|Year : 2016 | Volume
| Issue : 6 | Page : 14-19
|Date of Web Publication||30-Nov-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. CNS. J Can Res Ther 2016;12, Suppl S2:14-9
Retrospective analysis of adult ependymoma: A single institution experience
Asha Arjunan , Nazneen Ameer, Anitha Mathews, V. Jiji,
Jaganath Krishna, Beela Sarah Mathew, K. Ratheesan
Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]
Introduction: The aim of the study was to review clinical outcome of adult ependymoma patients treated at our institution. Materials and Methods: The clinical data of all patients (>17 years) with histologically proven ependymoma treated at our institution from 1 st January 2010 to 31 st December 2014 were reviewed retrospectively. Data regarding demographics, pathology, extent of resection (gross-total resection [GTR], subtotal resection [STR] or biopsy), radiotherapy (RT), disease recurrence & 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: 18 patients were identified, 8 females & 10 males. Median age at diagnosis: 32 years (range: 18-61 years). Intracranial ependymoma (n = 10): (4 supratentorial & 6 infratentorial). Spinal ependymoma (n = 8). All patients had surgical excision. GTR (n = 8) and STR (n = 10). Histology: Grade II (n = 9) & grade III (n = 9). 1 patient with infratentorial tumour had leptomeningeal dissemination & received craniospinal irradiation. 16 patients with localized disease received 3-D conformal radiotherapy targeting GTV (Dose 54.0 to 59.4 Gy). One patient refused radiotherapy. Atmedian follow up of 32.5 months (range, 6-65 months), 5 patients (27%) developed progressive disease & 2 patients died. Of 5 patients with progressive disease, 4 had grade III histology. The 3 year PFS and OS were 80.8% and 91.7% respectively. Conclusions: Survival rates for adults with ependymoma in this study were comparable to published literature. Longer follow up is required to further assess patterns of failure.
A case of multiple myeloma presenting as intracranial space occupying lesion
Department of Radiotherapy Govt. Medical College, Thiruvananthapuram, Kerala, India. E-mail: [email protected]
Introduction : Multiple myeloma is a haematological malignancy that comprises 10% of all haematological malignancies. It is a neoplastic proliferation characterised by the uncontrolled proliferation of plasma cells in the bone marrow. Common presenting features of multiple myeloma include bone pain and bone fractures, anemia, increased susceptibility to infection, hypercalcemia and renal failure. CNS involvement in multiple myeloma is very rare and account for only 1% of the cases. Again, neurological presentation due to intracranial involvement is extremely rare. Case Report : A 50 year old lady presented with headache, blurring of vision and proptosis. Examination of the patient revealed no light perception on right eye and restricted extra ocular movement in the same eye. CECT was suggestive of an enhancing dural based lesion of size 6.5 × 5 cm in the right temporal region with extension to retro orbital space and inseparable from the optic nerve sheath complex with bone destruction. Patient underwent right frontotemperoparietal craniotomy with decompression of spheno-orbital ICSOL and removal of involved bone. Histopathology of skull bone specimen and tissue biopsy was reported as plasmacytoma. Patient was evaluated with bone marrow aspiration and serum immunofixation and finally diagnosed as Multiple Myeloma ISS stage II. Patient was started on BLD chemotherapy regimen. After four months of treatment, patient is in remission. Conclusion: This is an unusual case of multiple myeloma presenting with symptoms of ICSOL. We report this case due to its rare presentation and the unique diagnostic and therapeutic challenges it presents.
Immunohistochemistry based outcome analysis and sub-group stratification of anaplastic gliomas: A pilot study and our institute experience
Uday Krishna, Vani Santosh 1 , th T. Arun , P. Sravya 1 , T. Naveen, V. Lokesh
Department of Radiation Oncology, Kidwai Memorial Institute of Oncology, 1 Department of Neuropathology, NIMHANS, Bengaluru, Karnataka, India, E-mail: [email protected]
Objective: Recent WHO classification recommends addition of molecular testing to morphological classification of diffuse and anaplastic Gliomas. We assessed utility of two IHC markers-antibody to IDH1/R132H and ATRX, to stratify anaplastic gliomas into subgroups and analyze their outcomes. Materials and Methods: Histopathology of 21 grades 3/4 gliomas, previously treated by radiation and TMZ with atleast 6 months follow up was reviewed and IHC for IDH1+/-ATRX proteins was tested as per standard protocol. IDH positives were grouped as G1 and negatives as G2. Sequencing of IDH negatives to reconfirm IDH wild status was not performed. ATRX testing was performed for tumours with Oligodendroglial component. A retained ATRX protein was considered as a positive result while loss as negative. Survival analysis was done by Kaplan-Meier analysis using SPSS 21.v. Results: The four subtypes of anaplastic gliomas were equally distributed among 21 patients. 57% cases were classified as G1 (IDH positive) & the rest G2. In those tested, ATRX protein retained/loss ratio was equal. At median F/U 12 months, OS of the cohort is 76%. Survival difference in G1 vs. G2 (Log Rank test P = 0.085) was significant. While the ATRX protein expression was not prognostic for survival in G1, patients with loss of ATRX survived longer in the G2 cohort (LR, P = 0.02). Conclusion: Outcome analysis and subgroup stratification of anaplastic gliomas is possible by immunohistochemistry and shows that IDH mutant and ATRX lost non-Oligo tumours better than their counterparts. Our pilot study forms basis for further testing in a large group of patients in controlled setting.
