|Year : 2016 | Volume
| Issue : 6 | Page : 29-43
|Date of Web Publication||30-Nov-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Gynaecology. J Can Res Ther 2016;12, Suppl S2:29-43
Treatment response and toxicity profile in cases of carcinoma cervix with metastatic para-aortic nodes treated with extended field radiotherapy using intensity modulated radiotherapy technique
Misra Biplab, th Roy Sanjoy , D. Lahiri, T. Maji
Department of Radiotherapy, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India, E-mail: [email protected]
Background and Purpose: Cervical Cancer presents at an advanced stages especially in rural India. Probability of PAN involvement also increases with advancement of stages. But still there are lots more to explore to come to a consensus about many aspect of EFRT. So the profile and feasibility of EFRT using IMRT technique in treatment of PAN node positive cervical cancer in Indian scenario will be a useful experience and subject for further exploration. Materials and Methods: Forty-five PAN positive cervical cancer patients in 2014-2015 were treated with EFRT using IMRT technique with chemotherapy. The prescribed dose of EFRT was 50.4 Gy in 28 fractions to the PTV. All patients received 4 fractions of weekly Brachytherapy started from 4 th week of EBRT with a Dose per fraction of 6 Gy. Results: 41 patients (93.2%) among 44 total patients achieved complete response. Till last contact 29 patients (70.73%) were disease free. The mean DFS was 16.39 ± 6.74 months. Only 3 patients suffered treatment interruption of more than 7 days. Acute grade 3 toxicities were observed in the form of anaemia and leucopenia (22.2%). Incidence of acute grade 3 skin reaction was in 2 patients (4.4%), whereas incidence of acute grade-3 toxicity for upper GI, lower GI & GU system was minimal (2.2%). Grade 3 or grade 4 late toxicities were observed in 4 patients (9.1%). Conclusion: Pelvic and PAN control rates were satisfactory and comparable to those in the published literature. The technique was associated with an acceptable acute and late toxicity profile without significant treatment prolongation.
Cancer cervix with skin metastasis: A case report with review of literature
M. S. Kang, A. K. Chauhan, P. Kumar, P. Kumar, th Ayush Garg
Department of Radiotherapy, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India, E-mail: [email protected]
Introduction: Cancer cervix is the commonest malignancy among women in rural parts of India accounting for 65% incidence. Cutaneous metastases from carcinoma cervix are extremely rare around 0.1-2% incidence. Materials and Methods: Fifty-four years old postmenopausal woman presented with bleeding & foul smelling discharge per vagina for 2 months and ulceroproliferative growth in cervix involving both lips, all fornices & extending to upper 1/3 rd of vagina. Biopsy revealed keratinizing squamous cell carcinoma. After complete haematological, biochemical & radiological work up, she was diagnosed as carcinoma cervix, FIGO Stage IIIB. She was planned for concurrent chemoradiation (50 Gy/25 fractions/5 weeks by four field box technique with concurrent cisplatin (35 mg/m 2 weekly). Patient tolerated treatment well with mild reactions. On follow up there was no evidence of disease. After 10 months she developed multiple subcutaneous nodules over right arm & forearm, firm to hard, 2 × 2 cm, nontender, fixed & nodular subcutaneous lesions. FNAC from both the nodular swelling showed squamous cell carcinoma. PET-CT scan revealed bilateral lung and intramuscular deposits. Patient was delivered 6 cycles of chemotherapy (paclitaxel and carboplatin). Complete clinical response is seen. She is due for PET-CT scan. Conclusion: Prognosis for such cases are poor as cutaneous metastasis is considered as a hallmark for pre-terminal disease, the mean survival being 3 months & survival for more than 1 year is seen in only 20% patients.
CT - image guided brachytherapy for cervical cancer: Adapting ICRU report 89
Prashanth Bhat Kainthaje , Anees Malavat, Pradeep Gaur, Rajan Paliwal, Shweta Mutha, Vivek Sehra, Devesh Gupta
Department of Radiotherapy, Dr. S.N. Medical College, Jodhpur, Rajasthan, India, E-mail: [email protected]
Objective: To investigate and test the feasibility of computed tomography (CT) based volumetric planning in Brachytherapy for cervix cancer patients so as to adapt to ICRU Report no.89 in a resource constrained institution. Materials and Methods: Carcinoma cervix IB2 - IVA (FIGO) patients with initial CT/MRI workup were treated with concurrent chemo-radiation (RT 50 Gy/25 Fr) followed by HDR intracavitary brachytherapy (22.5 Gy/3 Fr to Point A). 2D X-ray based standard plan, CT based standard plan and volume optimized plans were generated. The plans were compared for parameters as defined in ICRU report no. 38 and ICRU report no. 89. Results: 20 plans in 12 patients were evaluated for the study. The mean HRCTV was 47.33 (S.D ±8.83) cc, IRCTV 119.57 (S.D ±21.28) cc, HRCTV-D90 std 6.74 ± 0.62 Gy (per fraction), HRCTV-D100 std 4.5 ± 0.62 Gy, HRCTV - D90 optimized 7.67 ± 0.99, HRCTV-D100 optimized 4.9 ± 0.76. The doses received by OARs are as follows, B2cc std 5.02 ± 0.89 Gy, R2cc std 4.49 ± 0.79 Gy, B2cc optimized 5.32 ± 0.78 Gy and R2cc optimized 4.97 ± 0.65 Gy. Student t-test analysis revealed that the dose escalation achieved with HRCTV-D90 optimized was statistically significant (P = 0.001), without any statistically significant increase in doses received by bladder (P = 0.28) and sigmoid colon (P = 0.15). The estimated mean HRCTV-D90 TTD delivered was 78.2 Gyα/β10 and the projected mean TTD with volume optimization was 83.9 Gyα/β10. However, the rectal dose was found to be significantly increased in optimized plans (P = 0.03). Conclusions: CT based planning in brachytherapy for cervical cancer is feasible in resource constrained settings. It results in better understanding of doses delivered to OARs with the scope for dose escalation based on target volumes.
Avoidance of general anesthesia in high dose rate intracavitary brachytherapy without influencing dosimetry in carcinoma cervix
P. C. Bana, th A. K. Jain
Department of Radiotherapy, Rnt Medical College, Udaipur, Rajasthan, India, E-mail: [email protected]
Introduction: An observational study set out the comparision of dosimetric dose distribution in high dose rate intracavitary brachytherapy/radiotherapy (ICRT) in carcinoma cervix with general anaesthesia v/s conscious sedation. Materials and Methods: This study was conducted prospectively on 80 applications of ICRT in carcinoma cervix patients with stage IB2 to IIIB from October, 2015 to November 2015 at Radiotherapy Department, RNT Medical College, Udaipur. ICRT was done using Fletcher suit applicators and the machine named Eikert and Zeigler HDR remote after loaded brachytherapy unit with Co-60 radionuclide source. At point 'A' dose is prescribed 6 gray per session, and dose distribution were recorded at bladder reference point and rectum reference point. Patients were randomly divided into two groups AG and CS. Group AG: ICRT done in 40 applications under general anaesthesia. Group CS: ICRT done in 40 applications under concious sedation without anaesthesia. Results: The mean bladder dose in group AG ranges from 17.7-69.2% (1.07-4.14 Gy) and in Group CS from 15.54-74.24% (0.93-4.45 Gy). P value is 0.130 (insignificant). The mean rectum dose in group AG ranges from 32.5-17.73% (1.95-4.78 Gy) and in Group CS it ranges from 21.07-79.16% (1.26-4.75 Gy). P value is 0.126 (insignificant). Conclusion: The avoidance of general anesthesia for Intracavitary radiotherapy in case of carcinoma cervix can be done even without compromising the dosimetry.
Mucinous cystadenocarcinoma of ovary metastasizing to breast and incisional scar site: A very unusual presentation
S. Gupta, K. N. Pradeep , L. Pandey, A. Mudgal
Department of Radiotherapy, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, E-mail: [email protected]
Background: Primary ovarian carcinoma with metastasis to the breast is quite rare, ovarian metastasis to the breast presenting as inflammatory breast carcinoma is even more infrequent, with only 6 cases reported. In our case we have got metastasis to incisional scar site and to the left breast. Case: We are reporting a case of a patient who presented to us with a huge multi nodular fungating abdominal wall lump over the abdominal scar and another similar lump over the left breast on proper workup patient was found to be a follow up case of stage IIIC mucinous cystadenocarcinoma ovary for which she was operated approximately 12 year back. Histo pathology from both the lump revealed a high-grade adenocarcinoma. morphologically similar to the previously diagnosed ovarian cancer. In addition, to this CA-125 was also raised. CT scan abdomen showed soft tissue density in retro vesical pouch with a large lobulated intra abdominal mass. The patient died of diffuse metastasis 3 months after the diagnosis. Conclusion: Although ovarian metastasis to the breast presenting as inflammatory breast cancer is rare, it should be included in the differential diagnosis for any patient with a previous history of ovarian cancer. Ovarian metastasis to the breast and incision site confers a poor prognosis: patient survival ranged from 3 to 18 months, with a median survival of 6 months after the diagnosis of the breast and incision site metastasis.
Synchronous occurrence of uterine cervix and breast carcinoma: A case report with review of literature
M. S. Kang, A. K. Chauhan, P. Kumar, P. Kumar, Shubhi Agarwal
Department of Radiotherapy, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India, E-mail: [email protected]
Introduction: Multiple metachronous primary malignancies are increasingly frequent. Among gynaecological malignancies, carcinoma cervix is rarely associated with carcinoma breast. We present a rare case of synchronous uterine carcinoma and breast carcinoma. Case Report: Sixty-year female presented with right breast lump was 4 × 4 cm, in upper outer quadrant involving nipple and not involving skin stage T2N0M0 and ulceroproliferative growth in cervix extending to lower one-third vagina and left pelvic wall, FIGO stage IIIB. FNAC right breast lump revealed infiltrating ductal carcinoma and cervical biopsy as moderately differentiated squamous cell carcinoma. Breast carcinoma was managed outside our hospital by right modified radical mastectomy (pathological staging pT2N2aM0) with 6 cycles of adjuvant chemotherapy (taxane based; last on 20.08.15). Patient presented us again after 3 months and on 3T MRI whole body for metastatic screening disseminated metastatic disease involving the entire vertebral column, bilateral ribs, iliac bones and bilateral femur was seen. On per vaginum examination, ulceroproliferative growth was present over both cervical lips and all fornices were free and bilateral parametrium free. External beam radiation therapy was delivered to whole pelvis and post operative chest wall simultaneously along with bisphosphonates. Post treatment P/V/S examination revealed residual growth in cervix. Patient was planned for intracavitary brachytherapy but her general condition deteriorated. Patient had to be admitted in ICU due to sepsis. Eventually, patient died on 21.12.15. Conclusion: As the aetiological factors for carcinoma of the cervix and of the breast are altogether different and not related, their synchronous occurrence is a rarity.
