|Year : 2015 | Volume
| Issue : 7 | Page : 36-39
|Date of Web Publication||24-Nov-2015|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Genitourinary. J Can Res Ther 2015;11, Suppl S3:36-9
Primary renal non-Hodgkins lymphoma: A rare site of presentation
thM. Kumar , Y. Verma, N. Bansal, A. Khurana, P. Kaur, A. Chauhan
Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]
Background: Primary renal lymphoma is uncommon and NHL is even rare, incidence reported less than 1%. Diffuse large B-cell lymphoma (DLBCL) is the most common histology of PRL. Aim: To report a rare case of NHL kidney and discuss treatment strategy. Materials and Methods: A 40-years old Indian female presented in surgical OPD with history of vague episodic pain in the right flank for three years which was relieved on taking analgesics. There was no associated history of altered bowel & bladder habits or symptoms like fever, night sweats or weight loss. Ultrasonography of the abdomen and pelvis showed an irregular large, hypoechoic retroperitoneal mass at the upper pole of the right kidney of size 8 Χ 10 cm. The contralateral kidney appeared to be normal. CECT revealed heterogeneously enhancing space occupying lesion on the antero-superior pole of right kidney, extending into suprarenal fossa and abutting inferior hepatic margin. Adrenal gland not separately visualized from mass. Soft tissue plane with hepatic margin were indistinct and lesion was reaching up to hilum compressing IVC, encasing renal vascular pedicle both renal artery and vein. IVP showed normal functioning kidney. Right nephrectomy was done for diagnosis of renal mass. Biopsy was suggestive of NHL, B-cell type. Immunohistochemistry was LCA +, CD20+ and CK, Vimentin & CD negative confirming the diagnosis of renal lymphoma. Whole body PET CT scan revealed no abnormal uptake elsewhere, so the patient diagnosed having primary renal lymphoma. Physical examination in radiotherapy OPD showed a healthy healed scar mark on the right flank of surgery. No significant cervical, supraclavicular, axillary, inguinal or popliteal lymph nodes were noted. Complete blood picture and renal/liver function tests were normal. Patient was given six cycle of chemotherapy (CHOP regimen). Results: Post-chemotherapy 18 F-FDG whole body PET CT showed no definitive evidence of metabolically active disease anywhere in body. Patient is symptom-free as of now (6 months after chemotherapy). Conclusion: PRL is a rare disease in which the etiology and pathogenesis are unclear. There is no standardized treatment for PRL in view of rarity of disease and standard protocol for management of lymphoma is followed.
Stereotactic radiotherapy for prostate carcinoma by cyber knife: An early experience, feasibility and tolerance (emerging treatment approach)
thP. Kumar , S. Halder, S. Hukku, E. H. Annex, A. Tyagi
Dr. B. L. Kapur Memorial Hospital, New Delhi, India, E-mail: [email protected]
Background: Prostate cancer has a unique low α/β ratio as compared to rectum and bladder, so a therapeutic gain can be achieved by giving high dose per fraction as used in HDR brachytherapy. Stereotactic Body Radiotherapy (SBRT) is another alternative to deliver hyofractionated Radiotherapy to prostate but with a non invasive approach by Cyber Knife (CK). Cyber Knife has robotic maneuverability and prostate motion tracking system, in real time. Methods: Between Oct 2012 to June 2015, 49 patients (4 of Low risk, 19 Intermediate risk and 26 High risk patients) underwent CK treatment for prostate cancer. After proper bladder and bowel preparations four gold fiducial markers were placed in the prostate under transrectal ultrasound guidance followed by treatment planning CT scan and MRI. Images were imported and fused in Multiplan TPS. Target area and critical normal structures were delineated and planning was done. Prescribed dose was 35 Gy in 5 daily fractions of 7 Gy in 39 patients and 50 Gy to whole pelvis on linear accelerator followed by 21 Gy in 3 daily fractions of 7 Gy in 10 patients on CK. Results: Median age of patients was 72 years, median GS - 7 (range 3 - 9), and PSA ranges from 4.2-310 ng/ml. Median follow up was 11 months during which 38 patient showed complete biochemical remission (Median post treatment PSA: 0.19 ng/ml). Median PTV volume was 87.55 cc, Median V100 was 95.4% and D95 was 35.04 Gy. Median dose to 3 cc volume of penile bulb was 18.8 Gy, 15cc of bladder wall received 24.5 Gy, 20 cc of rectum received 20.16 Gy, 20cc of bowel received 9.38 Gy, 10 cc of right and left femoral head received 8.83 Gy and 9.4 Gy respectively. Median Conformality index was 1.06 and Homogeneity index was 1.16. There were only 2 patients who developed Gd II rectal toxicity after treatment which was managed conservatively. 7 patients were lost to follow up without disease and 1 with disease. Conclusion: SBRT on CK for prostate cancer with dose coverage is well tolerated with good quality of life and decreased over all treatment time as compared to conventional methods. Long term data is needed to validate the result of SBRT for prostate cancer by CK.