Feasibility and toxicity of VMAT radiotherapy for residual/recurrent functional pituitary adenoma
Sandip Barik , Rahat Hadi, D. K. Singh 1 , Rohini Khurana,
Departments of Radiation Oncology and 1 Neurosurgery, Dr RML IMS, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Objective: To access the feasibility of VMAT Radiotherapy for recurrent/residual functional pituitary tumors and evaluation of toxicity. Materials and Methods: 12 patients of functional Pituitary Adenoma who either had a residual or recurrent disease postsurgery were taken up for the study. All the patients were taken up for VMAT Radiotherapy. Gross tumor volume was delineated using fused MRI. A margin of 0.5 cm expansion was given for HRPTV and was prescribed a dose of 54 Gy in 30#. LRPTV was also delineated with a margin of 1 cm from GTV and prescribed a dose of 45 Gy/30#. Acute CNS toxicity was evaluated according to RTOG acute radiation morbidity scoring criteria. Results: Median follow up for the study was 12 months (range 6-18 mths). 10 out of 12 patients had residual disease and 2 had recurrent disease after surgery. All 12 patients had symptoms of hypersecretion. Hormonal levels were reduced in the first year of follow up in 7 patients. The 95% isodose coverage of HRPTV was 98.28%, and LRPTV was 96.6%. The brain stem constraints were achieved in all the patient but this was not seen with respect to optic chiasma due to very large volume of disease in the study. None of the patients had Grade III/IV CNS Toxicity. Conclusion: VMAT Radiotherapy is effective in reducing secretory and mass effect of functional pituitary tumors without any increase in CNS toxicity.
Impact of radiation dose to neural stem cell niche on outcomes in malignant gliomas 4
Katta Charu Goutham Reddy
Department of radiotherapy, Yashoda Hospital, Hyderabad, India, E-mail: [email protected]
Background: Malignant gliomas represent most aggressive form of brain tumours. They are characterised by poor prognosis and universal recurrences. Recent studies indicate that malignant gliomas contain cancer stem cells which are capable of self-renewal and tumour propagation. The origin Gliomas Cancer stem cells is believed to be from normal neuronal stem cells (NSC) located in subventricular zone (SVZ) of adult human brain. The purpose of this study was to examine the relationship between radiation dose to the subventricular zone and survival in malignant glioma patients. Methods: 40 adult patients diagnosed as Grade III or Grade IV Glioma at Yashoda Hospitals between January of 2014 and July of 2014 were included in this study. Using radiation planning software and patient radiological records, the subventricular zone was reconstructed for each of these patients and dosimetry data for these structures was calculated. Log Rank Test and Multivariate analysis were used to find the impact of High Subventricular Zone dose on survival. Results: The mean of age of the sample population is 49.68 years (range, 20-78 years). ECOG Status for the all the patients enrolled in the study is 1. Out of 40 patients enrolled into the trial 31 are of Grade 4 Tumors (Glioblastoma) and 9 were Grade 3 tumours. Median doses of the means of Ipsilateral subventricular zone, Contralateral subventricular zone and Total subventricular zone are 50.89, 34.66 and 41.04 respectively. Median overall survival of the sample population is 21 months. One year survival of the sample population is 85%; 2 year survival is 35%. Univariate analysis has not shown any significant impact higher median dose in malignant gliomas. However when Univariate analysis was done in Grade IV gliomas there is significant impact of higher median dose to Ipsilateral Subventricular zone (P value 0.01) and Total Subventricular zone on Overall survival (P value 0.04). Conclusions: This study leads us to hypothesize that in glioma targeted radiotherapy of the stem cell niches in the adult brain could yield significant benefits over radiotherapy of the primary tumor mass alone. Prospective randomised interventional study is needed to validate subventricular zone irradiation as standard of practice.
