and the details were reviewed retrospectively from the hospital records. The volume of the lesions and radiotherapy details were analysed from the TPS database. Patients were started on high dose steroids 2 days prior to starting of HFSRT. Eighteen patients received 36 Gy in 6 fractions on alternate days over a period of 2 weeks. For six patients the dose was reduced to 33-30 Gy in 6 fraction when the lesions were close to critical structures. Results: Hypofractionated Stereotactic Radiotherapy was carried out in 24 patients and in these patients 25% of the lesions were in the posterior fossa followed by 17% parieto occipital region. Average RT volume was 35.88 cc (3.7-96 cc). Fifteen patients have come for follow up with a median follow up period of 18 months (range 6-36 months). One patient required hospital admission for management of raised intracranial tension during radiotherapy. One patient had developed motor weakness after RT and it resolved with a course of dexamethasone over a period of 6 months. One patient had persistent seizure even after radiotherapy. Six patients had regression of the lesion and nine patients had stable lesion in their follow up MRI scan. None of the patients on follow up had progression or intracranial bleeds. Conclusion: Hypofractionated Stereotactic Radiotherapy is a feasible option in large AVMs which are not amenable for SRS.
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