Dosimetric comparison between SBRT versus interstitial brachytherapy in locally advanced carcinoma cervix patients
S. Dutta , S. Mitra, M. K. Sharma, I. Kaur, U. Saxena, P. Ahlawat, M. B. Mishra, S. Tandon, A. Mandal, M. Verma
Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India, E-mail: [email protected]
Purpose/Objective: External beam radiotherapy along with concurrent chemotherapy followed by brachytherapy has been the standard of care in locally advanced carcinoma cervix patients. The addition of brachytherapy serves to boost the gross disease and improves disease control and survival, with sparing of normal surrounding tissues. SBRT seems a probable substitute for brachytherapy in patients not deemed appropriate for brachytherapy. Its goal is to non-invasively mimic the dose distribution that can be achieved with HDR brachytherapy. Dosimetric studies have shown SBRT to provide good target coverage and doses to organs at risk similar to brachytherapy. In this study, we have dosimetrically compared brachytherapy and SBRT treatment plans in terms of HRCTV coverage, 2 cc bladder and 2 cc rectum doses. Materials and Methods: 8 patients diagnosed as a case of carcinoma cervix; were selected from the period of 2015 to 2016 who received EBRT by IMRT and for whom ICBT couldn't be done for various reasons. These patients were then taken up for Martinez Universal Perineal Interstitial Template (MUPIT) image based ISBT. A descriptive analysis was done for doses received by HRCTV, bladder, rectum and sigmoid colon and it was compared to dose received by the same volumes had the patient been treated with SBRT. Results: All the patients recruited were locally advanced with 2 patients in IIB, 1 patient in IIIA and 3 patients belonging to IIIB and 2 patient of vault carcinoma. The mean dose received by 95% High Risk CTV (HRCTV) by IMRT was 49.16 Gy. Out of 8 patients, 3 were taken up for ISBT due to anatomical restriction whereas remaining 5 patients were included because of lack of dose coverage by ICBT. The mean doses received by 90% of HRCTV, 2 cc bladder, 2 cc rectum and 2 cc sigmoid colon by MUPIT/SBRT were 20.33 Gy/21.34 Gy, 3.03 Gy/4.72 Gy, 2.9 Gy/3.83 Gy, and 2.63 Gy/1.58 Gy respectively. Conclusions: Our descriptive analysis of 8 patients being treated by image based ISBT have revealed that locally advanced cervical cancer patients for whom ICBT is unsuitable can achieve equitable LRC and OS with a combination of EBRT by IMRT and image based HDR-ISBT.
How much margins are required around involved pelvic nodes for planning simultaneous integrated boost in patients of cancer cervix undergoing pelvic radiotherapy? - An institutional study
Bhavana Rai , Raviteja Miriyala, Sushmita Ghoshal, Nagarjun Ballari, Veenu Singla
Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India, E-mail: [email protected]
Introduction: Intensity modulated radiotherapy with simultaneous integrated boost is the standard of care for external radiation in patients of cervical cancer with pelvic lymphdenopathy. Despite studies reporting significant movement of pelvic lymph nodes with respiration, expansion margins around the gross nodes have not been standardized. The aim of the study was to calculate the expansion margin around the gross nodal disease necessary to encompass internal motion and set up errors, during SIB in pelvic IMRT. Materials and Methods: 4D CT scans were obtained for 18 patients of cervical cancer having FDG avid pelvic lymph nodes, and gross nodal disease was contoured in each of the respiratory phases. An internal target volume (ITV) was generated by post processing, and compared with mid respiratory phase volumes. Difference in maximum diameter of both the volumes was used for estimating the internal motion. Expansion margin around the nodes was calculated by including set up errors, as per the departmental protocol. Results: A total of 28 lymph nodes were analyzed. An internal margin of 2.5 mm, 3 mm and 2 mm were required in supero-inferior, antero-posterior and lateral directions, to encompass respiratory motion in 95% of cases. No significant difference in motion was observed between the lymph nodes of various pelvic groups on ANOVA. Adding a setup margin of 5 mm according to departmental calculation, a total expansion of minimum 8 mm will be necessary around the grossly involved pelvic lymph nodes for simultaneous boost. Conclusions: Apart from the institution specific set up margins, an internal margin of 2.5 mm, 3 mm and 2 mm are required in supero-inferior, antero-posterior and lateral direction respectively to account for respiratory motion in grossly involved pelvic lymph nodes.
A dosimetric comparison between two different applicators for intracavitary brachytherapy in carcinoma cervix
Aparna Suryadevara , E. Vasundhara, Krishnam Raju Alluri, M. Vijay Kumar, Shabbir Ahamed
Department of Radiation Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India, E-mail: [email protected]
Materials and Methods: This is a single institute dosimetric comparison study done prospectively. Ten patients from our institute who were diagnosed with carcinoma cervix (ca cx) in June 2016 were included in the study. There were 5 patients with FIGO stage IIB and 5 with IIIB disease. All patients were planned to receive EBRT of 50 Gy at 2 Gy per fraction. They also received 3 fractions of ICR brachytherapy starting at 30 Gy of EBRT. Each patient received ICR by Ir192 HDR remote after loading technique by Fletcher's and Henschke applicator alternatively for first 2 ICR treatments. Third ICR was done with the applicator which gave a favorable dosimetry. Results: The results of 2D computer based planning done for the 2 applicators by ICRU reporting are shown below [Table 1]. Conclusions: There are differences between the 2 applicator types used. The doses to point-A and Point-B and OARs are lower for Fletcher's applicator. So Fletcher's applicator gives lower OAR doses, particularly for bladder without compromising the dose at Point A.
Prognostic significance of obstructive uropathy in locally advanced cervical carcinoma: IMPACT on morbidity and treatment outcome
Shina Goyal, Jeba Karunya Reddy, Saikat Das , Subhashini John
Department of Radiotherapy, Christian Medical College, Vellore, Tamil Nadu, India, E-mail: [email protected]
Objectives: A significant proportion of cervical cancer patients (14-44%) present with obstructive uropathy like hydroureteronephrosis (HUN). Aim of this study was to review the role of obstructive uropathy in terms of morbidity and mortality in locally advanced cervical carcinoma. Materials and Methods: Carcinoma cervix patients who presented with HUN were included in this study. Patient, tumor and treatment related factors were analyzed. The impact of urinary diversion on morbidity, mortality was assessed. Kaplan Meier and logistic regression were used for statistical analysis. Results: Total of 72 patients who had obstructive uropathy at initial presentation were included (mean age 50.4 years; IIIB 44 [61.1%], stage IVA 20 [27.8%] and IVB 8 [11.1%]); 57% had unilateral and 43% had bilateral HUN; mild (23.6%), moderate or severe (76.4%). Among these patients, 18 underwent unilateral or bilateral urinary diversion (PCN = 16, DJ stent = 2). 80% patients received radiotherapy with or without chemotherapy. Bilateral HUN, as compared to unilateral, was associated with a poorer survival (medial survival 13 vs 10 months, P = 0.087). The patients who received radiotherapy had a better outcome. Early intervention with urinary diversion was not associated with improved survival (medial survival 10 vs 11 months, P = 0.577). Severe pain and urinary tract infection occurred in 60% of patients who underwent urinary diversion and 50% patients had two or more visits to OPD or emergency for procedure associated complications. Conclusion: Patients with bilateral hydronephrosis had a poorer outcome. Urinary diversion did not improve overall survival but was associated with considerable morbidity and poorer quality of life.
Dosimetric comparison of point B and obturator lymph node dose in 3D planned high dose rate cervical cancer brachytherapy
D. L. Rahul , S. Mohan Kumar
Department of Radiotherapy, M.S. Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]
Introduction: Brachytherapy has been an integral component of cervical-cancer treatment for almost 100 years. Acoording to Manchester system Point B represents dose received by obturator lymph nodes. In this study we examine the relationship between point B dose and the dose delivered to the obturator lymph nodes by analyzing a series of HDR brachytherapy applications for cervical-cancer patients treated using CT-based treatment planning at our institute. Material and Methods: 20 Patients with FIGO Stage IIB cervical cancer post external beamradiotherapy received HDR applications using CT-based treatment planning. Obturator nodal group was contoured according to RTOG guidelines and D2cc calculated in the dose volume histogram. The point A and B were plotted according to ICRU38 recommendations in the digitally reconstructed radiograph and the dose at point b was calculated. The dose received was calculated for both left and right sides. Results: The D2cc for the obturator group of nodes ranged from 0.6 Gy to 1.1 Gy. The dose received by point B ranged from 1.6 Gy to 2.1 Gy. Conclusions: In this study the dose received by the obturator group is not correlating with point B hence further studies are required to compare clinical outcomes for patients with nodal disease.
High-dose-rate interstitial brachytherapy for previously untreated locally advanced cervical carcinoma
Vedamanasa Ikkurthi , S. D. Shamsundar, Aradhana Katke, R. Nanda, B. Thejaswini, G. V. Giri
Department of Radiotherapy, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India, E-mail: [email protected]
Objective: The purpose of this study was to determine locoregional control (LRC), disease-free survival (DFS), and toxicity of high-dose-rate interstitial brachytherapy (HDR-ISBT) in the treatment of locally advanced cervical cancer. Methods and Materials: Between January 2010 and December 2013, 74 patients with locally advanced carcinoma cervix (FIGO stage IIB to IVA) were treated with Intestitial brachytherapy boost after EBRT. The EBRT dose was 45 to 50 Gy in 25 fractions, and HDR ISBT 3 fractions with 6 to7 Gy per fraction. Results: The Median follow up was 37 months for the whole group. LRC was achieved in 59 (79.8%) patients. Three-year DFS and overall survival was 58% and 62% respectively. Acute and late toxicities were within acceptable limits. Conclusions: Locally advanced cervical cancer patients for whom intracavitary BT is unsuitable can achieve excellent LRC and OS with a combination of EBRT and HDR-ISBT with acceptable toxicity.