Key words: Cancer stem cells, malignant glioma, neural stem cells, subventricular zone
Molecular characterization and clinical outcome in oligodendroglial and oligoastrocytic tumours: A report from a tertiary care cancer centre from India
Jatin Bhatia, Jayant Goda, Tejpal Gupta, Rakesh Jalali, Sridhar Epari 1 , Ayushi Sahay 1 , Prakash Shetty 2 , Ali Asgar Moyiadi 2
Departments of Radiation Oncology, 1 Pathology and 2 Neurosurgery, Tata Memorial Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]
Aims : To study the molecular profile and clinical outcome of Oligodendroglial and oligoastrocytic tumours. Materials and Methods: Between January 2008 and September 2015, we reviewed 238 low grade glioma patients, out of which 88 were available for analysis. We analysed the clinical and the molecular profile of these patients and correlated with clinical outcome. All the patients had standard therapy in the form of maximal safe resection followed by focal conformal RT with or without concurrent oral temozolomide according to standard institutional protocol. Results: The median age of the patients was 40 years (inter quartile range 34-48). 50 patients were males and 38 females. Near total tumor excision was performed in 35%, partial excision in 43% and decompression in 10% patients. 1p19q co-deletion was observed in 40 pts (45%), IDH was mutated in 71 pts (81%). Wild type p53 was observed in 71 pts (81%), ATRX was retained in 69% and lost in 31% pts. Median Mib-1 labelling Index was 8.5% (IQR: 5-15%). 64% patients received concurrent RT+TMZ and adjuvant TMZ. Mean overall survival was 85 months (95% CI: 76 months-93 months). Estimated 5-years overall survival was 85.5%. IDH mutation was found to be significant prognostic factor for OS on univariate analysis (P = 0.001). Conclusions: Patients with oligodendroglial and oligoastrocytic tumours generally have a good prognosis with a 5 year survival of 85%.1p19q co-deletion was observed in 45% patients, although IDH mutation was seen in 81% patients. IDH mutation was found to be statistically significant prognostic factor for overall survival.
Dosimetric comparison of volumetric modulated arc therapy and three-dimensional conformal radiotherapy in high grade glioma
Harikesh Bahadur Singh , Madhup Rastogi, Kamal Sahni, Rohini Khurana, Rahat Hadi, Shantanu Sapru, Surendra P. Mishra, Anoop K. Srivastava
Department of Radiotherapy, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Background: Radiotherapy for high grade gliomas typically is 3-Dimensional Conformal Radiotherapy (3D CRT). Intensity Modulated Radiotherapy (IMRT) can provide better coverage of target volumes while sparing normal structures. Volumetric Modulated Arc Therapy (VMAT) is a modification of IMRT in which arcs are used to deliver dose. VMAT plans are supposed to be easier/faster to generate; and beam on time is lesser than with fixed field IMRT. However these benefits are not proven for post-operative RT in high grade gliomas; we performed a dosimetric comparison of 3D-CRT and VMAT plans for the same. Aims and Objective: Dosimetric comparison of 3D CRT plans with VMAT plans in terms of (1) PTV (planning target volume) coverage (2) OAR (organ at risk) sparing (3) Conformity index (4) Homogenity index. Materials and Methods: A prospective observational study was performed. All patient underwent CT based planning along with MRI fusion. Prescription dose and vital structure constraints were identical for 3DCRT and VMAT. Planning objective was to cover >95% of PTV with 95% of prescription dose. Standard RTOG dose constraints were used for brainstem, optic nerves, chiasma and lens. Two PTVs were delineated, PTV46 (resection cavity + edema) treated to 46 Gy and PTV60 (resection cavity) boosted by 14 Gy. Results: VMAT yielded superior target coverage in terms of conformity and homogeneity for PTV46 (P = 0.001, P = 0.045 respectively) than 3DCRT, but not in PTV60. For brainstem Dmean was significantly lower (P = 0.006), but not Dmax. The Dmax was significantly lower in bilateral optic nerves and chiasma (P = 0.004, P = 0.009, P = 0.033) favoring VMAT. To the right lens, VMAT delivered significantly higher doses (mean Dmax 10.25 Gy vs 5.51 Gy, P = 0.026). The Dmax to the left lens was similar but Dmean was higher with VMAT (3.38 Gy vs 6.60 Gy, P = 0.022). Conclusion: VMAT achieved better coverage of the PTV while sparing the optic nerves and chiasma, but failed to spare the brainstem and lens. With careful selection, it may be a viable option for treating these patients.
