|Year : 2016 | Volume
| Issue : 6 | Page : 20-25
|Date of Web Publication||30-Nov-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Gastrointestinal. J Can Res Ther 2016;12, Suppl S2:20-5
External beam radiotherapy with concurrent chemotherapy followed by intraluminal brachytherapy boost in carcinoma oesophagus patients: A prospective observational study
Pulkit Nag, Virendra Bhandari, Om Prakash Gurjar, K. L. Gupta, Priyusha Bagdhare
Department of Radiotherapy, Sri Aurboindo Institute of Medical Sciences, Indore, Madhya Pradesh, India, E-mail: [email protected]
Introduction: The main objective is to evaluate response and toxicity profile in patients receiving external beam radiotherapy (EBRT) with concurrent chemotherapy followed by intraluminal brachytherapy (ILBRT) boost in carcinoma oesophagus patients. Materials and Methods: 20 patients with carcinoma oesophagus received EBRT (50 Gy/25#) with concurrent chemotherapy (cisplatin-40 mg/m 2 ). After a gap of 2-3 weeks ILBRT (10 Gy/2# each 1 week apart by HDR CO 60 source) was given. Response was evaluated clinically (relief of dysphagia) and on endoscopy at 1 month and at 1 year of completion of treatment. Also acute and chronic toxicity was evaluated at 1 month and 6 months of treatment. Results: Completer response were seen in 80% of patients and partial response 20% at 1 month. And there were 65% complete response, 10% local recurrences, 15% patients showed local control with distant metastasis and 10% patients died at 1 year. Grade 2 oesophagitis was seen in 70% of patients. 40% shows stricture and 10% who died had fistula. There was no spinal cord, cardiac and nephrotoxicity found. Conclusions: With the concept that high tumoricidal dose for adequate tumour control achieved by ILBT, as a mean of dose escalation, at the same the sparing surrounding normal tissue, and potentially improving therapeutic ratio, EBRT followed by ILBT could be better choice for carcinoma oesophagus.
Carcinoma gastro-esophageal junction with submandibular lymph node metastasis, progressing to skin metastasis: A case report with review of literature
V. S. Naidu , M. S. Kang, A. K. Chauhan, P. Kumar, P. Kumar
Department of Radiotherapy, SRMS IMS, Bareilly, Uttar Pradesh, India, E-mail: [email protected]
Introduction: Gastro-Esophageal Junction cancers usually present initially in advanced stage. Extra-nodal metastases are seen in 20% of the patients but cutaneous metastases are rare. We report a rare case of carcinoma gastro-esophageal junction with submandibular lymph node metastasis, progressing to skin metastasis. Case History: A 27 year old male presented with complaints of difficulty in swallowing 2 & months, vomiting since 1 month, pain in upper abdomen & swelling over the left side of the mandible since 1 month. On clinical examination submandibular lymph node enlargement - single, hard, tender 3 × 2 cm fixed to the stem and the underlying skin. UGIE showed - mitotic growth at GE-Junction. CECT W/A showed asymmetric mural thickening involving GE junction, cardia & lesser curvature of stomach with encasement of abdominal aorta. Biopsy from the left submandibular swelling showed - adenocarcinoma; FNAC from GE junction growth - Signet ring cell carcinoma. 2 cycles of NACT (EOX+C) was given followed by IVER LEWIS + left extended supra omohyoid neck dissection. 4 cycles of adjuvant chemo with EOX was given. During treatment, the patient developed subcutaneous skin nodules in the neck whose biopsy showed metastatic adenocarcinoma. PET-CT revealed no other site of metastasis. 1 cycle of 2'nd line chemotherapy (DCF) was given to the patient, the patient was lost to follow up. The patient presented with disease progression along with lymphedema of face & is on conservative management since 4 months. Conclusions: The presence of Cutaneous metastases, denotes an advanced disease. Survival is dismal with an average of 4 months.