A comparison of radiation dose distribution among various OAR in a series of patients of carcinoma cervix
Department of Radiotherapy, Aditya Birla Memorial Hospital, Pune, Maharashtra, India, E-mail: [email protected]
Objective: To evaluate the radiation dose received by various normal structures in VMAT and IMRT plans. Materials and Methods: A total of 10 diagnosed patients of carcinoma cervix in a series, who were eligible, were planned for Radical Concurrent Chemoradiotherapy. Five (5/10) patients were planned for VMAT and five (5/10) patients were planned for IMRT. All the patients received treatment as per their respective plans. The DVH statistics for all plans were studied and interpreted. The normal structures that were studied were Anorectum, Urinary Bladder, Bowel and Right and Left femoral heads. The radiation dose received by these normal structure were compared against the Dose Volume Constraints defined by RTOG 0418. Results: The urinary bladder (35%) received mean dose of 3430 cGy in the VMAT technique and 3451 cGy in the IMRT technique. The Anorectum (60% of total volume) received a mean dose of 2919 cGy in the VMAT and 3150 cGy in the IMRT technique. Only 3.08% of the bowel in VMAT and 4.27% in IMRT received 4500 cGy. The right femur (15% of the total volume) received 2161 cGy in VMAT and 2071 cGy in IMRT, whereas the left femur (15% of the total volume) received 2240 cGy in VMAT and 2225 cGy in IMRT technique. Conclusion: VMAT appears to minimise the radiation dose to the most important adjacent normal structures, Urinary bladder, Anorectum and Bowel maximally, followed by IMRT and IGRT in locally advanced carcinoma cervix patients in our Set up. Further studies are needed to validate these results.
Clinical outcomes and dosimetric optimization in CT based interstitial brachytherapy using MUPIT in gynecological malignancy
Pareek Vibhay , Bhalavat Rajendra, Chandra Manish
Department of Radiotherapy, Jupiter Hospital, Eastern Express Highway, Thane West, Maharashtra, India, E-mail: [email protected]
Introduction: To evaluate the clinical outcomes and dose optimization using CT based planning in gynecological malignancy (Cervical and endometrial cancer) undergoing interstitial (MUPIT) brachytherapy . Materials and Methods: 30 patients histologically diagnosed endometrial or cervical malignancy and underwent hysterectomy who received external beam radiation followed by HDR interstitial brachytherapy with MUPIT. The clinical target volume and organs at risk were delineated and optimization done for optimum CTV coverage and sparing of organs at risk. The Coverage Index (CI), dose homogeneity index (DHI), overdose index (OI), dose non-uniformity ratio (DNR), external volume index (EI), conformity index (COIN) and dose volume parameters recommended by GEC-ESTRO were evaluated. The patients were followed up and toxicities were graded as per the RTOG scales and local control rates and disease free survival were evaluated . Results: The mean CTV volume and D90 and D100 were calculated. The OARs which included Bladder and rectum were assessed for the volume along with D2cc, D1cc and D0.1cc were assessed for bladder and rectum/recto-sigmoid. Mean CI, DHI, OI, DNR, EI, COIN were evaluated. The median follow up was assessed and as per the RTOG toxicity scale was used to evaluate the toxicities on follow up for the patients. The Local Control rate and Disease free survival were assessed for the same. Conclusions: CT based planning using MUPIT for gynecological brachytherapy implants has good outcomes as assessed in our study. Plan evaluation and documentation using various indices and parameters recommended by GEC-ESTRO assist in objective evaluation and reproducibility and correlate with clinical outcomes in the disease.
Validation of bone marrow sparing IMRT and comparison with standard IMRT in cervical cancer patients
Madhuri Kavikondala , Vijay Anand P. Reddy, Kausik Bhattacharya, Prashant Upadhyay, Nandita Seshakiren
Department of Radiotherapy, Apollo Cancer Hospital, Hyderabad, Telangana, India, E-mail: [email protected]
Introduction: To validate feasibility of BMS (bone marrow sparing)-IMRT in carcinoma cervix. To compare acute hematological, gastrointestinal (GI), genitourinary toxicities (GU) and Quality Of Life (QOL) parameters of BMS-IMRT with s (standard)-IMRT, along with its impact on chemotherapy compliance and total treatment time in patients receiving concurrent chemo radiation for carcinoma cervix. Materials and Methods: A prospective, open label study where 40 patients were randomized to two arms- s-IMRT (n = 20) and BMS-IMRT (n = 20) was conducted over a 2 year period. Pelvic bone marrow constraints prescribed in BMS-IMRT were BM V10<90% and BM V20<75%. RTOG acute hematological, GI and GU toxicity data was collected weekly and at first follow up. QOL data was collected at treatment commencement, week 5 and week 14. Study had a power of 80% with a one sided alpha error of 0.05. Comparison of data was done using student T test, ANOVA and Chi square test. Results: Bone marrow constraints were achieved in all patients in BMS-IMRT arm (V10 93.7% vs. 87.15%; V20 83.15% vs. 73.55%, P < 0.0001). End of treatment mean Hb was lower in BMS-IMRT arm (10.2 vs. 8.9, P = 0.01). GI (Grade 1.3 vs 1.1, P = 0.001) and GU (Grade 0.9 vs 0.8, P = 0.01) toxicity was more in BMS-IMRT arm. QOL parameters in BMS-IMRT arm were worse. There was no difference in chemotherapy compliance (4.6 vs 4.5 cycles, P = 0.6) and total treatment time (59 vs. 61 days, P = 0.3) between both arms. Conclusions: Pelvic bone marrow sparing is feasible using IMRT techniques. There is a statistically significant difference in Hb toxicity in favour of BMS-IMRT arm. There was a slight increase in GI, GU toxicity and worsening of QOL parameters in BMS-IMRT arm which did not impact treatment duration or compliance.
A comparative study between two dose fractionation schedules for hdr intracavitary brachytherapy in cases of carcinoma cervix stage II & III
Department of Radiotherapy, Acharya Tulsi Regional Cancer Treatment And Research Institute, Bikaner, Rajasthan, India,
E-mail: [email protected]
Introduction: EBRT has been recognized as an effective and safe treatment for carcinoma of the uterine cervix over the past few decades. Different dose schedules of brachytherapy adjuvant to EBRT have been tried and their efficacy tested in the form of response rate and complications. Materials and Methods: In this study 36 histologically proven cases of S.C.C. cervix FIGO stage II & III were first treated with EBRT (50 Gy/25 Fr/5 weeks) with weekly cisplatin. After completion they were assessed and 30 cases fulfilled the fitness criteria for HDRBT and were randoly assigned into two groups 7.5 Gy × 3 Fr & 6 Gy × 4 Fr. Total radiation treatment inclusive of EBRT and HDRBT was concluded in 8 weeks. Patients were closely followed for RT toxicity and disease response as per WHO criteria during and post treatment. Study is to be continued with enrollment of more patients. Results: The results of both the groups were comparable in terms of response with complete response in 28 patients and partial response in 1/15 patients in each arm. Toxicity reported in 7.5 Gy arm was 2 patients with cystitis, one with VVF and only one patient in 6 Gy arm developed proctitis. Conclusion: In conclusion both arms have equivocal response rate with better toxicity profile in 6 Gy/fr arm. To establish the results larger cohort and longer follow up is needed.
Role of brachytherapy in early endometrial cancer and assessment of quality of life
Pareek Vibhay , Bhalavat Rajendra, Chandra Manish
Department of Radiotherapy, Jupiter Hospital, Eastern Express Highway, Thane West, Maharashtra, India, E-mail: [email protected]
Introduction: To assess the role of Brachytherapy in the form of Central Vaginal Source (CVS) in Early Endometrial Cancer and its relation with the functional quality of patients following treatment. Materials and Methods: 20 Patients with Early Endometrial Cancer treated with External Beam irradiation followed by Brachytherapy (CVS) during November 2015 to April 2016 in our department were included in this study. The Patients were treated with 50 Gy in 25 fractions with external beam irradiation followed by Brachytherapy with central vaginal source with varying diameter (2 - 3.5 cm) and giving 12 - 14 Gy in two fractions one week apart. The patient's Quality of Life was assessed by using European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (QLQ C30) and Endometrial Cancer Module QLQ EN24. The questionnaire was taken at start of treatment and later before start of Brachytherapy and at end of Brachytherapy and the results were analyzed using appropriate statistical tests . Results: The patients showed better physical and role functioning in patients after the use of brachytherapy as compared to that after External beam irradiation alone. The symptom score, lymphedema, pain and diarrhea were also better after completion of Brachytherapy. Among the sexually active patients, the sexual function was not worsened after brachytherapy. The functional scores were better in patients with normal body mass index as compared to those with Obesity especially lymphedema was affected in such cases. Conclusions: The role of Brachytherapy is an important part of treatment of early endometrial cancers and does not affect quality of life especially the functional and sexual aspects as compared to outcomes after external beam irradiation. The BMI also affects the outcome in quality of life.
Prospective comparitive study of two chemotherapy regimens (cisplatin versus cisplatin and capecitabine) with concurrent radiotherapy in locally advanced cancer cervix
Niharika Bisht , Sharad Bhatnagar, S. Vishwanath, Arti Sarin, Sankalp Singh
Department of Radiotherapy, Command Hospital, Pune, Maharashtra, India, E-mail: [email protected]
Introduction: Continued identification of more effective chemotherapy agents used individually or in combination with concurrent radiotherapy is important for patients with cervical cancer. In our study we compare single agent cisplatin (Arm 1) versus double agents - cisplatin and capecitabine (Cisplatin and capecitabine) with concurrent radiotherapy in locally advanced cancer cervix. Materials and Methods: 40 women diagnosed with histologically proven locally advanced cervical cancer were serially assigned to different chemotherapy regimens i.e. cisplatin (Arm 1) versus cisplatin and capecitabine (Arm 2) along with concurrent external beam radiotherapy followed by brachytherapy. They were compared for total treatment time including treatment breaks, treatment related toxicities and tumor response at 3 months of follow up. Results: All patients were able to complete their treatment in both the arms. The mean treatment time of Arm 1 was around 62 days and in Arm 2 was 63.7 days. 2 patients (10%) in arnm 1 and 5 in arm 2 (25%) had treatment toxicity induced breaks. Equal number of patients in arm 1 and 2 i.e 8 out of 20 (40%) had haemotological grade II and III toxicities. 3 out of 20 (15%) in arm 1 and 6 out of 20 in arm 2 (35%) had treatment related proctitis. Response assesment done clinico radiologically at 3 months was suggestive of residual disease in 2 out of 20 patients in arm 1 (10%) and 3 out of 20 (15%) in arm 2. Conclusions: Capecitabine and cisplatin based chemotherapy is a fairly well tolerated regimen in the patients of locally advanced cancer cervix with comparable toxicity profile and local response rate.