Limited margin radiation therapy in GBM
Haridas M. Nair , Durgapoorna, M. Dinesh
Department of Radiation Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India, E-mail: [email protected]
Objectives: Dosimetric comparison of limited margin target volumes with that of RTOG protocol and also to report on the preliminary outcome and recurrence patterns observed in patients treated with limited margin radiation. Materials and Methods: 40 consecutive GBM patients, planned for postoperative limited margin radiotherapy were included. Our protocol for limited margin radiotherapy includes GTV - T1 enhancing tumor/resection cavity and initial CTV (46-50 Gy) delineated as GTV + 1.5 cm margin which is edited to intentionally include T2-HSI. Boost CTV (total of 60 Gy) is GTV + 1 cm margin. PTV of 0.3 cm margin is uniformly applied. For all patients, a hypothetical radiation plan based on RTOG protocol is simultaneously created and its dose volume parameters and percentage of brain irradiated are compared. MRI images at the time of progression are used to categorise the pattern of recurrence as central, infield, marginal or distant. Results: Dose volume comparison of both the radiation plans revealed that initial PTV and boost PTV of our treatment plans were approx. 50% less Vs RTOG protocol. There was a significant reduction in the volume percent of brain irradiated to doses of 60 Gy, 50 Gy, 46 Gy and 40 Gy according to our target volume delineation protocol. Patterns of recurrence documented in available MRI for 20 patients revealed that 75% recurrences were central/infield, 5% marginal and 20% distant. Survival analysis with a median follow up of 12.7 months revealed a median OS of 16 months and median PFS of 10.9 months. Conclusion: From preliminary analysis, limited margin radiotherapy for GBM seems reasonable. There is a significant reduction in target volumes without an increased risk of marginal recurrence or compromise in survival during our study period.
Patient characteristics, patterns of care and survival outcome in patients with Giant cell glioblastoma: An individual patient data analysis
Rony Benson , Supriya Mallick, Wineeta Melgandi, Goura Kishor Rath
Department of Radiotherapy, All India Institute of Medical Sciences, New Delhi, India, E-mail: [email protected]
Objectives: Giant cell Glioblastoma (GBM-GC), is an extremely rare variant of Glioblastoma with only about 100 cases reported so far in literature. We did an individual patient data analysis to identify the patterns of care and prognostic factors for this rare tumor. Materials and Methods: We performed PubMed search to find all possible publications pertaining to GBM-GC. Individual patient data on "age, gender, type of surgery, radiation use, chemotherapy use and survival" were tabulated. Data was analyzed with SPSS version 16. Results: A total of 99 cases were found eligible. Median age at diagnosis was 38 years (range: 2-76 years). The male: female ratio was 1.41:1. 29.3% underwent a gross or near total resection while 27.3 % underwent a subtotal resection and 43.4% underwent an excision or biopsy only. Radiation was used in 57.6% of the patients while chemotherapy was used in only 25.3% of the patients. Median follow up was 13 months. The median progression free survival (PFS) was 7.3 months (95% CI 3.26-11.3). The median overall survival (OS) was 18.3 months (95% CI 12.4-24.1). Univariate analysis showed extend of surgery (gross total excision vs. less than gross total excision) to be a significant factor affecting OS with a hazard ratio of 3.16 (95% CI 1.50-6.70, P-0.003). Age, gender, or uses of adjuvant radiation and chemotherapy were not found to be significant factors affecting survival. Conclusion: Giant cell Glioblastoma (GBM-GC), is an extremely rare variant of Glioblastoma and produces similar survival outcomes with those of the GBM unspecified.