"Out of trial" outcomes in locally advanced esophageal cancers: A retrospective audit
A. Srivastava, th K. Tekta , S. S. Saluja 1 , K. Singh, A. K. Rathi, M. Sharma
Department of Radiotherapy, Maulana Azad Medical College, 1 Department of Surgical Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India, E-mail: [email protected]
Objective: To assess the impact of multimodality treatment in locally advanced cancer esophagus treated out of trials. Materials and Methods: Between 1.1.14 to 31.1.16, 60 cases were included. Records were reviewed retrospectively for demography, staging, treatment modalities and outcomes. Survival analysis was performed by Kaplan Meier method assuming 'worst case scenario'. Results: Mean age at presentation was 56.9 ± 11.1 years, ECOG status ≤2 in 98% with gender distribution being 1.2:1 (M:F). Radiologically all cases were ≥ stage III; 83.3% were squamous and 16.7% adenocarcinoma, located in cervical region in 10%, mid-thoracic in 83.3% and at the gastro-esophageal junction in 6.7%. 65% patients received neoadjuvant therapy (NAT) (chemotherapy alone [n = 16], or in combination with radiation [n = 21]), 10% with radical chemoradiation (CTRT) and 25% palliatively. Post NAT, 43.3% patients underwent surgery. Mean follow up was 8.5 ± 4 months with 23% patients interrupting treatment for an average of 3.9 ± 1.8 months. Response at end of treatment was complete in 40%, partial in 18.3%, none in 16.7% and progressive disease in 25% cases. At time of analysis, 23.3% patients were dead, 33.3% lost to followup, 21.7% each being alive with and without disease. Median overall survival was 10 ± 1.3 mths, (95% CI 7.2 - 12.7); 13 ± 7 mths with CTRT, 11.0 ± 1.4 mths with NAT and 8.0 ± 0.7 mths with palliative. Conclusion: Real world outcomes in locally advanced cases continue to be poor despite multimodality treatment. Major limitation is large number of lost to follow ups and treatment interruptions.
Key words: Cancer esophagus, lost to follow up, multimodality treatment, treatment breaks
A prospective study to compare concurrent chemo-radiotherapy with radiotherapy alone in management of oesophageal carcinoma
A. K. Arya, th K. N. Pradeep , Anuj Tyagi, Tabassum Samani,
Department of Radiotherapy, S. N. Medical College, Agra, Uttar Pradesh, India, E-mail: [email protected]
Background: Carcinoma esophagus mostlypresents in advance stage. Surgery is considered to be prime modality of treatment, though radiation therapy is also an important therapeutic modality. Concurrentchemo radiation has been accepted as the standard of care in patients who are deemed unfit for surgery, but the outcomes are controversial. Our goals were to compare the therapeutic effects of concurrent chemo radiotherapy and radiotherapy alone in locally advanced esophageal cancer using meta-analysis. Materials and Methods: The study carried out between December 2014 to July 2016. 31 locally advanced esophagealcancer were evaluable. Following a written informed consent, patients with previously untreated, documented as squamous cell carcinoma of esophagus were inducted into this study if they satisfied KPS >50, Hb >10, normal liver and kidney function. Endoscopic and radiological evaluation was done. Patients were randomized into two groups. Group B - control receivedonly radiotherapy. Group B - receivedconcurrent chemo-radiotherapy. Cisplatin 35 mg/m 2 (max-50 mg) given weekly. The treatment outcome was assessed in terms of response, dysphagia free interval and toxicities. Results: Out of 31 pt, 19 were male. Male to female ratio was 3:2. The median age at diagnosis was 52 yr. and median follow up was 6.5 months. Majority patients (77.4%) got complete response at the end of treatment. 18 pts. were enrolled in Arm A and 13 in Arm B. 2 local recurrence and 3 distant metastasis were reported in Arm A whereas it was zero in Arm B. Mean dysphagia free survival in Arm A and B (DyFS) were 2.5 and 6.5 months respectively. DFS were 1 and 7 month whereas OS 9 and 15 months in Arm - A & B respectively. Acute toxicities were more in Arm - B. 24 patients alive, 5 patients died, 2 patients were lost of follow up. Conclusion: Concurrent chemo radiotherapy significantly improve overall survival, Dysphagia free survival, reduced the risk of persistent and recurrencewith increase toxicity.