Image guided interstitial brachytherapy for locally advanced disease after external beam radiotherapy in carcinoma cervix: Our institutional experience
S. Dutta , S. Mitra, M. K. Sharma, I. Kaur, U. Saxena, P. Ahlawat, S. Tandon, A. Mandal, M. Verma
Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India, E-mail: [email protected]
Purpose and Objective: Definitive chemo radiation is the standard of care for locally advanced cervical cancers. Intracavitary brachytherapy (ICBT) is an important part of definitive radiotherapy shown to improve overall survival. Interstitial brachytherapy (ISBT) as a part of definitive radiotherapy is generally reserved for patients with either extensive pelvic and/or vaginal residual disease after external beam radiotherapy (EBRT) or anatomy not allowing ICBT with standard applicators. This study demonstrates the dosimetric parameters and survival analysis for patients who underwent image guided HDR-ISBT at our institute. Materials and Methods: Eleven patients diagnosed as a case of carcinoma cervix were selected from the period of April 2012 to May 2016 who received EBRT by IMRT and for whom ICBT could not be done for various reasons. These patients were then taken up for Martinez Universal Perineal Interstitial Template (MUPIT) image based ISBT. The dosimetric parameters such as target coverage (HRCTV) and doses received by OARs (bladder, rectum & sigmoid colon) were analysed. Response evaluation done at 3 months of completion of ISBT, overall survival (OS) and disease free survival (DFS) was also calculated. Results: Of 11 patients recruited, 4 patients in IIB, 1 in IIIA and 4 in IIIB and 2 patients of vault carcinoma. The mean dose received by EBRT was 49.51 Gy. Of 11 patients, 4 were taken up for ISBT due to anatomical restriction whereas remaining 7 patients were included because of lack of dose coverage by ICBT. The mean doses received by 90% of HRCTV, 2 cc bladder, 2 cc rectum and 2 cc sigmoid colon were 20.32 Gy (SD 3.86 Gy), 3.09 Gy (SD 1.12 Gy), 3.30 Gy (SD 1.32 Gy) and 2.88 Gy (SD 0.90 Gy) respectively. The early response at 3 months was 57.14%. The DFS at 1 year and median DFS were 34.3% and 10.25 months (1.66 - 18.83) respectively. The OS at 1 year was 76.2% and median OS has not reached yet. Conclusions: Locally advanced cervical cancer patients for whom ICBT is unsuitable can achieve equitable LRC and OS with a combination of EBRT by IMRT and image based HDR-ISBT.
Clinical, applicator related and dosimetric factors affecting the late bowel and rectal toxicity in patients of carcinoma cervix treated with intracavitary brachytherapy
Kaushik Roy , Anis Bandyopadhyay, Poulami Basu, Sandip Ghosh, Sujana Biswas, Shyamal Sarkar
Department of Radiotherapy, Medical College, Kolkata, West Bengal, India, E-mail: [email protected]
Purpose: The aim of study is to compare the impact of different applicator parameters on dose volume histograms of vagina, rectum, bladder and sigmoid colon using image based 3D planning for intracavitary brachytherapy. Materials and Methods: Between 2011 and 2014, 98 patients with advanced carcinoma cervix (stage II B to IIIB) treated with CT - compatible HDR brachytherapy with postimplant pelvic CT. Four sets of patients with four types of applicators namely Manchester, Modified Fletcher, old Fletcher, and ring applicator were compared regarding various parameters and DVHs of rectum, bladder, sigmoid and vaginal point doses. To compare doses to OAR, 2cc volumes compared. Results: Mean dose 2cc rectum was least in modified Fletcher suit and maximum in Manchester applicator. The mean 2cc bladder dose was maximum in modified Fletcher suit applicator and least in ring applicator. Mean volume of 100% isodose (without optimization) was maximum for Fletcher suit and least for manchester applicator. Near significant association was between the length of intrauterine tandem and sigmoid colon 2cc dose. No significant association was found between angle of central tandem, separation of ovoid, use of rectal guard or vaginal packing with 2cc rectal dose. Conclusions: Though there is no significant difference among the dose volume parameters using different types of applicators, careful selection of the applicator type can optimize better in achieving better target coverage and reducing OAR dose.
Comparision of conventional point 'A' based planning and CT based image guided volumetric planning for intracavitary brachytherapy in cervical cancer: Target volume coverage, organs at risk doses and doses at various points - A single institutional study
Rajiv Lochan Jena , Anis Bandyopadhyay, Poulami Basu, Upasana Mukherjee, Praloy Basu, Arnab Adhikary, Arunima Gupta, Shyamal Kumar Sarkar
Department of Radiotherapy, Medical College, Kolkata, Kolkata, West Bengal, India, E-mail: [email protected]
Objective: Dosimetric analysis and comparision of HRCTV mean dose; D 90 (Dose received by 90% of HRCTV volume); D1cc and D2cc doses for both bladder and rectum; doses at Point A, Point B, Pelvic point and defined Vaginal points between conventional Point A based and CT based plannings in intracavitary brachytherapy in carcinoma cervix. Materials and Methods: Approved ICBT plans of 20 carcinoma cervix patients who had undergone intracavitary HDR brachytherpy in our institution were retrospectively reviewed. Two new plans were made for each patient. In one plan the 100% dose was prescribed to Point A, and in the other the 100% dose was prescribed to the HRCTV volume which was contoured according to CT based contouring guidelines given by ABS. The two new unoptimised plans were compared for the above mentioned parameters by using Wilcoxon signed ranks test for all doses and volumes. P value less than 0.05 were considered statistically significant. Results: The HRCTV mean dose and D 90 were significantly higher (1.45 times) with the CT based plan than with the Point A based plan. In the point A based plan, the HRCTV coverage with the 100% isodose volumes diminished with increasing tumour size and stage, leading to under treatment of the disease. Similarly, smaller disease volumes lead to over treatment in the Point A based plan. The average D2cc rectum and bladder doses were respectively 1.3 and 1.2 times greater in the CT based plan. The mean Point A, Point B, Pelvic point and defined vaginal point doses were respectively 1.44, 1.48, 1.37 and 1.39 times higher in the CT based plan in comparision to the Point A based plan. Conclusion: The CT based plan is superior to the conventional plan in target volume coverage with a minor increase in radiation doses to normal organs.
A comparative study of Nab-paclitaxel with cisplatin as concurrent chemotherapy & radiotherapy in management of carcinoma cervix
Varsha Mandloi , V. Yogi, O. P. Singh, A. Shrivastava
Department of Radiotherapy, Gandhi Medical College, Bhopal, Madhya Pradesh, India, E-mail: [email protected]
Introduction: This is a prospective comparison of response and toxicity of Cisplatin versus Nab - paclitaxel as a concurrent chemotherapy with standard External Beam Radiotherapy for locally advanced cervical cancer. Materials and Methods: Between July 2014 to July 2016, 120 women with FIGO stage II A - III B primary untreated squamous cell carcinoma of Cervix with KPSS >80 were enrolled, response was assessed according RECIST V1.1 Criteria and Univariate Analysis was done using Chi-Square Test. In this study the patients were selected based on our inclusion criteria and randomized to receive, on a weekly basis either Cisplatin 30 mg/m 2 (Group A; 60 patients) and Nab - paclitaxel 80 mg/ m 2 (group B; 60 patient) concurrently with External Beam Radiotherapy 46 Gy/23# after 3 cycle of Paclitaxel - Cisplatin based Induction Chemotherapy with standard premedication followed by 4 application of ICRT 6 Gy/# with minimum 6 month follow up. Results: 120 patients were evaluated. The mean age of presentation was 49 years; most of patients belong to Stage III B. In Group A gastrointestinal toxicity was 81% and Group B was 95%, Grade II toxicity was more common in Group B. One patients had Grade III toxicity in Group B. Haematological toxicity was more common in Group B. The response in Group A was 48.3% and in Group B is 68.3% with all manageable toxicities. Conclusion: The efficacy of Nab- paclitaxel as concurrent chemotherapy with all manageable toxicities is better than Cisplatin in Carcinoma Cervix.
Efficacy and effects - image guided intensity modulated radiotherapy in post-operative endometrial cancer patients: A prospective clinical study
S. Sowmiya , R. Agrawal 1 , S. Agarwal 1 , S. De 1
Department of Radiotherapy, Vadamalayan Integrated Cancer Centre, Madurai, Tamil Nadu, 1 Max-Pushpanjali Hospital, Vaishali, Ghaziabad, Delhi-NCR, Uttar Pradesh, India, E-mail: [email protected]
Background: Radiotherapy plays an important role in the adjuvant treatment of endometrial cancer patients. The post-hysterectomy patients are exposed to the potential side effects of both surgery and radiation. To minimize bowel and bladder toxicities image- guided intensity modulated radiotherapy (IG-IMRT) is being utilized for whole pelvic radiotherapy in such patients. Objectives : To analyze the overall survival, DSS and late effects in post-operative endometrial cancer patients receiving adjuvant whole pelvic image-guided intensity modulated radiotherapy (IG-IMRT). Methods and Materials: We performed a prospective study at our institute from January 2009 to September 2014 by enrolling all patients of endometrial cancer who had undergone surgery and they later received postoperative pelvic IG-IMRT (50.4 Gy) and intra-vaginal brachytherapy. All patients were analysed for any late bowel, bladder and rectal toxicities during follow up and graded as per RTOG/EORTC Late Radiation Morbidity Scoring Schema. All loco-regional and distant failures were also recorded. Results: A total of 43 patients were analysed, 40 patients (93%) had endometrioid adenocarcinomas, 2 patients (4.7%) had clear cell carcinoma. Median follow-up was 22 months (range, 1-79) and bowel toxicities were noted in 4.6% (grade II-1, grade IV-1), rectal toxicities were noted in 4.6% (grade I-1, grade III-1). 1 patient (2.3%) had grade I bladder toxicity. 2 year estimates of OS was 81% (Early stage I, II) and 33% (Advanced Stage III). 2 year estimates of disease specific Survival 88% and 44% respectively. Conclusion: Hence, the use of IG-IMRT in post-operative endometrial cancer patients was associated with significant decrease in the rate of gastro-intestinal toxicities without compromising disease control rates seen with conventional radiation treatment modalities.