Thalamic gliosarcoma in a 4-year-old child treated with simultaneous integrated boost: A case report
Shyama S. Prem, Pragna Sagar, th Anupam Datta , V. Parthasarathy
Department of Radiation Oncology, Regional Cancer Center, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, E-mail: [email protected]
Introduction: Gliosarcoma is biphasic tumor with astrocytic and sarcomatous elements and an incidence of 1 to 8 percent of all malignant primary brain tumors. Median age is 50 years and is uncommon in children. Case Report: A 4-year-old male child presented with a well-defined 3.6 × 3.2 × 3.1 cm sized T1 iso to hypointense and T2 FLAIR iso to hyperintense mass lesion in the region of left thalamus. He underwent maximal safe resection and HPE revealed a majority of cells having spindle shape alternating with looser areas containing cells of glial morphology with high mitoses. The glial component stained positive for GFAP. The sarcomatous and glial components are vimentin positive. P53, EMA, and synaptophysin are negative. INI-1 expression is retained. He received postoperative chemoradiotherapy with SIB technique and concurrent Temozolomide 75 mg/m 2 /day. A total of 27 fractions were given with 59.4 Gy (EQD2 of 61.78 Gy) to the high-risk PTV and low risk PTV received 45 Gy. On follow up the patient had no residual, no neurological symptoms and was started on adjuvant chemotherapy with Temozolomide. Conclusion: The available data on paediatric gliosarcoma is limited with only 30 cases being reported in English literature. The proximity of location to brainstem made it highly difficult to deliver 60 Gy to the tumor even with limited margins. So we have employed SIB technique in this patient and could deliver 59.4 Gy to the tumor without compromising in the brainstem tolerance. This method can help in reducing the overall treatment time and also higher dose per fraction can be employed without risking the OARs.
Not all multicentric brain lesions in a known cancer patient is not always metastases
Vinayakumar Muttagi , Surendra Reddy, B. C. Sreedhara 1 , Monish 1 , Harish 2 , J. Mathangi
Departments of Radiation Oncology, 1 Radiology and 2 Nuclear Medicine, BGS Global Hospitals, Bengaluru, Karnataka, India, E-mail: [email protected]
Objectives: To present a rare case of known breast cancer presenting with neurological deficits. Materials and Methods: A 74 year old postmenopausal female presented with episodes of generalized tonic clonic convulsions associated with an episode of loss of consciousness followed by motor aphasia. She had a history of diagnosis of locally advanced breast cancer, 8 years before for which she underwent mastectomy followed by radiotherapy to the chest wall. She did not take chemotherapy and was only on hormones for 5 years. She also had a history of fall from bed with a similar episode of LOC 1 month before for which MRI scan showed ischemic changes suggestive of infarct with no other space occupying lesions and was managed conservatively. Results: MRI scan done now for this episode of convulsions showed two small lesions in left parietal lobe and the other in left occipital lobe with disproportionate edema and a high choline peak on MRS, suggesting a possibility of metastases with a background of history of cancer. PET CT scan done revealed no recurrent systemic disease. But the disease interval from diagnosis and brain lesions and the absence of systemic disease went against the diagnosis of metastases. Hence surgical decompression was done and postoperative Histopathology was suggestive of multicentric glioblastoma multiformae and she was treated accordingly. Conclusion: Usually histopathological confirmation is done for single brain lesions as many nonconcological lesions like abscess have been reported to be the reason for such lesions. Not all multicentric brain lesions in a known cancer patients should also be taken as metastases if not really clinically correlating.
Does high precision radiotherapy have impact on the outcome in high grade gliomas?
Nagarjuna Burela , Nidhi Patni
Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India, E-mail: [email protected]
Introduction: The aim of this study was to compare the overall survival and dose to normal brain in high grade glioma treated with 3D-Conformal Radiation Technique (3DCRT), Intensity Modulated Radiation technique (IMRT) and Rapid Arc technique. Materials and Methods: Eighty patients with high grade gliomas were treated with concurrent chemoradiation post operatively. 27 patients received 3DCRT, 25 received IMRT and 28 were treated with Rapid arc. Temozolamide 75 mg/m 2 /d seven days a week was given concurrently with radiation (60 Gy in 30 fractions) followed by 6 cycles of adjuvant Temozolamide with a dose of 150 mg/m 2 /d for 5 days in every 28 days. Primary end point was overall survival and secondary end point was effect of radiation technique on overall survival and dose to organs at risk. Results: All patients completed concurrent chemoradiation but only 52 patients completed 6 months course of adjuvant chemotherapy. Median age was 52.5 years; median overall survival was 6 months. The median survival for patients who completed 6 months of adjuvant chemotherapy and those who did not was 12 months and 3 months respectively. Median overall survival was 7 months for patient treated with high precision radiotherapy and 3 months for those treated with 3DCRT. Survival at 12, 18 and 24 months were 24.5%, 13.2% and 11.3% respectively for patients treated with high precision radiotherapy. One year survival in 3DCRT group was 3.7%. Mean dose to normal brain was 28.7 Gy in 3DCRT, 23.9 Gy in high precision technique respectively. Conclusions: Reducing doses to normal brain with high precision techniques might improve survival.