Impact of neoadjuvant chemotherapy on organ preservation in muscle invasive urinary bladder carcinoma
thC. Dracham , N. Kumar, S. Kumar, B. S. Yadav, R. Mohan, A. Lal
Post Graduate Institute of Medical Education and Research, Chandigarh, India, E-mail: [email protected]
Background: Conservative approaches in Muscle Invasive Urinary Bladder Carcinoma (MIBC) aim of avoiding radical surgery, which have a negative impact on the patient's quality of life. There is growing evidence that newer chemotherapeutic regimes and radiotherapy techniques have made bladder preservation a competitive alternative to cystectomy in selected patients. Our study aims to evaluate the impact of neoadjuvant chemotherapy (NACT) on organ preservation in MIBC. Aims: (1) To assess response after NACT. (2) To assess response after radical radiation therapy. (3) To evaluate acute treatment related toxicities. Materials and Methods: A total 11 male patients with Urothelial carcinoma of Urinary bladder of stage T2-T4, N0- N1, M0 (AJCC 2009) were enrolled in the study. All were treated with three cycles of NACT with Inj. Gemcitabine 1.2 gm/m2 on day 1 and day 15, Inj. Cisplatin 70 mg/m2 on day 1, at 4 weekly intervals. After chemotherapy, patients were radiologically assessed with RECIST criteria, by CECT chest, abdomen, pelvis and Cystoscopy. Radiotherapy was given with 6 or 15MV photons by 3Dimentional Conformal Radiotherapy (3D CRT) technique in 2 phases, Phase I: 46 Gy/23#/4 1/2weeks to Bladder plus nodal area; Phase II: 16 Gy/8#/1.5 weeks to bladder only. After Radiotherapy, patients were reassessed with RECIST criteria. Acute toxicities were graded using CTCAE v3. Results: The median age of patients was 65years. Of the 11 patients, 4 were stage II, 3 were stage III and 4 were stage IV. After NACT, 10 (90.9%) patients had Partial Response (PR) >50% and 1 (9.1%) patient had PR <50% who underwent radical cystectomy. Response assessment at 6 weeks post RT showed Complete Response (CR) in all 10 patients (90.9%). All 4 patients having nodal involvement at presentation achieved CR. We encountered an early local recurrence at 7 months post treatment in 2 patients who had achieved CR after RT. They underwent salvage cystectomy. Toxicity outcomes were as follows: Grade 3 anaemia was observed in 1 patient, grade 2 urgency/frequency in 6, grade 2 diarrhoea in 3 and grade 2 dermatitis in 3 patients respectively. None had Grade 3 or more hepatic/renal/bowel/skin toxicity. The median follow up was 8 months. Local control at one year was 41%. Conclusion: Our trial shows that organ preservation is a valid option in only MIBC. Patients tolerated the treatment well. Therapeutic option for organ preservation in MIBC patients needs large scale evaluation.