Acute hematological toxicities and compliance in patients with carcinoma cervix and HIV treated with
Sachin Kotur, Durga P. Sahoo, Sougoumarane Dashanamurthy, Sivasankari Krishnan, Shivakumar Hiraganna, Imtiaz Ahmed
Department of Radiotherapy, KLE's Belgaum Cancer Hospital, Belgaum, India, E-mail: [email protected]
Objectives: To evaluate the acute haematological toxicities in patients with HIV and cancer cervix treated with chemoradiation. Materials and Methods: A total of 10 patients with HIV and cervical cancer who were treated with chemoradiation followed by brachytherapy were assessed for treatment toxicities and compliance. Pelvic EBRT was delivered with LINAC using 3DCRT to a dose of 50.4 Gy at 1.8 Gy per fraction over 5.5 weeks with weekly cisplatin 40 mg/m 2 . Brachytherapy was delivered after a planned gap of one week to a total of 3 HDR sessions weekly, at 7 Gy per session. Acute haematological toxicities were assessed by RTOG-EORTC acute toxicity grading. Results: Median age of presentation was 46.5 years. 8 patients had HIV before the diagnosis of cervical cancer. As per FIGO staging, 5 patients had stage IIB, 2 had IIIB and 3 had IVA. All patients received 50.4 Gy pelvic EBRT dose except 1 who discontinued treatment after 19 fractions and 7 patients completed planned 3 fractions of brachytherapy. Mean cisplatin cycles were 4 (range 2-5), mean cumulative dose was 200 mg (range 100-300); 70% received all 5 cycles. Overall treatment time was 62 days (range 33-82). Acute hematological toxicities are shown in Table 1. Grade 2 genitourinary, gastrointestinal and skin toxicities were seen in 4, 7 and 3 patients respectively; only 2 had grade 3 gastrointestinal toxicities and none had Grade 4 toxicities. All patients are alive and advised regular follow up. Conclusion: Chemoradiation in carcinoma cervix and HIV is well tolerated without any untoward toxicities.
Dosimetric comparison of volumetric modulated arc therapy and 3-dimensional conformal radiotherapy in locally advanced cervical cancers
A. Grawal, R. Hadi, M. Rastogi, K. Sahni, R. Khurana, S. Sapru, S. P. Mishra, A. K. Srivastava, Animesh Agrawal
Department of Radiotherapy, Dr. RML Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Introduction: Radiotherapy (RT) is the management of choice for locally advanced carcinoma cervix (LACC). It is typically delivered by 3D conformal techniques, but this leads to substantial acute and late morbidity. IMRT allows similar or better coverage of target volumes while protecting the organs at risk (OARs) through rapid dose fall off outside the PTV. Volumetric Modulated Arc Therapy (VMAT) is a form of IMRT that delivers treatment through arcs, but because of substantial internal organ motion IMRT is yet to gain widespread acceptance. Therefore we performed a dosimetric study to compare VMAT against 3DCRT. Objective: Dosimetric comparison of 3DCRT and VMAT plans with respect to PTV coverage and OAR doses. Materials and Methods: It was an observational study. After standard 3D-conformal pelvic RT (45-50 Gy in 1.8-2 Gy per fraction), VMAT plans were generated and comparison done in terms of PTV coverage, conformity and homogeneity indices (CI, HI); and OAR (bladder, rectum, abdominal cavity and b/l femora). Results: VMAT plans provided significantly better coverage of the PTV (higher D95, V95, D98; P < 0.0001, better HI; P < 0.0001 and CI; P = 0.003) than the 3DCRT plans. Doses to all OARs were significantly lower (Bladder, Rectum, Abdominal cavity V45; P < 0.0001, b/l femora V30; P < 0.0001) though constraints were achieved in only around half of all patients and low dose volume outside the PTV was higher. Conclusions: VMAT can adequately spare OARs while covering the PTV in a significant number of patients. Further work is warranted to determine the optimal treatment volumes.
Does addition of paclitaxel to cisplatin base chemoradiation improve outcome in carcinoma cervix IIIB: Long term results from a single institution?
P. Thakur , R. K. Seam 1 , M. K. Gupta 1 , M. Gupta 1
Department of Radiation Oncology, MMISER, Ambala, Haryana, 1 Department of Radiation Oncology, RCC, IGMC, Shimla, Himachal Pradesh, India, E-mail: [email protected]
Introduction: Despite the use of concurrent chemoradiotherapy (C-CRT) with Cisplatin in locally advanced carcinoma cervix, many patients continue to fail in the pelvis (20-25%) and at distant sites (10-20%). These relapses are more pronounced in stage IIIB patients. Cochrane Meta-analysis has also shown decreasing relative effect of C-CRT on survival with increasing tumor stage (3% in stage III). To improve upon these results various strategies have been studied, one of which is use of combination chemotherapy, which was tested in the present analysis. Materials and Methods: From 1/6/10 to 31/5/12, 70 Women with newly diagnosed, histopathologically proven squamous cell carcinoma cervix with FIGO stage IIIB were randomized to two arms, Cisplatin 40 mg/m 2 /week for 5 weeks was given in Cisplatin (C) arm while Cisplatin 30 mg/m 2 /week and Paclitaxel 50 mg/m 2 /week for 5 weeks were given in Cisplatin and Paclitaxel (CP) arm along with external beam radiotherapy (EBRT) followed by intracavitary brachytherapy. Acute toxicities were monitored by RTOG criteria. Overall survival (OS) and Disease-free survival (DFS) were compared at median follow up. Results: Median age was 52 years; median duration of treatment was 8weeks with a median follow up of 45 months. Hematological and cutaneous toxicities were comparable however grade III & IV Gastrointestinal toxicities were significantly more in CP arm 18 Vs 6 (P = 0.002). No statistically significant difference was found in DFS (52.9% Vs 47.2%) and OS (58.8% Vs 50%) between CP and C arm at median follow up. Conclusion: These long term results show no added benefit of addition of Paclitaxel to Cisplatin based C-CRT, although acute toxicities are increased which however are manageable.
Impact of various parameters on isodose coverage of Point A in cancer cervix brachytherapy
Department of Radiotherapy, Hope International Hospital, Kakinada, Andhra Pradesh, India, E-mail: [email protected]
Objective: To analyze the type of dose distribution in HDR intracavitary Brachytherapy in carcinoma cervix patients and the factors affecting it, particularly ovoid separation. Materials and Methods: Retrospective analysis of 29 cases of uterine cervix randomly chosen in past 12 months (July 2015-June 2016). Various parameters like ovoid separation, dose to bladder and rectum points as specified in ICRU-38 are recorded. Distance between bladder point and rectum point is noted in each ICRT. Isodose lines with maximum separation both in AP and Lateral directions are recorded. These parameters are analyzed statically. (Bi-variate analysis). Results: All the parameters recorded are co-related with the isodose coverage (AP, Lat) and the most significant parameter affecting the point A isodose distribution is inter-ovoid distance. The Lateral isodose coverage increases with increase in ovoid separation up to approx 30 mm, while the AP isodose coverage remains constant. Conclusion: The Lateral isodose coverage increases with increase in ovoid separation up to approx 30 mm, while the AP isodose coverage remains constant. This study needs more number of patients particularly with inter-ovoid distance more than 30 mm to measure the impact on isodose coverage.
Endometrial carcinoma with soft tissue metastases: A rare scenario
Anice Fathima , R. Sreekanth, Sreenivas, Prashanth
Department of Radiotherapy, Government General Hospital, Kakinada, Andhra Pradesh, India, E-mail: [email protected]
Introduction : Endometrial carcinoma with soft tissue metastasis is very rare. In view of the rarity of incidence with very few cases documented in literature, we hereby report a case of this rare pattern of dissemination. Case Summary: A 54 year old postmenopausal female presented with soft tissue nodules beneath the skin in subcutaneous plane in left para umbilical region without any associated symptoms in an already diagnosed and treated case of endometrial carcinoma (Endometrioid type) on regular followup of one and half years duration. Biopsy of the soft tissue nodule showed metastatic deposits of adenocarcinoma and metastatic workup did not reveal any other spread. Patient was planned for palliative chemotherapy. Discussion: The prevalence of muscular and soft tissue metastases in an endometrial carcinoma is 2-6%.  These manifest as enhancing nodules or masses in the abdominal wall along the laparotomy scar or at remote locations and confer poor outcomes. Conclusions: Atypical metastases like soft tissue dissemination from endometrial carcinoma (Endometrioid type) is very rare and not well known. This case emphasizes the need for proper examination and focused imaging to encounter this rare dissemination which will confer poor outcomes.
Key words: Endometrial carcinoma, endometrioid type, soft tissue metastasis
1. Sohaib SA, Houghton SL, Meroni R, Rockall AG, Blake P, Reznek RH. Recurrent endometrial cancer: patterns of recurrent disease and assessment of prognosis. Clin Radiol 2007;62:28-34.