Neoadjuvant radiation for rectal cancer: Analysis of clinical outcomes from a 5-year institutional experience
Tejinder Kataria, th Manoj Tayal , Adarsh Chowdahry, Dheeraj Gautam, Sonal Krishan, Garima Srivastava, S. Sasikumar
Department of Radiotherapy, Medanta - The Medicity, Gurgaon, Haryana, India, E-mail: [email protected]
Objective: To examine clinical outcomes in patients receiving neoadjuvant chemoradiation for locally advanced rectal adenocarcinoma. Methods: Retrospective review was performed on 72 consecutive patients (from Feb 2010-May 2015) received neoadjuvant radiotherapy (RT) (±chemotherapy) for adenocarcinoma rectum. Surgery was performed 4-8 weeks after completion of chemoradiation. Standard statistical methods were used to analyze recurrence and survival. Results: Median follow-up was 12 months, mean age 55.5 years. 94% patients received long course RT (45-53.6 Gy in 25-28 fractions). CT-scan or MRI used for staging, 72% were T3, 11% each were T2 & T4, 57% lymph-nodes (N) positive and 43% were N0/Nx. Radiotherapy and chemotherapy were well tolerated. 50 patients (70%) underwent surgery, 15% did not report for surgery, 8% were found inoperable and 7% developed distant metastasis before surgery. On pathologic analysis, 78% of the operated patients were downstaged (complete or partial response), and 22% (of operated patients) showed poor pathological response; 26% specimen were T0N0 (complete response). 24% (12 of 50 operated patients) developed relapse with 14 instances (1 local, 8 distant & 5 combined). Of the total 14 relapsed instances 58% were from the poor response, 34% from the partial responders and 8% from the complete response group. Of the 8 distant relapses, 63% were poor responders and 37% were partial responders. Postoperative pathologic response is found to have effect on recurrence pattern. Poor response status predicted increased local and distant recurrence. Conclusions: Neoadjuvant chemoradiation is effective, and well tolerated. Postoperative pathologic response is found to have effect on recurrence pattern.
Impact of preoperative chemoradiation on tumour regression in rectal cancer
Rahil Patel , M. G. Janaki
Department of Radiotherapy, M S Ramaiah Memorial Hospital, Bengaluru, Karnataka, India, E-mail: [email protected]
Introduction: Most rectal cancer patients are treated with chemoradiotherapy followed by surgery. Objectives: To assess efficacy of preoperative chemo radiation on tumour regression. Materials and Methods: Database from 15 patients was retrospectively reviewed. Data for preoperative tumour staging was collected using CT scan imaging modality. Neoadjuvant radiotherapy was given mainly with a dose of 45 Gy/25# over 5 weeks along with two cycles of three weekly chemotherapy of 5-Fluorouracil - 1 gm. All patients underwent AR/LAR/APR 6-8 weeks later. Post-operative histopathology reports were collected and correlated with preoperative CT scan findings to assess the response to neoadjuvant chemoradiation using Dworak and Rodel tumour regression grading system. Results: All patients received neoadjuvant chemoradiation. 53% and 47% patients were male and female respectively. Most of the patients (86.6%) received radiotherapy with dose of 45 Gy/25# with one patient receiving dose of 50 Gy/25# and one patient receiving dose of 50.4 Gy/28#. All patients received chemotherapy of 5-Fluorouracil - 1 gm. On preoperative imaging 73.3%, 20% and 6.6% of patients had stage IIIB, IIA, IIIC respectively. On post op staging 26.6%, 26.6% and 20% of patients had stage IIIB, I, IIA respectively. One patient achieved pCR. Overall tumour regression was seen in 46.6% of patients. Dworak and Rodel tumour regression grading systems were used to quantify the response. Conclusions: Nearly half of the patients showed effective tumour regression. Those who had lesser response could be considered for an aggressive adjuvant treatment.
Anorectal melanoma with lung and axillary lymph node metastasis: A case report
R. K. Spartacus , Rohitashwa Dana, Ajay Singh Choudhary, Aseem Rai Bhatnagar, Neeraj Sharma, Sandeep Bhaskar, Kartick Rastogi, Kampra Gupta
Department of Radiotherapy, Sawai Man Singh Medical College and Attached Hospitals, Jaipur, Rajasthan, India, E-mail: [email protected]
Introduction: Anorectal melanoma (ARM) accounts for less than 0.05% - 4.6% of all anorectal malignancies and 0.4% - 1.6% of all malignant melanomas. ARM is the third most common primary origin of melanoma following skin and retina. It has a predilection for early infiltration and distant spread resulting in poor overall survival. Because of the rarity of this tumor, it has been difficult to define an optimal treatment approach. Case Presentation: A 37 year old man presented with complains of constipation of 10 months duration, per rectal bleeding for last 7 months. On clinical examination, an elongated oval nodular mass (approximately 6 cm x 3 cm) could be seen protruding from the anal canal. CT scan abdomen revealed a circumferential enhancing mass (50-30 mm) in anorectum with 14 cm cranio-caudal extension. There were multiple enlarged lymph nodes in peri-rectal fat and bilateral iliac region. CECT thorax revealed multiple nodules in both lung fields suggestive of metastases. Multiple enlarged lymph nodes were noted in left axilla. Biopsy from the anorectal growth was suggestive of a malignant neoplasm. On Immunohistochemistry (IHC), tumor cells expressed S-100 protein, HMB-45, Melan-A & Cytokeratin and were immunonegative for LCA establishing a diagnosis of malignant melanoma. After routine investigations and explaining the prognosis, the patient was started on Dacarbazine chemotherapy. Conclusions: ARM especially those presenting with metastases has grave prognosis. No systemic therapy regimen for metastatic anal melanoma is considered standard of care. The best hope for improved survival lies in early detection and complete surgical removal.