Vaginal, bone metastasis and retroperitoneal lymphadenopathy from renal cell carcinoma: A very unusual presentation
thL. Pandey , S. Gupta, N. Sharma, D. Sachan
S.N. Medical College, Agra, Uttar Pradesh, India, E-mail: [email protected]
Background: Renal cell carcinoma represent 85% of kidney cancers. Histopathologically 75% are clear cell, while papillary RCC and chromophobe RCC present 11% and 5% respectively. Apprx 30% of RCC present with metastatic lesions. Mostly these tumors metastasize to lung, soft tissue, bone, liver and brain. Nephrectomy is considered even in metastatic disease followed by target therapies. Most cases of vaginal secondaries represent metastasis from the cervix, endometrium, or colon cancer. Metastasis of renal cell carcinoma to the vagina is extremely rare. Aim: This case is the rarity of this type of presentation and to give emphasis that targeted therapy provides an extended survival along with improving quality of life of patient. We present a case of metastatic renal cell carcinoma in a 40-year-old woman, who presented to us in March 2014 after post nephrectomy recurrence. Patient presented to us with chief complains of bleeding per vaginum pain in abdomen right lower leg pain and on and off fever. Per vaginal examination revealed a haemorrhagic cystic vaginal mass of app. Sized 3 x 3 cm and a small nodule of 3 X 2 cm on right shin of tibia. USG Abdomen revealed-paraumblical and lumbar adenopathy of size 5.6 X 5.1 cm and another of 5.5 X 4.1 cm. Biopsy from vaginal growth showed clear cell carcinoma suggestive of metastatic deposit of RCC. In view of wide spread metastatic lesions patient was kept on oral chemotherapy that is tab sunitinib 37.5 mg daily. Results: Patient is still on tab sunitinib with good subjective and objective response with no fresh complains. Conclusion: This case is a clear example of how unpredictable is the clinical presentation of this disease and targeted therapy can give a better and longer overall survival to the patient.
Spermatocytic seminoma testis with sarcomatous differenatiation: Very rare but is it really fatal?
thS. Samdariya , P. Bagri, P. Pareek, R. Kumawat, S. Khera, H. Bohra, P. Elhence, S. Bhattacharya
All India Institute of Medical Sciences, Jodhpur, Rajasthan, India, E-mail: [email protected]
Background: Spermatocytic seminoma (SCS) is an uncommon germ cell tumor accounting for 4% to 7% of all cases of testicular seminoma. Clinically SCS is an indolent neoplasm with rare potential to metastasize, thereby carrying a good prognosis. Sarcomatous transformation of gcts is an unusual phenomenon with only 12 cases in literature have been reported so far. Sarcomatous differentaitaion in SCS is associated with a propensity for aggressive and malignant tumor behavior and caries grave prognosis. Aim: We present an exceptionally rare case of SCS with sarcomatous differentiation in a elderly male. We believe this to be only the 13 th report to date of SCS with sarcomatous differentiation. Materials and Methods: A 60 year old farmer from Jodhpur presented with complaints of swelling of right testis since 5-6 years and pain in the swelling since 2 months. On examination a firm nontender swelling measuring 10 x 7 cms was palpated in right scrotum. Testis was not separately felt from the swelling. There were no palpbale lymphadenopathy anywhere. Ultrasonography of scrotum revealed well defined hypoechoic heterogenous lesion with scattered area of necrosis of size 15.8 x 10.2 cm seen occupying 4/5th of right testis with increased vascularity suggesting malignant mass. There were no retroperitoneal LN or distant metastasis. His serum, β-HCG and LDH were 4.28 ng/ml, 4.3 miu/ml and 426 U/ml respectively. Rright high inguinal orchiectomy was done. HPE showed a testicular mass measuring 17.5 x 13 x 11.5 cm. Microscopically a well circumscribed testicular tumor with a foci of brisk mitotic activity (20 Mitotic figures/5HPF) with areas exhibiting sarcomatous differentiation were seen. The tumor was not invading into epididymis, spermatic cord margin or the tunica. Cord resection margin was free of tumor. ITGCN or LVSI were not seen. On IHC the tumor cells were diffusely positive for C-kit and negative for CD-30 & Oct-4. Sarcomatous areas were desmin positive. Results: A final diagnosis of SCS of Right Testis with sarcomatous differentiation was made. Given the rarity and a localized disease confined to testis which was completely resected with negative margins, patient was on close follow up. Patient is disease free at 6 months of follow up. Conclusion: SCS of testis with sarcomatous differentiation is an extremely rare presentation of scrotal mass. Such cases need to be followed up closely as chances of distant failure are high and carries poor prognosis.