Malignant pericardial effusion at initial presentation in a patient with metastatic carcinoma of the uterine cervix
G. K. Maheshwari , Ahmed Ragheb, Abraham Varghese, Dia Mohammad 1 , Henny Amanguno 2 , E. S. Hareram 3
Departments of Radiation Oncology, 1 Radiology, 2 Pathology and 3 Medical Physics, Kuwait Cancer Control Centre, Kuwait, E-mail: [email protected]
Introduction: Involvement of heart and pericardium is an extremely rare occurrence in a patient with gynecologic malignancies. Pericardial metastasis from cervical cancer is an extremely rare event. Till date, only a few such cases have been reported in the English Literature. In this case report a 26-year-old Afghan female patient with clear cell adenocarcinoma of the cervix was diagnosed to have malignant pericardial effusion at initial presentation. The patient was treated with palliative pelvic radiotherapy and pericardial effusion was managed with repeated peri-cardiocentesis and chemotherapy. A brief review of the literature on the management of this type of metastatic manifestation in patients with cancer is also presented in this presentation. Materials and Methods: A 26- year-old Afghan woman was referred to our institute in the month of November 2014, with complaints of post coital bleeding (2 months duration), shortness of breath and heaviness in chest. Her past medical history was insignificant. Clinically, she was afebrile, pulse rate was 84/minute and regular, Blood pressure 106/70 mm of mercury, heart sounds were faintly audible on auscultation, jugular venous pressure was slightly raised. Pelvic examination revealed a growth measuring about 4 × 4 cm in size at the cervix with involvement of upper half of vagina. Both parametria were infiltrated up to the lateral pelvic walls. The patient also found to have edema of the left upper limb and cervical adenopathy. X-ray chest showed enlarged cardiac silhouette. Her routine blood counts, urine examinations etc. were normal. Ultrasonography of the abdomen and pelvic region, CT scan of the neck, chest, abdomen and MRI of the pelvis were done. MRI revealed 6 × 4 × 4 cm size lesion at cervix with multiple pelvic and para-aortic and inguinal nodes. CT scan showed extensive lymphadenopathy in the neck, mediastinum, abdomen and pelvis and inguinal region with moderate pericardial effusion. Bilateral hydro-nephrosis also noted. Doppler's study of the left upper arm showed thrombus in the left internal jugular vein and left sub-clavian vein. Electrocardiogram (ECG) showed sinus tachycardia and low voltage QRS complex consistent with findings of pericardial effusion. Echocardiography confirmed pericardial effusion. Her Left ventricular ejection fraction (EF) was 55%. The cardiac markers were normal. Biopsy from the cervical lesion was reported as clear cell adenocarcinoma. The patient underwent therapeutic pericardiocentesis and fluid cytology was reported as metastatic carcinoma. The patient was treated with a short course of palliative external beam radiotherapy to pelvic region. She received 4 cycles of carboplatin and paclitaxel based chemotherapy and also underwent repeated pericardio-centesis. The patient died due to the progressive disease in April 2015. Results: This is one of the very rare presentation of cervical cancer manifesting as malignant pericardial effusion at initial diagnosis. Despite aggressive multimodality treatment, the prognosis in such presentation is grave. Conclusions: (1) Metastatic carcinoma of the cervix can present with malignant pericardial effusion or even with cardiac temponade. (2) Gynecologists, Gynecological oncologists and Radiation oncologists need to be familiar with the diagnosis and management of this disease process.
Key words: Cervical cancer, malignant pericardial effusion
Role of interstitial brachytherapy using template (mupit) in locally advanced carcinoma cervix: A single institutional experience
Abhishek Gulia , Anil Kumar Anand, Charu Garg, Anirudh Punnakal, Anil Kumar Bansal, Ashish Bhange, Ch. Kartikeshwar Patro,
Naveen Kumawat 1
Department of Radiation Oncology, Max Cancer Centre, Max Super Speciality Hospital, New Delhi, India, E-mail: [email protected]
Objective: To determine clinical outcome and complications (acute and chronic) in locally advanced carcinoma cervix cases, treated with EBRT ± concurrent chemotherapy followed by interstitial brachytherapy using MUPIT (Martinez Universal Perineal Interstitial Template). Materials and Methods: It is a retrospective analysis of 37 cases (stage IIB-2, IIIB-30, IVA-5), treated from December 2009 to June 2015. MUPIT was done with straight and divergent needles (median 26, range 19-29) to cover parametrium adequately. Target volume contouring was done followed by 3D-brachytherapy planning. Dose normalized to 5 mm box surface from outermost needles and dose optimization was done. Dose 25 Gy in 5#, delivered twice daily. Results: Median V100 was 36.1 cc (range 10.26-54.65cc), median V200 was 6.81cc (range 0.84-10.4cc), median D2cc dose to bladder - 60.5 Gy, rectum - 64.9 Gy, sigmoid - 55.1 Gy. With a median follow-up of 23 months local control was 73.3%, disease free survival was 62% and overall survival was 73.3%. Residual disease was seen in 7 patients and local recurrence in 3 patients. 11 patients had acute lower GI toxicity (Grade 1 [n = 8], Grade 2 [n = 3]), 7 patients had acute bladder toxicity (Grade 1 [n = 4], Grade 2 [n = 3]). 1 patient had grade 4 bladder toxicity. Chronic rectal toxicity was seen in 8 patients (Grade 3 [n = 7], Grade 4 [n = 1]). Conclusions: Excellent local control with acceptable complication rates can be achieved with Interstitial Brachytherapy in locally advanced carcinoma cervix cases. The achieved local control rate is superior to reported literature with intracavitory brachytherapy in similer cases. Interstitial Brachytherapy should be used in cases with lateral parametrial and lower vaginal wall involvement.
Does cervical adenocarcinoma carry worser prognosis than squamous variant in patients treated with definitive chemoradiation: A retrospective study
Avik Mandal , S. Mitra, M. K. Sharma, P. Ahlawat, I. Kaur, R. Khurana, M. Verma, S. Dutta
Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India, E-mail: [email protected]
Introduction: Squamous cell variant is predominant in cervical cancer but the relative and absolute incidence of adenocarcinoma has been risen in recent years. This study aims to evaluate direct comparison of survival outcomes and response between locally advanced cervical adenocarcinoma and squamous cell carcinoma patients treated with definitive chemoradiation. Materials and Methods: Seventy three patients diagnosed as a case of carcinoma cervix were selected from the period of January 2011 to December 2015 who received definitive chemoradiation. Sixty one had squamous carcinoma histology. Twelve had adenocarcinoma variant. It is a retrospective analysis and direct comparison between two histological variants was done. Response evaluation was done at 3 months of completion of treatment. Endpoints for the study were progression rate, progression free survival, recurrence free survival, locoregional control, Distant metastasis free survival, and overall survival. Results: Median follow up for surviving patients is 18.06 months. No significant difference is noted between the two histology groups with respect to rate of achieving complete response (78.6 vs 75%, P = 0.718) and rate of disease progression (36% vs 50%, P = 0.517). Conclusions: Locally advanced squamous cell carcinoma and adenocarcinoma treated with definitive chemoradiation have similar outcomes in response and survival. Small sample size is the limitation of this study. Further research in a randomized controlled trial setting is needed.
Image guided brachytherapy in cervical cancer: A dosimetric comparison between intracavitary, interstitial and combined interstitial intracavitary approach
Bhaskar Vishwanathan, Rishabh Kumar , Venugopal, Shreeya Pabi, Geeta S. Narayanan, Bhanumathy
Department of Radiotherapy, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India, E-mail: [email protected]
Introduction: Brachytherapy in cervical cancer plays a crucial role in improving the treatment outcome by optimizing the dose to the tumor volume. IC gives a better dose to the central uterine disease. IS approach has a dosimetric advantage over IC in gross, bulky and large parametrial disease By combining these approaches we aim to investigate whether an added dosimetric advantage exists with ISICBT when compared with IS and IC approaches individually. Materials and Methods: 65 patients were enrolled in this study in whom 25 ICBTs, 25ISBTs and 15 ISICBTs were performed using syed-neblett applicator. Whenever interstitial needles were used a CT was done for contouring and planning and for ICBT MRI was done. Dose of 7 gy was given for the 1 st fraction and evaluated. Results: HRCTV D90 for ISBT, ICBT and ISCBT were 688.4, 723.2 and 798.5 cGy respectively with dose to bladder 2cc 493, 462 and 409 respectively, dose to rectum 2cc being 481, 306 and 293 cGy. In the subset analysis of ISBT plans it was found that excessive anterversion of uterus resulted in a poor coverage when compared to a non anterverted uterus. Conclusions: ISICBT gives a better coverage to HRCTV in terms of both D90 and D100 without exceeding dose to the OARs when compared with ISBT and ICBT even when the mean HRCTV volume was higher. This is probably due to the higher conformity achieved when individual needles are placed in the parametrium along with the tandem in the uterine cavity, with uterine tandem providing a high central dose and the interstitial needle covering the disease in the parametrium without increasing dose to the OAR.
Initial institutional experience of computed tomography-based image-guided brachytherapy for cancer cervix using the tandem-ovoid applicator
Pushpendra H. Hirapara , Arvind Kumar Patidar, Ranjana Agrawal, Neha Patel, Meena Shah, Sanjay Nandeshwar
Sh. D B Tejani Cancer Institute Managed by Lions Cancer Detection Centre Trust, Surat, Gujarat, India, E-mail: [email protected]
Objectives: We evaluate institutional outcome of chemoradiotherapy for cervical cancer with CT based image-guided HDR brachytherapy (CT-IGABT). Materials and Methods: Patients who were treated (May 2014-December 2014) with initial EBRT (50 Gy/25 fractions ± chemo) followed by CT-IGABT (22.5 Gy/3 Fr to point A) were studied for dosimetric parameters and Clinical outcomes (Locoregional Control [LRC], Progression free survival [PFS], Overall survival [OS] & serious late toxicities). Results: Total 37 patients with median age 55 years (30-75) were treated. Almost 2/3 rd (24/37) diagnosed in advanced stage & tumor ≥4cm (median 4.3 cm, 2.6-7.9) in 70.8% (26/37) while 45.8% (17/37) patients had involved pelvic nodes. Median overall treatment time (OTT) was 78 days (57-111) with median gap of 2 weeks (1-8) between EBRT & BT. Median CT-CTV was 65cc (39-99). Median cumulative EQD2 to point A was 78 Gy (60-97). Median D90 for the CT-CTV were 81 Gy (70-91 Gy), and ≥83 Gy in 45.9%. Median V100 for CT-CTV was 85.7% (60-94%) The D2cc for the bladder, rectum and sigmoid was 88 ± 6, 76 ± 5, 62 ± 8 Gy. Modifications in dose/standard loading were needed to reduce dose to OAR/improve tumor dose in 91.8% (34/37) patients. At a median follow-up of 24 month (5-28), 2 year LRC, PFS & OS were 82%, 84.5% & 91.5% resepectively. The overall actuarial risk of grade 3 late rectal morbidity and vaginal fibrosis were 10.5% and 24% respectively. Conclusions: Standard loading pattern of ICBT may not be applicable to all patients and CT based dose adaptation might be required. Further improvement of clinical outcomes at our institute might be possible by reducing OTT and using interstitial needles in patients with larger tumor size and reduction in dose to OAR.
Sexual function in cervical cancer survivours after radiotherapy
Dhiraj Daga , Rohitashwa Dana, Pradeep Gaur, R. K. Spartacus
Department of Radiotherapy, RUHS College of Medical Sciences, Jaipur, Rajasthan, India, E-mail [email protected]
Introduction: To access sexual function in cervical cancer survivors after radiotherapy. Materials and Methods: Cervical cancer survivors, who had completed RT at least one year back at Dr. S. N. Medical College, Jodhpur were enrolled in the study. Female Sexual Functioning Index (FSFI) questionnaire were used to access the sexual function, the cut off point score of the FSFI to identify female sexual arousal disorder (FSAD) is 26.55; a score less then 26.55 is indicative of FSAD. Results: Total 48 cervical cancer survivors were included in the study. The median age was 46.5 Yrs. All had received chemoradiotherapy along with intracavitary brachytherapy during their treatment with average time of completing. The average score for sexual desire was 2, 2.3 for arousal, 2.3 for sexual satisfaction and 2.1 for pain during intercourse, overall average score of 11.84, range 19.5 - 3.2, suggestive of FSAD in all the cervical cancer survivors. Conclusions: Cervical Cancer survivors have declined sexual function, indicative of FSAD in them. Educating patients and actively treating complications related to cancer treatments is must to improve the sexual function among the survivors.