The symptom-to-treatment delay and stage at the time of treatment in cancer of oesophagus
Ram Singh Jamre , O. P. Singh, V. Yogi, A. Shrivastava
Department of Radiotherapy, Gandhi Medical College, Bhopal, Madhya Pradesh, India, E-mail: [email protected]
Introduction: The main objective of this study was to analyze the time delay from the first symptom to treatment in oesophageal cancer and to analyze the relationship between the delay and stage at the time of definitive treatment. Materials and Methods: 70 patients were analysed prospectively and retrospectively between July 2014 and June 2016 at Gandhi Medical College Bhopal. Patients were interviewed at their first presentation to our hospital. Dates were recorded according to the patient's recollection, written information in the doctor's records during diagnosis process, and hospital files. Details from the patient's first symptoms and course of diagnosis and treatment were recorded. The overall delay in months was recorded from appearance of the first symptoms to the date when the patient had definitive cancer specific treatment (end point), and was divided as: (1) Time of appearance of the first symptoms to first contacting the health care system (patient delay). (2) Time from first contacting healthcare system to histopathological diagnosis (histopathological delay). (3) Time from histopathological diagnosis to the end point (treatment delay). Results: The median age of presentation was 54.6 yrs. The first symptoms were progressive dysphagia in all the patients (100%), abdominal or chest pain, regurgitation and odynophagia. The mean delay from first symptom to end point was 360.4 days. Total symptom-to-treatment was due to: patient delay (86%) - histopathological delay (5.3%) treatment delay-(8.7%). Conclusion: Long delays occur in patients. Patient delay is the most important factor, community education programs may help in their early presentation to the hospital for better QOL.
Volumetric modulated arc therapy in preoperative chemoradiation in carcinoma esophagus: A single institution experience
V. Aswin Chandran , S. Shyama Prem
Department of Radiotherapy, RCC, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, E-mail: [email protected]
Objectives: To evaluate the dosimetric parameters of Volumetric Modulated Arc Therapy (VMAT) technique in patients undergoing Neoadjuvant chemoradiation in Carcinoma Esophagus with respect to target volume coverage and dose received by organs at risk. Materials and Methods: 20 patients of Carcinoma esophagus underwent neoadjuvant chemoradiation in our institute between 2014 and 2016. VMAT was delivered in dual arcs. Each arc was set with 98 control points. Progressive Resolution Optimizer (PRO-3). Algorithm was used to produce VMAT plans. All plans used 6 MV photons with a dose rate of 600 Monitor Units. The radiation dose was 41.4 Gy in 23 fractions with weekly Paclitaxel (50 mg/m 2 ) and Carboplatin (AUC-2) chemotherapy. The patients underwent surgery post Neoadjuvant treatment after 4 weeks. The treatment plans have been retrospectively analysed with respect to target volume coverage and dose to OARs. Results: Dosimetric analysis of the plans showed excellent target volume coverage and critical organ sparing. The mean and median V 95 of PTV was 97.46% and 98.38% respectively with a standard deviation of 2.71. The mean conformity and homogeneity indices were 1.06 and 0.11 respectively and median values were 1.06 and 0.1 respectively. The mean D mean , V 5 , V 10 , V 20 and V 30 of right lung was 1244.9 cGy, 76.96%, 53.42%, 17.14% and 6.57% respectively. The mean D mean , V 5 , V 10 , V 20 and V 30 of left lung was 1345.6 cGy, 77.51%, 58.05%, 23.85% and 10.5% respectively. The mean D mean , V 5 , V 10 , V 25 , V 30 and V 40 of heart was 2286.7 cGy, 93%, 86%, 39.45%, 28.87% and 15.11% respectively. The mean D mean of left and right kidneys were 747.2 cGy and 1016.7 cGy respectively. Conclusions: Volumetric Modulated Arc Therapy provided excellent dose conformality with adequate sparing of critical organs.