Spontaneous regression of pulmonary metastasis in renal cell carcinoma: Durable is rare
thS. Samdariya , P. Bagri, P. Pareek, R. Kumawat, D. Kumar
All India Institute of Medical Sciences, Jodhpur, Rajasthan, India, E-mail: [email protected]
Background: Spontaneous regression of metastatic disease in malignancy is rarely observed. Renal cell carcinoma (RCC) is one of them with approx 3% rate of spontaneous regression. Additionally the regression remains for only limited duration. Aim: We present a rare case of durable spontaneous regression of pulmonary metastasis following nephrectomy for RCC. Materials and Methods: A 72 year old gentleman presented with complaint of blood in urine since 2 weeks. A CT of abdomen showed a large enhancing hypodense right renal mass with central necrosis measuring 7.8 x 6.8 x 5.7 cm. Perinephric fat stranding & infiltration of right psoas was noted. X-ray chest revealed a right upper lobe radiodense lesion, circular with irregular margins & suspicious for metastasis, following which a CT thorax was done which showed a well-defined lobulated soft tissue density lesion measuring 2.5 x 2.1 cm in apical segment of right upper lobe of lung strongly suggestive of a metastatic lesion. CT guided FNAC proved it to be of renal origin. He then underwent right radical nephrectomy. HPE revealed large unifocal greyish white tumor measuring 7.5 x 7.0 x 6.2 cm involving upper pole of kidney invading renal capsule and perinephric fat but not invading renal fascia. Microscopy revealed renal cell carcinoma clear cell type with presence of sarcomatoid component. The final diagnosis of clear cell type of right sided renal cell carcinoma, AJCC stage pT3aN0M1, stage IV was made. Patient was on close regular follow up since then. Serial X-ray chest were done initially monthly for the first year. The lung lesion gradually reduced in size and after 9 months of surgery, completely disappeared. Results: Although immune modulation has been stated to be the most likely process causing spontaneous regression, other mechanisms, such as telomeric exhaustion, infection and fever, apoptosis, antibody, have also been mentioned. In the present case, complete regression of the metastatic lung lesion was documented nine months after nephrectomy. Presently patient is disease free and on three monthly follow up since 2 years. Conclusion: Spontaneous regression of tumors is a rare phenomenon and durability of these regressions is exceedingly rare. The possible explanation of this phenomenon may be multifactorial, and the exact mechanism remains to be elucidated.
Locally advanced inoperable urachal carcinoma: A case report
thA. S. Anand , V. Jayalekshmi
Government Medical College, Trivandrum, Kerala, India, E-mail: [email protected]
Background: Urachal carcinoma is a rare form of bladder cancer arising from the urachus, a vestigial musculofibrous band that extends from the dome of the bladder to the umbilicus. It accounts for only 0.5% of all bladder cancers. Case Report: A 72 year old male, with previous history of potts spine presented with urinary obstructive symptoms of 1 year duration, abdominal discomfort, suprapubic swelling and haematuria of 2 months duration. He was evaluated with a computed tomography (CT) scan which showed a large heterogenous soft tissue density mass measuring 11 * 12 * 8.2 cms centered near dome of urinary bladder. The lesion was seen infiltrating into the peritoneum and bilateral rectus sheath. It also showed mesenteric and serosal infiltration in the mid sigmoid colon. A final impression of urachal carcinoma with small bowel and sigmoid infiltration was given by the radiologists. A biopsy of the mass via cystoscopy revealed urachal carcinoma. Surgical management was deferred due to the locally advanced disease and the patient was started on chemotherapy. He was started on combination regimen of paclitaxel and carboplatin planned for every 3 weeks. Following the first cycle of chemotherapy, the supra pubic swelling ruptured with discharge of pus and faeculant matter. An emergency CT scan revealed necrotizing myofascitis, abdominal wall cellulitis with abscess formation and focal peritonitis. The CT also revealed reduction in the size of the lesion in dome of the urinary bladder. Surgical intervention was sorted out for the drainage of pus and effective intravenous antibiotics were started empirically and after pus culture and sensitivity. The patient responded well to treatment with excellent control of the infection. Chemotherapy was restarted with paclitaxel and carboplatin after 1 month. He has now completed five cycles of chemotherapy and is doing fine with a better performance status. Discussion: Chemotherapy has been proposed as a treatment for unresectable urachal carcinoma, no standard and effective regimens have been developed. The choice of regimens has based on case reports and institutional experiences. The first line regimens which have been used include gemcitabine and cisplatin, 5-fluorouracil and cisplatin, paclitaxel and cisplatin. In our setting the patient was started on combination chemotherapy with taxane and platinum which proved to be effective with significant reduction in in size of the lesion and improvement in performance status.