Steroid cell tumour of ovary: A case report
Department of Radiotherapy, Government Medical College,Trivandrum, Kerala, India, E-mail: [email protected]
Background: Ovarian steroidal cell tumours, not otherwise specified (NOS), are rare sex cord stromal tumours of the ovary with malignant potential, accounting for less than 0.1% of all the ovarian tumours. They are divided into three subtypes: Stromal leuteoma arising from ovarian stroma, leydig cell tumour arising from leydig cells in hilus, steroid cell tumour not otherwise specified, when the lineage of tumour is unknown. The last type accounts for approximately 60% of the steroid cell tumours,25-45% of which are clinically malignant. Case Report: 65 year old post menopausal lady, P3L3, with no co-morbidities, treated radically with surgery followed by systemic chemotherapy and radiotherapy in 2012 for carcinoma left breast, presented with abdominal swelling and bloating for 4 months duration. Physical examination revealed features of virilisation with frontal baldness, male hair pattern and an abdominal swelling of size 3 × 3 cm just above the umbilicus. CECT abdomen and pelvis revealed bulky right ovary measuring 4.4 × 3.1 cm with diffuse heterogenous enhancement, mesenteric and peritoneal deposits, omental caking, moderate ascites suggesting the possibility of right ovarian neoplasm. Asicitic fluid cytology was negative for no malignant cells. She underwent staging laprotomy with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Histopathology was reported as uterus with atrophic endometrium, adenomyosis and leiomyomata; cervix-CIN II changes; right ovary: steroid cell tumour (NOS): Tumour size-5 × 2.5 × 1 cm; left ovary-normal; omentum shows congested vessels. A final diagnosis of ovarian steroid cell tumour (NOS)-Stage IA was made. Since the histological characteristics did not meet the criteria highly associated with malignancy, the patient is being kept on follow up. Discussion: The main stay of treatment is surgery. For women who have completed child bearing, total abdominal hysterectomy with bilateral oohorectomy and complete surgical staging is indicated. Adjuvant chemotherapy is only indicated in high risk cases.
A review of literature exploring ovarian germ cell tumors
Department of Radiotherapy, Post Graduate Institute of Medical Sciences, Rohtak, India, E-mail: [email protected]
Objective: Ovarian germ cell tumors (OGCTs) are rare tumors with incidence 3.6% globally. They are diagnosed at a median age of 16-20 years. Over the past three decades, significant progress has been achieved in their treatment. Materials and Methods: The WHO classification of OGCTs includes dysgerminoma, yolk sac tumor, embroyonal carcinoma, polyembryoma, nongestational choriocarcinoma, immature teratoma and mixed OGCTs. Clinical features may vary from vague abdominal pain to ascitis. Physical examination, sonography and serum markers including β-HCG, LDH and AFP assist in making the diagnosis. FIGO staging of ovarian cancer is used for staging of epithelial ovarian cancer. Published recommendations for an appropriate staging procedure for ovarian GCTs include peritoneal washings for cytology, a unilateral salpingo-oophorectomy, and biopsies of the omentum, contralateral ovary and locoregional lymph nodes. Except stage I dysgerminoma or low-grade immature teratoma, in all other OGCTs independent of stage, chemotherapy is recommended after surgery. Typically 3-4 cycles of 3-weekly BEP are given every 21-days. It has been reported in the literature that healthy pregnancies after chemotherapy for MOGCT. Results and Conclusion: Patients who have no evidence of disease after surgical staging followed by three cycles of a BEP regimen can expect a 96-100% PFS with acceptable toxicity profile.
A case of basaloid squamous cell carcinoma of the cervix with review of literature
Rishabh Kumar , Geeta S. Narayanan
Department of Radiotherapy, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India, E-mail: [email protected]
Introduction: Basaloid squamous cell carcinoma (BSCC) of the uterine cervix is a rare malignancy of the female genital tract with a poorer clinical outcome than SCC of the uterine cervix. We report a case of BSCC of the uterine cervix developing rapidly in an adult Indian. A 42-year-old woman, visited the emergency room with severe dizziness, palpitations and sudden excessive vaginal bleeding with hemoglobin of 3.0 g/dl. She had been well and healthy but intermittent vaginal bleeding developed for around 6 months back which progressed to severe bleeding 2 weeks back. On examination, she had an ulcerated and necrotic lesion of 5 cm of the cervix. A cervical biopsy revealed typical BSCC. With MRI and clinical examination she was staged as IVA with rectum, sigmoid colon, ovary and uterine fundus involvement. She was planned for chemoradiation followed by brachytherapy but didn't respond well to treatment as she developed repeated hemorrhagic ascites which was positive for malignant cells during the course of treatment. Only EBRT and chemo were given bust sadly the patient died 3 months after completion of EBRT. Materials and Methods : Pub med search revealed a total of 5 cases reported with only one from India, we are reporting the 1 st case from India with a clinical outcome. Results: Review of literature will be presented along with the detailed case report. Conclusions: BSCC is an aggressive tumor with poor prognosis and it is Essential to document the treatment response of this rare histology of cervical cancer.
Patterns of distant failure in carcinoma cervix: An Regional Cancer Centre Experience
Meher Papuji , Padhi Sanjukta, B. R. Routroy, L. Pattanayak, N. Panda
Department of Radiation Oncology, A.H. Regional Cancer Centre, Cuttack, Odisha, India, E-mail: [email protected]
Background: Cervical cancer is the most common malignancy among Indian females and is the leading cause of death. However, patients with locally advanced cervical cancer after concurrent chemoradiation distant failure occurs in many cases. Aim: To study the age distribution, clinical profile, sites, patterns, & duration of development distant failure in carcinoma cervix after completion of primary treatment. Materials: Retrospective study from the treatment records of patients of carcinoma cervix undergoing treatment at AHRCC. From January 2010 to June 2016, 91 patients of metastatic carcinoma cervix were selected & analysed retrospectively. Results: Majority of patients were from 5 th and 6 th decade followed by 7 th decade. Majority of them were in stage IIIB followed by stage II. Squamous cell histology was the most common entity. Majority presented with non-regional nodal metastases out of which para-aortic lymph node metastases. Following nodal metastases lungs was the second most site. Liver, bone and brain metastases were seen. Most of the patients presented with metastasis within a period of 2 years from initial treatment time. Conclusion: Distant failure in carcinoma cervix depends upon the initial stage, age of presentation and histological findings. Though cervical carcinoma frequently spreads to the para-aortic nodes, lungs, liver and other uncommon sites are also reported. It necessitates a stringent follow up during period of first two years.
Assessment of three-dimensional set-up errors in image guided pelvic radiotherapy for uterine and cervical cancer using kilo voltage cone beam computed tomography and its effect on PTV margins
Nidhi Patni, Nagarjuna Burela , Jaishree Goyal, Tej Prakash Soni, T. Senthil Kumar, T. Natrajan
Department of Radiotherapy, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India, E-mail: [email protected]
Introduction: To achieve the best possible therapeutic ratio using high precision techniques (IGRT/VMAT) of external beam radiation therapy in cases of carcinoma cervix using kilo voltage cone beam computed tomography (kV CBCT). Materials and Methods: One hundred and five patients of gynecological malignancies who were treated with image guided radiation therapy (IGRT/VMAT) were included in the study. CBCT was done once a week for IMRT and daily in IGRT/VMAT. These images were registered with the planning CT scan images and translational errors were applied and recorded. In all 2,078 CBCT images were studied. The margins of PTV were calculated from the variations in the set up. Results: The set up variation was 5.8 mm, 10.3 mm & 5.6 mm in anteroposterior, superoinferior and mediolateral direction. This allowed adequate dose delivery to the clinical target volume and the sparing of organ at risks. Systemic error (SE) of population (Σpop) was found out by calculation of arithmetic mean of SE of individual patient (Σind ) while Random error of population was calculated as standard deviation of random error of individual patient (σind ). All statistical calculations were done by using Med Calc Version 18.104.22.168 software. Conclusions: Daily kV CBCT is a satisfactory method of accurate patient positioning in treating gynecological cancers with high precision techniques. This resulted in avoiding geographic miss.
Adenoid cystic carcinoma of Bartholin gland - A rare presentation: Case report
L. Pavan Kumar , Spandana 1 , Megha Uppin 2 , Fayaz Ahmed 3
Department of Radiation Oncology, Yashoda Hospital, 1 Department of Radiation Oncology, MNJIO&RCC, Departments of 2 Pathology and 3 Radiation Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India, E-mail: [email protected]
Introduction: Primary carcinoma of Bartholin gland, documented first by Klob in 1864. It is a rare malignant tumor comprising 0.001% of all female genital tract malignancies and 2-7% of all vulvar carcinomas. Materials and Methods: Case details - A 50 yr old female patient P3L3 postmenopausal presented with complaints of painless swelling over external genitalia on right side. On examination 3/3 nodular swelling over right labia majora located on inner surface and at the middle of the right labia majora. It was misdiagnosed initially as bartholin's abcess and excision was done. Histopathology - Post operative histology showed columnar cells along with lesion comprised of cells arranged in tubules, cribriform pattern, acinar pattern. There was myxoid basement membrane like material in cystic spaces between the cells. The cells were cuboidal with moderate amount of eosinophilic cytoplasm, round to oval vesicular nuclei with inconspicuous nucleoli, also seen are fragments of skeletal muscle. Immuno Histo Chemistry showed CD 117 positivity in lesional cells, Ki67 -14%. Results: Radiotherapy - in view of inadequate surgical resection post operative EBRT by 3D-CRT 2 Gy/fr 25 fractions to pelvis followed by 2 Gy in 5 fractions local boost was given treatment completed 6 months back now she is on follow up and doing well. Conclusions: Adenoid cystic carcinoma is a rare carcinoma of the vulva. This lesion is often overlooked as a benign process. So, the possibility of cancer should be considered in any women older than 40 years of age with a mass near the Bartholin's glands. Often multimodality therapy may be a advocated for effective management.