Hypertensive profile of metastatic colorectal carcinoma patients treated with bevacizumab
Mintu Mathew Abraham
Department of Radiotherapy, Trivandrum Medical College, Trivandrum, India, E-mail: [email protected]
Background: Bevacizumab is a recombinant humanised monoclonal (IGg1) antibody and is an anti angiogenesis factor inhibitor acting on the VEGF (vascular endothelial growth factor) receptor pathway. It is extensively used in metastatic colorectal carcinoma as first line therapy. Hypertension is an on-target and common side effect of the treatment affecting up to 67% of patients. This prospective study aims to find the prevalence and pattern of hypertension of patients treated with Bevacizumab. Materials and Methods: All patients with metastatic colorectal carcinoma were treated with FOLFOX4 or CapOx schedule with Bevacizumab 5 mg/kg administered as infusion given every 3 weekly. Blood pressure was monitored before and after chemotherapy and for the next 7 days using standard procedure at the same time of day. Patients who developed hypertension were treated with calcium channel blockers. Data over a period of 3 months was analysed. Blood pressure was recorded and day of peaking was analysed. A total of 30 patients were enrolled in the study and blood pressure was monitored over 4 cycles of chemotherapy. Results: The overall occurrence of hypertension in our study is 100% irrespective of the status of blood pressure prior to the study. The mean systolic BP after the treatment ranged from 133 to 145.5 mm Hg. The mean diastolic BP after the treatment ranged from 85.3 to 91.3 mm Hg. In this study, the maximum peak of hypertension was observed on the 6 th and 7 th day post Bevacizumab in all the cycles. Discussion and Conclusion: Majority of the clinical trials have shown hypertension in up to 80% of the patients. Our study reveals that the incidence is 100% stressing the point that hypertension may be considered as a biomarker of VEGF inhibitor treatment. This change in the Indian context is important and must be taken into account while treating Indian patients.
Colonic carcinoma with left sided axillary lymphadenopathy: An exceedingly rare clinical experience
Pranabandhu Das , R. Ramesh Reddy, B. V. Subramanian
Department of Radiation Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India,
E-mail: [email protected]
Objective: Metastasis to axillary lymph nodes from right colon cancer are extremely rare with only four cases have been reported so far to our review in English literature. Here we report a case of a middle aged man presented with right axillary lymphadenopathy diagnosed as right colon cancer undergone palliative surgery, chemotherapy and radiotherapy for symptomatic palliation. Materials and Methods: A 40-year-old male patient presented with loss of appetite, frequent loose motions persisting snce three months for which he was treated symptomatically at local hospital and referred to SVIMS hospital OPD for further care. He had complaints of dyspepsia and left sided neck and axillary swelling and tightness. FNAC from axillary swelling-was suggestive of metastatic adenocarcinomatous deposits. Ultrasonography ofabdomen showed features suggestive of carcinoma right hepatic flexure of colon. Colonoscopy reveals polypoidal growth lyingin ascending colon. Patient underwent right extended hemicolectomy. Biopsy revealed adenocarcinoma of signet ring cell type. Patient received 12 cycles of palliative chemotherapy FOLFOX over six months. The axillary swelling apparently progressed and became painful and referred for palliative radiotherapy. Results: Patient received palliative radiotherapy to axillary swelling to a dose of 39 Gy/13 fr. He had achieved symptomatic palliation. The patient was advised to be on best supportive care. The patient died two months after discharge at home which may be due to disease progression. Conclusion: This case has been presented because of its extremely rare in incidence, poor clinical outcome which warrants its early detection through clinico-radiological, endoscopic or functional imaging that may contribute towards better quality of life and overall survival.
To study the impact of integrated 18F-FDG PET with CT and MRI on staging and target delineation in neoadjuvant intensity modulated radiotherapy planning of rectal carcinoma
Prashant V. Surkar , Swarupa Mitra, Manoj K. Sharma,
Kumardeep Dutta, Parveen Ahlawat, Maninder Mishra,
Upasna Saxena, Inderjeet Kaur Wahi
Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India, E-mail: [email protected]
Introduction: IMRT for treating rectal cancer has evolved over a period of time. It mandates accurate delineation of target volumes, which requires incorporation of MRI and PET/CT in addition to conventionally used computed tomography. This can resolve discrepancies in target delineation in rectal carcinomas resulting in better local control. We hereby report the alterations in GTV and staging in rectal carcinoma when MRI & PET/CT are incorporated in the IMRT planning and their concordance indices. Materials and Methods: 30 patients with rectal cancer were taken into this study. MRI, PET/CT and CT scans were done as per standard guidelines. Three sets of primary GTVs namely GTV PET-CT, GTV MRI-CT and GTV-CT were contoured on fused images. All the three volumes and concordances among the volumes were analyzed. Results: The mean GTV PET-CT, GTV MRI-CT and GTV-CT volumes were 102.84 cc ± 42.87, 99.23 cc ± 42.70 and 86.41 cc ± 41.71 respectively. There was a significant difference in the GTV-MRI-CT volumes (P = 0.000) and GTV-PET-MRI volumes (P = 0.001) and GTV-PET-CT volume (P = 0.000). The mean CI (PET-MRI), CI (CT-MRI) and CI (PET-CT) was 0.39, 0.28 and 0.36 respectively, which depicts a moderate concordance. In present study, upstaging was found in 4 patient from nodal stage cN0 to cN1 (13.33%) on PET/CT. Conclusions: PET and MRI are useful imaging tools in rectal malignancies and should be used in conjunction with CT scan for improved target volume delineation.