A comparative study between radical radiotherapy or radical prostatectomy with or without adjuvant radiotherapy in locally advanced prostate cancer
thP. K. Gupta , N. Rastogi, K. Sharmad, K. J. Maria Das, R. Kapoor,
A. Mandhani, S. Kumar
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, India, E-mail: [email protected]
Purpose: For locally advanced prostate cancers (LAPC) Radical Radiotherapy (RRT) or Radical Prostatectomy (RP) with or without Adjuvant Radiotherapy (ART) is the current standard of care. We did a retrospective study to compare RRT or RP followed by ART or RP alone in patients with LAPC. Materials and Methods: Medical records of 94 high risk LAPC treated between 2008-2013 were analysed. All biopsy proven adenocarcinoma of prostate with high risk category (PSA>20 ng/ml or Gleason score (GS) >7 or t2c-T4) were included. Patients either underwent RRT (group 1) or RP followed by ART (group 2) or RP alone (group 3) along with hormonal treatment for 2-3 years. Group 1, 2 and 3 had 37, 17 and 40 patients respectively. The primary end points of the study were biochemical relapse free survival (bRFS), bladder and rectal toxicity, urinary incontinence (UI) and secondary end point was cancer specific survival (CSS). Results: Median age was 66, 65 & 65 years respectively. Median pre-treatment PSA was 22, 19 and 23 ng/ml. T3/T4 lesions were 65%, 94% and 88%. Nodal metastasis was seen in 22%, 41% and 33%. Median GS was 8, 8 & 7. Positive surgical margins were 82% and 70% in group 2 and 3. Mean RRT dose was 76 Gy and ART dose was 64 Gy with conventional fractionation using image guided/3D-conformal RT. With a median follow up of 3 years, 5-year bRFS was 78%, 91% and 72% in 3 groups. (p = 0.12) Subset analysis showed significant difference in bRFS between group 2 and 3 (p = 0.03) Median bRFS was not reached in group 1 and 2 while in group 3, it was 79 months. Post treatment UI was seen in 0, 7 (41%) & 6 (15%) patients respectively. Radiation Therapy Oncology Group (RTOG) grade III-IV bladder toxicity (hematuria and bladder neck contracture requiring incision) was seen in 2 (6%), 4 (24%) and 7 (18%) respectively and rectal toxicity in 2 (6%) and 1 (6%) in group 1 and 2 and peroperative rectal injury occurred in 2 (5%) in group 3. Five year CSS was 65%, 91% and 87% respectively (p = 0.086) and no significant difference in CSS was found between the groups in subset analysis. Median CSS was not reached in any group. Six (16%), 1 (6%) and 7 (18%) patients were lost to follow up. Distant metastasis was seen in 8 (22%), 2 (12%) and 1 (3%). Conclusion: Adjuvant RT for LAPC significantly improves bRFS at the cost of increased bladder toxicity and UI. UI is the complication associated with RP and aggravated by ART. Further long term follow up is needed to assess the effect on distant disease free survival and CSS.
Radiotherapy with or without chemotherapy as bladder-sparing treatment for muscle invasive urinary bladder cancer: Our clinical experience
thS. Gupta , S. De, S. C. Sahay 1 , S. Agarwal, R. Agarwal, P. Choudhary, K. Ritu, S. Srinivasan
Galaxy Cancer Institute, 1 Pushpanjali Crosslay Hospital, Ghaziabad, Uttar Pradesh, India, E-mail: [email protected]
Background: Radical cystectomy is the standard therapy for urinary bladder carcinoma with an expected 5-year survival of 45-60%. Maximal transurethral resection of bladder tumor followed by radiation therapy with concurrent chemotherapy has validated outcomes similar to those reported with radical cystectomy with complete response (CR) rates of 40%-50% with Radiation alone. Aim: The present study was done to assess the outcome of patients with invasive bladder carcinoma treated by transurethral resection of the bladder and concomitant chemoradiation therapy. Materials and Methods: 39 patients diagnosed case of carcinoma urinary bladder who had undergone treatment between January 2010 to January 2015 were evaluated in the present study. The T staged from cT2a-T4a. All the patients underwent maximum bladder tumor resection and then were considered for concurrent chemotherapy and Radiotherapy. Follow up was done by 3 monthly clinical examination with 6 monthly check cystoscopy, urine cytology and CECT scan Abdomen for the first 2 years. Data regarding the toxicity profile and occurrence of locoregional or distant failure were recorded. Observation: Age ranged between 45- 84 years. Male to female ratio was 8.75:1.15 (38.5%) patients had T2 disease and 24 (61.5%) patients had T3-T4 disease. PTV volume ranged from 69-548.9 cc. Radiotherapy dose ranged from 60 Gy/30# -70.3 Gy/37# to primary target and 59.2 Gy/37# to the nodal disease. 23 patients received concurrent chemotherapy weekly (Inj Cisplatin 40 mg/m2). 11 patients had cystitis (Grade I-5, II-4, III-2). 5 patients had myelosuppression. 10 patients had acute gastrointestinal toxicity (Gr I-5, II-4, III-1). Follow up ranged from 3-42 months (median 1 year). Out of 39 patients 3 were lost to follow up. Out of 36 patients 24 (66.6%) are disease free, 4 (11.1%) patients have residual disease for which 1 underwent salvage cystectomy and is disease free whereas 3 patients received chemotherapy. 5 patients developed distant metastases (4 bone, 1 brain metastasis). 2 patients developed second primary lung with bone metastases. 1 patient died due to liver cirrhosis. Conclusion: Although Radical cystectomy with urinary diversion is the mainstay of treatment, organ preserving regimens using multimodality therapy have emerged as attractive alternative. But appropriate infrastructure and availability of multidisciplinary team services are essential for any successful organ preservation protocol.