Systematic review and independent patient data meta-analysis of astroblastoma: An analysis of 152 cases
Supriya Mallick , Rony Benson, Wineeta Melgandi, K. P. Haresh, Subhash Gupta, Dayanaand Sharma, G. K. Rath
Department of Radiotherapy, All India Institute of Medical Sciences, Delhi, India, E-mail: [email protected]
Objectives: Astroblastoma (AB), a rare tumor with significant dilemma regarding diagnostic criteria, behavior and optimum treatment of these tumors. Materials and Methods: We searched PubMed, google search, and Cochrane library for eligible studies with the following search words: Astroblastoma, High grade astroblastoma, anaplastic astroblastoma till July 1 st 2016 published in English language and collected data regarding age, sex, site of disease, pathological grade, and treatment received, DFS, OS. Results: Data of 152 patients were retrieved from 63 publications. Median age was 16 years (Range: 0-71). Females were affected twice more frequently than male (70.3% vs. 29.7%). Tumors were located in frontal (39%) followed by parietal lobe (26.7%). 52% and 25% patients had headache and seizure at presentation. 76.3% patients underwent a gross total resection. 41 out of 89 had a high grade tumor. 56 patients received adjuvant radiation with a median dose of 54 Gy (Range: 20-72). Adjuvant chemotherapy was used in 23 patients. Temozolomide was the most common drug used in 30% patients. Combination of cisplatin, Etoposide with Vincristine or Ifosfamide was used in 17%. Median follow-up duration was 37 months (Range: 1-238). Median PFS and OS were 36 and 184 months respectively. Patients with higher grade tumor had significantly worse OS with HR-5.260; P-0.001. 40 patients experienced local progression. 65% patients required surgery and 50% required radiation for salvage. Conclusion: AB has two distinct grades as higher grade tumors have significantly poor survival. Maximal safe surgery followed by adjuvant radiation and Temozolomide should be advocated for these tumors.
Central neurocytoma: A single institutional experience
Department of Radiotherapy, Christian medical College, Vellore, Tamil Nadu, India, E-mail: [email protected]
Background: Neurocytoma is a rare benign neuronal tumor representing about 0.1-0.5% of all primary CNS tumors. Radical excision is the mainstay of treatment. An elevated MIB-1 labeling index >2% was found to have increased chance of recurrence. Retrospective case reports have shown that radiotherapy has a role in residual tumor after incomplete resection or at the time of disease recurrence. Objective: To evaluate the treatment given for Central Neurocytoma in our centre. Materials and Methods: Retrospective review of patients with neurocytoma treated at our centre in 2015 and 2016 was done. Histopathology was confirmed either by stereotactic biopsy or surgical resection. We present the demographic details, clinical manifestations, pathological features and treatment of these patients. Results: Eight patients were treated during the study period. The median age of presentation was 30 years. Most common presentation was headache and features of raised intracranial tension. All were intraventricular and lateral ventricle was the commonest location. Three patients had radical excision, four had subtotal excision and one had STB. Six patients were atypical neurocytomas and all had MIB-1 index of >2%. All patients received adjuvant radiotherapy. The residual tumour with a margin of 2 cm was treated to 54 Gy in 30 fractions. Conclusion: Maximal safe resection followed by radiotherapy was well tolerated by patients with central neurocytoma. Long term follow up is required to find the outcome of this treatment.
Prepontine chordoma: A rare clinical case report and literature review
Teneti Sravanthi , P. P. Mohanty
Department of Radiotherapy,Yashoda Hospital, Hyderabad, India, E-mail: [email protected]
Background: Intradural chordomas are extremely rare tumors that originate from notochordal remnants. Echordosis physaliphora is ectopic notochordal remnant that has a similar biological behavior and is difficult to distinguish from intradural chordomas. They might exist in a continuum from benign notochordal tumor to malignant chordomas. A surgical resection remains main treatment of choice, with or without adjuvant radiotherapy. Case Report: Here we present a 37 year old male presented with blurring of vision in RT eye and headache since 6 months, giddiness and imbalance since 15 days. MRI brain revealed an extra axial homogenously enhancing lesion of 3.1 × 3 cm prepontine, RT cerebellopontine angle tumor, which was hypointense on T1W1 and hyperintense on T2 flair sequences. He underwent surgical resection of the lesion and post op histology suggestive of chordoma. He is further planned with adjuvant radiotherapy. Conclusion: We report a case of an intra dural prepontine chordoma in a 37 year old male who underwent surgical resection and planned for radiotherapy.