Key words: Concordance index, fusion, rectal carcinomas
Esophageal cancer treated with curative intent: A single institutional study over a period of three years
M. G. John Sebastian , M. G. Janaki
Department of Radiotherapy, M S Ramaiah Memorial Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]
Introduction: Carcinoma esophagus is the 9 th most common malignancy in India with 41,774 new cases and 38.683 deaths in 2012. Radiotherapy, chemotherapy and surgery form three important pillars of the treatment. Many patients are not suitable for curative treatment for various reasons. This work studies the role of radiation therapy either alone or as a part of radical therapy for carcinoma esophagus. Methods: 54 patients treated from January 2013 and Dec 2015 were analysed retrospectively. Median follow up period was 28 months. 4 patients underwent surgery following radical chemoradiation. 44 patients were treated with definitive chemoradiation whereas 10 patients received only radical radiotherapy. Results: Kaplan Meier analysis showed an Overall survival of 61% at 1 year and 42.8% at 2 years. Performance status, age, node positivity, concurrent chemotherapy were factors deciding the outcome of treatment. Conclusion: Radical chemoradiation is a reasonable option in the definitive treatment of Carcinoma esophagus. Careful selection of patients based on factors like performance status, comorbidities, age, weight loss is a must for deciding on radical treatment.
Analysis of toxicity, compliance and outcome of definitive chemoradiation in squamous cell esophagus: A prospective observational study
V. R. Anjali , A. Sajeed, K. R. Rajeev, S. Roshni, Arun Sankar, Lijeesh, Geethi, Jagath Krishna, C. Sivanandan
Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]
Introduction: Esophageal remains a highly lethal disease as evidenced by case fatality rate of 90%. The overall ratio of mortality to incidence is 88-93%, which implies that the optimal treatment remains to be defined. Chemoradiation remains as standard of care for locally advanced carcinoma esophagus. Our aim is to evaluate outcome, toxicity and compliance of definitive chemoradiation regime for carcinoma esophagus in our population. Materials and Methods: Prospective Observational Study on 30 patients with locally advanced squamous cell carcinoma of oesophagus who merits definitive chemo radiation is selected between March_2014-April_2015. Acute Radiation toxicities were evaluated using CTCAE scoring criteria. Statistical analysis using SPSS software and survival estimates are generated using Kaplan-Meier method. Overall survival (OS) is defined as the period from date of registration to last follow up or death. Progression free survival (PFS) is defined as period between start of treatment to date of first documentation of any relapse. Results: The mean age is 59 yrs. 63.3% of patients had Stage III disease at presentation. OS at 1 year is 66.9% and PFS at 1 year is 66.7%. On univariate analysis only tumor stage was found to have significant effect on overall survival (P - 0.03) and on PFS (P - 0.008). All patient were compliant to RT. Only 22 patients could complete all four cycles of chemotherapy. None of the patient developed grade IV mucositis or hematological toxicities. 3 patients developed grade III neutropenia. 63% patients had grade III mucositis. Conclusions: Treatment was well tolerated without any major toxicity. Only one third of the patients had complete response. Majority of patients had partial response. Patients had very good compliance to the radiation. Only 73.3% could complete all the four cycles of chemotherapy.