Spectrum of carcinoma urinary bladder: A retrospective study in tertiary care radiation oncology institution
thV. S. Naidu , A. Gavarraju, P. Kumar, A. K. Chauhan, D. P. Singh
Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India, E-mail: [email protected]
Background: Bladder cancer is the fourth most common cancer amongst all the cancers in men and ranks 11 th amongst the cancer in women Bladder cancer is a common urological cancer that has the highest recurrence rate of any malignancy. North America, South America, Europe, and Asia, the most common type is Transitional cell carcinoma. Other types include squamous cell carcinoma and adeno-carcinomas. Aim: The purpose of this study is to retrieve the data of patients of urinary bladder carcinoma treated with radiotherapy or chemotherapy in our department and study the clinical parameters and their outcomes. Materials and Methods: Retrospective data was retrieved from the patients of urinary bladder carcinoma presenting in our department in last seven years (from 2008 to 2015). Parameters like age, sex, stage; site, muscle invasion, tumour grade, perivesical spread, Hydronephrosis, total dose, concurrent chemo radiation, disease free survival (DFS) & overall survival (OS) were evaluated. Results: Between 2008-2015, 32 patients of carcinoma urinary bladder got registered in our department. Five patients were excluded from the study due to incomplete treatment. Five patients received Neoadjuvant chemotherapy followed by surgery and concurrent chemo radiation. Three patients did not receive concurrent chemotherapy due to deranged renal profile. Three patients received palliative chemotherapy after concurrent chemo radiation. Overall, 26 patients received concurrent chemo radiation. Grade 2 and Grade 3 genitourinary reaction was seen in 75% and 16.6% respectively. One patient had Grade 4 reaction. The mean OS is 18.5 months (Range 2-73 months) and the mean DFS is 14.3 months (Range 0.25-70 months). Conclusion: Bladder sparing surgery via concurrent chemo radiation for muscle invasive bladder cancer results in an acceptable rate of complete pathological response. Long term follow up is essential.
Dosimetric analysis of external beam radiotherapy plus HDR brachytherapy boost versus 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
thA. Manikandan , M. A. Laviraj, K. P. Haresh, D. N. Sharma, S. Gupta, S. Mallick, P. K. Julka, G. K. Rath
All India Institute of Medical Sciences, 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. Aim: 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 adenocarcinoma of prostate were randomized to receive either IMRT alone or IMRT plus brachytherapy. After randomization all patients received EBRT 45 Gy/25#/5 weeks by IMRT in phase I. In phase II patients received either HDR brachytherapy 19 Gy/2# (Arm A) or EBRT 29 Gy/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 3 Gy 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 32.7 ng/ml (Range 4.8-92.3). The median prostate volume was 45.8 cc (27.1-60.9). All patients received 45 Gy/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 48.6 Gy in HDR BT whereas 27.2 Gy in IMRT. The EQD2 of 33% of rectal volume received mean dose of 6.5 Gy and Dmean of rectum was 6.8 Gy with HDR BT. In comparison doses delivered with IMRT were 18.1 Gy and 12 Gy respectively. EQD2 of Dmean to bladder in HDR BT and IMRT were 4.1 Gy and 13.5 Gy 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.
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