Anaplastic ganglioglioma: A rare case report
R. Chitra , Rajeev, Anitha Mathews 1 , Beela Sarah Mathew
Departments of Radiation Oncology and 1 Pathology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]
Introduction: Gangliogliomas are rare neoplasms constituting 1% of central nervous system tumors. Rarely they undergo anaplastic transformation to form anaplastic ganglioglioma. This anaplastic transformation mostly occur in pediatric population. Case Report: This is a 4 year old male patient who presented with headache, vomiting and seizures for 1 year duration to a local hospital in September 2015. He was evaluated with MRI brain which revealed a heterogeneously enhancing tumor left frontoparietal region. He underwent near total excision of the lesion and HPR revealed ganglioma. After a progression free interval of 9 months he again presented with headache and vomiting. MRI brain was taken which showed a residual disease progression with hydrocephalus for which a reexcision was done along with ventriculo-peritoneal shunt. HPR came as desmoplastic infantile ganglioglioma with anaplastic features. Patient was referred to RCC for further management. MRI brain was done to assess the disease. A T1 hypointense and T2 hyperintense lesion was found involving the pineal region and quadrigeminal cistern and mass effect in the form of compression and distorsion of midbrain, third ventricle and cerebral aqueduct. Microscopy was reviewed which revealed sheets of cellular neoplasm with irregular hyperchromatic nuclei scanty cytoplasm and eccentrically placed nuclei. Several cells showed multinucleation or nuclear multilobulation. IHC showed strong positivity for GFAP and synaptophysin. MIB1 (Ki-67) index high 15%. Hence the diagnosis of anaplastic ganglioglioma was established. Patient is started on image guided radiation of 59.4 Gy at 1.8 Gy per fraction.
Anaplastic varient of ganglioglioma: A case report
R. Chitra, K. R. Rajeev, Anitha Mathews 1 , Beela Sarah Mathew
Departments of Radiation Oncology and 1 Pathology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]
Introduction: Gangliogliomas are rare neoplasms constituting 0.4-1% of central nervous system tumors. They are thought to arise from a glioneuronal precursor and consist of both neuronal and glial elements. Anaplastic transformation mostly occurs in pediatric population. Anaplastic Gangliogliomas have common clinical and radiological features as that of other malignant gliomas. We present a case of anaplastic variant of Ganglioglioma in a paediatric patient. Materials and Methods: We present a case of 4 year old boy who presented with features of raised intra cranial tension and seizures for 1 year duration to a local hospital in September 2015. On MRI brain, a heterogenous contrast enhancing space occupying lesion in left frontoparietal region was detected. He underwent maximum safe resection and there was no post-operative neurological deficit. Histopathology reported as Ganglioglioma and he was on close follow up. Nine months later he presented with a relapse for which a reexcision was done along with ventriculo-peritoneal shunt. Patient reported to our centre with a histopathology report of desmoplastic infantile ganglioglioma with anaplastic features. On evaluation with an MRI brain there was a T1 hypointense and T2 hyperintense lesion found involving the pineal region and quadrigeminal cistern with mass effect and distortion of midbrain, third ventricle and cerebral aqueduct. Pathology review showed sheets of cellular neoplasm with irregular hyperchromatic nuclei with scanty cytoplasm and eccentrically placed nuclei. IHC showed strong positivity for GFAP and synaptophysin. MIB1 index was high. The patient currently undergoing postoperative radiotherapy with 5940 cGy in 33 fractions using IMRT technique.