A rare case of intracranial dural metastasis in colorectal adenocarcinoma
Surendra Reddy , B. C. Sreedhara 1 , Vinayakumar Muttagi, J. Mathangi
Departments of Radiation Oncology and 1 Radiology, BGS Global Hospitals, Bengaluru, Karnataka, India, E-mail: [email protected]
Objectives: To present a rare case of intracranial Dural metastasis in a carcinoma rectum patient treated with APR followed by concurrent chemo radiation and adjuvant chemotherapy. Materials and Methods: A 60 years gentle man was diagnosed to have carcinoma rectum and he underwent APR, followed by concurrent chemo radiation with the dose of 54 Gy in 30 fractions along with daily Tab. Capacetabine and adjuvant chemotherapy with 8 cycles of CAPOX regimen 1 year back. Now he presented with left hemiperesis associated with lower limb radiculopathy for the duration of 1 month and hoarseness of voice for the duration of 15 days. He is evaluated with routine blood investigations, CT thorax and brain. CT thorax revealed metastatic bony lesions at thoracic vertebrae but Ct brain was normal. Results: He is evaluated further with MRI brain which is suggestive of multiple dural based lesions which is causing pressure over the brain parenchyma causing hemeperesis. Cerebral metastases are more common in adult malignancies, in which parenchymal lesions are more common in colorectal malignancies. In case of extra axial dural metastases common in breast, lung, renal, prostate, lymphoma and melanoma. Brain metastases from colorectal malignancies are uncommon phenomenon with reported incidence of 1.8% to 4% in autopsy studies performed on colorectal cancer patients. However dural metastases from colorectal adenocarcinoma is extremely rare. This patient was managed with 30 Gy/10 fractions over 2 weeks. He improved symptomatically in terms of hemiperesis, radiculopathy and hoarseness of voice. Conclusion: Intracranial dural metastases in colorectal adenocarcinoma is rare and mimics as dural masses like meningioma. These patients are managed with surgery followed by adjuvant radiotherapy in single metastasis, radiotherapy in multiple metastasis.
A prospective study of the role of FDG PET/CT scan in the initial management of carcinoma oesophagus
(Lt Col) Shweta Sharma , (Brig) Sharad Bhatnagar, Manoj Semwal, (Maj) Sankalp Singh
Department of Radiotherapy, Command Hospital (Central Command), Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Objectives: To prospectively study the role of FDG PET/CT scan in the initial management of 50 patients of Carcinoma Esophagus, treated with upfront Radiotherapy at our hospital during the period between Jan 11 to Mar 13, in terms of its impact on various phases of diagnosis & management like. (a) Staging, (b) Treatment decisions such as choice of treatment intent and treatment modality and (c) Radiotherapy treatment planning parameters, due to changes, if any, brought by the additional information provided by PET. Materials and Methods: Fifty patients selected over a period of two years with histologically confirmed (Adenocarcinoma/SCC/Adenosquamous) oesophageal cancers were selected, clinically evaluated and staged as per NCCN Guidelines. Whole Body FDG/PET CT was acquired within 14 days of CECT of the neck, thorax and abdomen and staged. Those planned to be treated with upfront radiotherapy [Definitive CCRT, Palliative EBRT, Radical RT or NACCRT] were evaluated prospectively. The impact of PET scan on changes in patient staging, initial management decisions and radiation planning parameters, like changes in tumor dimensions, addition of new nodal stations or structures which translated into changes in target delineation, doses to OARs and technical changes like beam number, geometry, orientation, weightage, energy etc. were measured and analysed. The data was tabulated on a master chart using Microsoft Excel and statistically analysed using SPSS Version 20. Results: PET/CT does not change the intent or the modality of initial management in the majority of patients despite substantially upstaging or down-staging the disease. Itwas found to be better in picking up supraclavicular lymph nodal metastases and skip metastasis which in turn altered treatment plans majorly. It can also be used to rule out doubtful cases of aortic invasion on CECT, thus influencing resectability. However, in patients in which it picks up distant metastases, it substantially alters the stage, the prognosis and hence the line of management. Its most profound impact was on radiation treatment planning whereby the metabolic inputs helped in better target contouring and coverage in 70% of the patients. Conclusion: As the experience and knowledge of PET/CT increases, its availability, affordability and proficiency will too. The integration of PET into PET based Radiation Treatment Planning Software should increase confidence in tumor targeting during treatment planning and help prevent geographical misses, thus adding to the armamentarium in our fight against cancer. The hazard from added radiation dose is outweighed by the tremendous benefits derived. However, larger numbers and longer follow ups are needed before changes in PET parameters during treatment, or changes in treatment parameters due to PET can be translated into more rational therapy and hence better long term controls and DFS.
Comparison of standard-dose versus high-dose radiotherapy with concurrent chemotherapy in esophageal cancer
Navin Nayan , M. Bhattacharyya, A. K. Kalita, Vikas Jagtap, T. R. Borborah, R. Sunku, P. S. Roy 1
Departments of Radiation Oncology and 1 Medical Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India, E-mail: [email protected]
Objective: Comparision of local and distant control rates with high-dose versus standard-dose radiotherapy along with concurrent chemotherapy in esophageal cancer - a prospective randomised study. Materials and Methods: Histologically proven stage I - III patients with carcinoma esophagus were randomised into two groups. One group has been treated with standard-dose radiotherapy i.e. a total dose of 50.4 Gy (1.8 Gy/day, 28#, 5 days per week). The other group (study arm) has received high-dose radiotherapy i.e. a total dose of 64.8 Gy (1.8 Gy/day, 36#, 5 days per week). Both groups have received 2 cycles of 3 weekly concurrent chemotherapy (cisplatin 75 mg/m 2 on day 1 and 5-FU 750 mg/m 2 continuous i.v. infusion over 24 hours on day 1-4). Follow up response evaluation was done by both endoscopy and CT scan after 6-8 weeks and and after 2 months thereafter. Results: Out of a total of 22 patients, 59% showed complete response, 23% showed partial response, and 18% patients developed progressive disease at first and subsequent follow up (Median follow up of 6 months). Among the complete response patients, rates were higher in high-dose group compared to standard-dose radiotherapy group (39% versus 33%, P = 0.99). Treatment related toxicities were acceptable in both group. Conclusion: High-dose radiotherapy with concurrent chemotherapy seems to be more effective with acceptable toxicity in our study. However, further follow up and large sample size may be required to validate the current study conclusion.
Effectiveness of chemoradiation versus radiotherapy alone in the treatment of esophageal carcinoma
Department of Radiotherapy, Assam Medical College, Dibrugarh, Assam, India, E-mail: [email protected]
Aims and Objectives: (a) To compare the degree of dysphagia resolution. (b) To compare the acute treatment complications. Materials and Methods: A hospital based prospective study designed to include 60 patients of histologically proved cases of carcinoma esophagus. The patients were randomized to receive radiotherapy alone (66 Gy in 33#) or Chemoradiation where chemotherapy was administered on every 21 days for five cycles; 3 cycles before radiotherapy and 2 cycles along with radiotherapy of 66 Gy in 33#. Results: In the radiotherapy alone treated group had a response of 63.3% to the therapy while 70% showed response to therapy in the chemoradiation group. All the toxicities were of mild to moderate grade in both the groups. No life threatening complications were found in both the groups. Acute complications were 63.3% in patients treated with chemoradiation while 33.3% patients experienced acute complication in the radiotherapy alone treated group. Local recurrence occurred in 3 patients (10%) in the chemoradiation treated group while 6 patients (20%) in the radiotherapy alone treated group. Conclusion: Carcinoma esophagus is one of the most common malignancies in the northeastern states of India. Chemoradiation is more efficacious in the treatment of the condition than radiotherapy alone. Treatment related acute complications are more in chemoradiation treated patients than in radiotherapy alone treated patients. Local relapse occurred earlier in radiotherapy alone treated patients than patients treated with chemoradiation.
Treatment outcomes with high-dose external beam radiotherapy combined with intraluminal brachytherapy in patients with esophageal cancer
Kaladhar Chillara , N. Suneetha, S. Prathima, M. S. Belliappa
Department of Radiation Oncology, HCG-Bangalore Institute of Oncology, Bengaluru, Karnataka, India, E-mail: [email protected]
Objectives: To evaluate and report treatment outcomes with high-dose external beam radiotherapy (EBRT) followed by high dose rate (HDR) intraluminal brachytherapy (ILBT) in patients with esophageal carcinoma. Materials and Methods: Patients with esophageal cancer, who were treated with definitive EBRT, 60 Gy in 30 fractions, followed by HDR-ILBT, between February 2010 and November 2015, were retrospectively analysed. Endpoints were overall survival (OS), disease free survival (DFS), local recurrence and late toxicities. Results: A total of 42 patients treated at our institute were identified. Patient characteristics include: Mean age 64.1 + 9.2 years, Male:Female = 60:40, all were squamous cell carcinomas, 60% Grade II, tumor length <5 cm in 71%, 70% node positive. All patients received a combined EBRT + ILBT dose >64 Gy EQD2 (range: 64-69.3 Gy, EQD2) and 31 patients (74%) received >67 Gy EQD2. Concurrent single agent platinum based chemotherapy was received by 31 patients (74%). After a median follow up of 17 months (5-77 months), median OS was 17.6 months and median DFS was 13.8 months. There were 15 local failures, of which 8 patients had persistent local disease. Median time to local recurrence was 14 months. Age, grade and tumor length were found to be prognostic factors for OS and local recurrence. Late toxicities reported were: strictures (14%), ulcerations (7%) and 1 patient developed perforation. No tracheo-esophageal fistulas and cardiopulmonary toxicities reported. Conclusion: Definitive, curatively intended chemoradiotherapy consisting of high-dose EBRT followed by HDR ILBT improved outcomes, with acceptable late toxicities. This could be a better choice for treatment of carcinoma esophagus.
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