Hypofractionated radiotherapy with temozolamide in glioblastoma multiforme
N. V. Kalaiyarasi, Baskar, Madhumathi, Sundaresan, Sanjal Kumar, Vijay Karthik, Poongodi, th C. Priyadarsini
Department of Radiotherapy, Barnard Institute of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]
Introduction: GBM accounts for approximately 75% of all high-grade gliomas. The standard treatment regimen is surgery followed by post operative radiotherapy 60 Gy in 2 Gy/# given in 30# along with temozolamide. Hypofractionated radiotherapy with reduced treatment time is considered to be an acceptable alternate form of treating elderly and poor prognosis younger patients. Aim: To evaluate the safety and efficacy of hypofractionated radiotherapy in RPA class 4, 5 and 6 glioblastoma patients and to assess quality of life after the end of treatment. The secondary objective is to assess overall survival. Materials and Methods: Single arm prospective study with 30 patients diagnosed with glioblastoma presented to the department of radiation oncology, madras medical college, Chennai. All patients are treated with phase 1: 30 Gy/3 Gy/# in 10# and boost of 7#/3 Gy/# to the tumour along with concurrent administration of temozolamide and advuvant temozolamide in 6 cycles. Toxicity of the treatment with RTOG and FACT-Br scale with quality of life at the end of the treatment period is noted. Radiological response and overall survival are secondary endpoints. Results: Among 30 patients, 21 are men and 9 are women. Median age is 58 years. There is no deterioration in the quality of life at the end of the treatment period. CNS late toxicity grade 1 observed in 16 patients, grade 2 in 8 patients and grade 3 in 5 patients. No grade 4 or treatment related deaths in this study. Median survival observed is 5.8 months. Conclusions: Hypofractionated radiotherapy with temozolamide can be considered as an acceptable alternate fractionated therapy protocol in glioblastoma patients with acceptable toxicity.
Glioblastoma multiforme: A retrospective case series in a tertiary cancer centre
Vijay Krishna Jasti
Department of Radioterapy, GSL Medical College, AP, India,
E-mail: [email protected]
Aims and Background: Glioblastoma is the most common primary brain tumor in adults. The current standard of care for glioblastoma is maximal surgical resection possible followed by adjuvant radiotherapy plus temozolomide, given concomitantly with and also after radiotherapy. In this retrospective study, the results of standard treatment and toxicity profile were evaluated. Methods and Study Design: In this report we retrospectively reviewed the clinical outcome of 16 patients with a diagnosis of glioblastoma multiforme and referred to our institute after surgery from August 2014 to September 2016. All patients received radiotherapy 2 Gy daily fractionation upto a dose of 60 Gy and concomitant temozolomide (at a dose of 75 mg/m 2 /day daily) followed by 6 cycles of adjuvant temozolomide after radiotherapy, every 28 days for 5 days at a dose of 200 mg/m 2 /day. Results: Concomitant RT plus temozolomide followed by adjuvant temozolomide was well tolerated. Non-haematological acute side effects were rare and only mild to moderate in severity. No grade 4 toxicities were reported. Grade 3 neutropenia was observed in 6.25% and grade 3 haematological toxicity was reported in 12.5%. The median follow up duration was 12.7 months (range 3-18 months). The one year survival rate was 60%. Median survival and response evaluation were not analysed in this study. Conclusions: The study confirmed the effectiveness of radiotherapy plus temozolomide in newly diagnosed glioblastoma. Favourable results were obtained in terms of toxicity profile and survival for patients in this study.
Patterns of care and survival outcomes in patients with pineal parenchymal tumor of intermediate differentiation: An individual patient data analysis
Department of Radiotherapy, AIIMS, New Delhi, India, E-mail: [email protected]
Background and Purpose: Pineal parenchymal tumor constitutes less than 1% of all CNS tumors. Pineal parenchymal tumor of intermediate differentiation is a rare tumor arising from the pineal parenchyma lying between the spectrum of Pineocytoma and Pineoblastoma. Materials and Methods: We performed PubMed search with the following MesH terms: "pineal parenchymal tumor, pineal parenchymal tumor of intermediate differentiation, pineal parenchymal tumor of intermediate differentiation AND treatment, and pineal parenchymal tumor of intermediate differentiation AND survival" to find all possible publications pertaining to PPTID. Individual patient data of "age, gender, surgery, type of surgery, radiation and type of radiation, chemotherapy, recurrence, and survival" were tabulated. Results: Median age was 33 years (range: 4.5-75 years). The male:female ratio of 1:1.6. Median MIB labeling index was 7 (range: 1-30). Adjuvant radiation was used in 46 (36.2%) of the patients and chemotherapy was used in 43 (33.9) patients. Of the patients who had recurrence 62.5% experienced spinal or leptomeningeal recurrence while 37.5% had local recurrence. The median progression free survival overall survival were 5.17 and 14 years respectively. Univariate analysis revealed female and the use of adjuvant radiation to be associated with better overall survival. Conclusion: PPTIDs is associated with a good outcome with a median progression free survival of 5.17 years and median overall survival of 14 years. Patients must be treated with adjuvant radiotherapy as addition of radiation is associated with better survival outcomes.
Key words: Chemotherapy, pattern of care, pineal parenchymal tumor of intermediate differentiation, radiotherapy, surgery
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