Ultrasound based intracavitary brachytherapy planning with MRI validation in carcinoma cervix
Department of Radiotherapy, Regional Cancer Centre, Trivandrum, Kerala, India, E-mail: [email protected]
Background: Brachytherapy is pivotal to curative treatment of carcinoma cervix. MR Image guided adaptive brachytherapy has emerged as the modality of choice for gynaecologic brachytherapy. Aim of the Study: To assess the feasibility of Ultrasound image based dose optimization for gynaecologic brachytherapy by comparing the resultant DVH parameters against that from MR Image based plans generated as per GEC-ESTRO recommendations. Materials and Methods: 20 patients with carcinoma cervix treated with EBRT and concurrent weekly Cisplatin were included in this study. For Ultrasound plan generation, the measurements of uterus and cervix were made on mid sagittal ultrasound image acquired after applicator placement. Dose optimization points were generated on the MR image set using measurements made on ultrasound image and dose optimization attempted to cover these dose points. MR image based plans were generated for all patients as per the GEC- ESTRO guidelines. The DVH parameters from both USS based and MR plans were compared using repeated measure ANOVA test. Results: Dose sculpting based on mid-sagittal ultrasound image information resulted in reduced doses to OARs without compromising on the target volume (GEC-ESTRO) coverage. The ultrasound generated plan faired similar to MR plans with respect to the HR-CTV (P = 0.3), bladder and rectal doses (P = 0.4). Conclusion: This study affirms the feasibility of using Ultrasound imaging for brachytherapy treatment planning in a centre with high patient load and limited access to MRI. Brachytherapy linked to ultrasound, as a commonly available low cost technology, holds promise of improvement over routinely practiced X-ray based treatments.
Impact of residual or recurrent disease on the outcome of postoperative cancer cervix patients
K. Srivastava , A. Batra, A. Singh, A. R. Kulshrestha, D. Tiwari, S. Singh, R. Kumar, M. L. B. Bhatt
Department. of Radiotherapy, King Georges Medical University, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Introduction: Cancer cervix is a major healthcare problem especially in developing countries. In India, 122,844 women are diagnosed and 67,477 die due to cervical cancer annually. Surgery can be done upto stage II A in carcinoma cervix, however adjuvant radiotherapy is needed in high risk patients. Materials and Methods: This is a retrospective cohort study of the patients registered as post-hysterectomy cancer cervix patients in the department of Radiotherapy at a tertiary care hospital between January 2012 and December 2013. All patients underwent External beam radiotherapy with or without concurrent cisplatin followed by intravaginal bachytherapy. We assessed various outcomes after completion of treatment. Results: Total 138 (28%) patients registered as postoperative cases amongst all cancer cervix patients. Of these 58 (42%) underwent complete treatment and were further analysed. Out of these 26 (46%) had residual or recurrent disease at vaginal vault initially. 7% patients were lost to follow-up, remaining patients available with the treatment outcome were divided into two groups. Group I patients (73%) remained without disease at the time of analysis whereas patients in group II (27%) had some or the other adverse event in the form of local or regional recurrence, distant metastasis. Various known prognostic factors were analysed to see their effect on the outcome. Conclusions: Adjuvant CRT after hysterectomy has improved local control & overall survival in patients with high-risk cervical cancer. Post-operative status (residual/recurrence) before CRT, LVSI & OTT had negatively impacted the outcome which is statistically significant (P value < 0.005).
Analysis of role of interstitial brachytherapy using template in locally advanced gynaecological malignancies: A retrospective study from single institution
Swarna K. Chatharaju , Krishnam Raju Alluri 1 Tasneem lilamwala 2
Department of Radiotherapy, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India, E-mail: [email protected]
Introduction: The aim of this retrospective study was to assess the treatment outcomes in patients with locally advanced gynaecological malignancies treated with interstitial brachytherapy using Syed Neblett template to study local control, overall survival complications of the treatment. Materials and Methods: 71 patients with HPE confirmation of SCC of cervix (56) vault (9) vagina (6) were treated by EBRT to the pelvis 50 Gy/25 fractions followed by interstitial brachytherapy using Syed Neblett applicator between July 2010 to May 2016. Median age was 51 yrs. Only those patients who were unsuitable for intracavitary application were treated by template. The dose delivered was 1500 to 2100 cGy treated in 3 fractions with a minimum gap of 6 hrs between fractions. Results: Among the 71 patients, 5 patients were lost to follow up and excluded from the study. The follow up duration was 2 months to 71 months. Median follow up was 20 months. Parameters studied were local control, acute and late sequelae and distant metastasis. Local control was achieved in 54/66 (81.81%), local recurrence was seen in 12/66 (18.18%) patients. Out of 10 patients who developed distant metastasis, 8 patients were locally controlled and 2 had local recurrence. Late sequelae mainly vaginal stenosis was observed in 61/66 (92%). Local control was better with non bulky tumors and in patients with good regression of the disease after EBRT. Conclusions: Interstitial template brachytherapy using Syed Neblett applicator is a good alternative to deliver high dose radiation to patients with locally advanced gynaecological malignancies in whom it is unlikely to get proper dose distribution with intracavitary radiation. Loco regional control achieved was definitely better than EBRT alone with acceptable complications.
A comparison of the hematological toxicities of concurrent chemo-radiation vs. radiotherapy alone in patients of locally advanced cervical carcinoma: A prospective study from eastern india
Sourav Sinha , Rudrajit Paul 1 , Swapan Kumar Mallick, Md. Asifullah, Indranil Khan, Amitava Manna, Shyamal Kumar Sarkar
Departments of Radiotherapy and 1 Internal Medicine, Medical College, Kolkata, West Bengal, India, E-mail: [email protected]
Background: Cervical carcinoma is now ranked as the commonest malignancy in females in India. In the locally invasive types, both concurrent chemo-radiation and radiotherapy alone are advocated as valid options. However, there is no definite comparative study involving haematological toxicity profile of the two treatment modalities among Indian patients till date. Materials and Methods: Our study area was a tertiary care centre of Eastern India. Female patients aged less than 70 years with locally advanced cervical carcinoma were included. We avoided older patients to nullify the effect of senile bone marrow changes and other comorbidities. They were allocated into 2 groups: those with concurrent chemo-radiation (CCRT) and those with radiotherapy (RT) alone. Blood for analysis was collected before starting treatment, then every weekly during therapy and again at two month after treatment completion. Those who required treatment discontinuation due to acute haematological toxicity were documented separately. SPSS was used for statistical analysis. Our sample size was 58 patients: 26 in CCRT and 32 in RT. Mean age of the patients were 59 ± 12 years. Results: We found anaemia in 50 (86.2%) patients, leukopenia in 44 (76%) and thrombocytopenia in 48 (82.7%) patients. Pancytopenia was present in 37 (63.8%) patients. In CCRT arm, anemia was found in 25 cases (96%) as opposed to 78% in the RT arm. Pancytopenia was found in 18 cases in RT and 19 cases in CCRT arm. Discussion and Conclusion: Our study shows that haematological toxicities are comparable in CCRT and RT arms. However, a bigger study is warranted for further clarification.
A study on prognostic outcome in cancer cervix patients treated with external beam radiotherapy followed by intracavitary radiotherapy & external beam radiotherapy interdigitated with intracavitary radiotherapy: A prospective study
Khushboo Rastogi , Vandana Jain, Bhushan Nikam, Siddharth Nagshet, Darshana Kawale
Department of Radiotherapy and Oncology, Rural Medical College, Pravara Institute of Medical Sciences, Rahata, Maharashtra, India, E-mail: [email protected]
Introduction: Cancer cervix is the third most common malignancy worldwide and the leading cause of cancer related deaths in women in developing countries. The growing risk of cervical cancer in women in India is 2.4% compared to 1.3% for the world. The single most important cause of cancer is Human Papilloma virus. Other risk factors include smoking, early age of first intercourse, multiple sexual partners STDs etc. Radiotherapy is the standard treatment of choice in stages IB2 to IVA of carcinoma cervix, with combination of external beam radiotherapy (EBRT) and intracavitary radiotherapy (ICRT). Objectives:Objectives: The objective of this study is to assess the overall treatment time, acute and late side effects, local control and disease free survival between the two treatment modalities. Materials and Methods: 100 patients with histopathologically proven carcinoma cervix, satisfying the inclusion criteria were enrolled in this study. After complete workup the selected patients were randomly given either of the two modalities of treatment, i.e, EBRT with concurrent weekly chemotherapy with inj. Cisplatin followed by ICRT or EBRT with concurrent weekly inj. Cisplatin interdigitated with ICRT. First follow up was after 6 weeks of treatment completion and then every 3 months (for a period of 6-18 months) and patients were assessed for treatment toxicity and response. Results: The final results are under compilation and will be presented at the time of conference. Conclusion: EBRT Interdigitated with ICRT has higher tumor control and lesser overall treatment time (OTT) and is a safe and effective treatment for patients with cancer cervix.
A prospective study of dosimetric evaluation comparing single channel versus multichannel vaginal applicator in post operative endometrial cancer patients undergoing high dose rate vaginal cuff intracavitary brachytherapy
Moumita Maity , Chandan Dasgupta, Krishnangshu Bhanja Choudhury, Kousik Ghosh, Santu Chandra, Subir Gangopadhyay
Department of Radiotherapy, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India, E-mail: [email protected]
Introduction: Comparison of DVH, dose distributions, response rates and bladder & rectal toxicities to vaginal vault and organs at risk (OARs) between multichannel vaginal applicator (Portio) and single channel vaginal Cylinder applicator in HDR Co60 brachytherapy for postoperative endometrial carcinoma. Materials and Methods: In this single institutional, prospective randomized controlled study, 52 patients with stage IA G3, stage IG 1, 2 LVSI positive were randomly assigned to adjuvant intracavitary vaginal cuff brachytherapy using single channel vaginal applicator or multichannel vaginal applicator. Results: Brachytherapy dose per fraction 7.23 ± 0.831 Gy. Pelvic EBRT was given in 12 patients in Portio vs 16 in Cylinder arm. IRCTV D90 EQD2 in Portio (n = 27) and Cylinder (n = 25) arms were 57.35 ± 17.53 Gy vs 55.47 ± 20.82 Gy (P = 0.725). Bladder D2cc EQD2 (53.19 ± 21.37 Gy vs 56.22 ± 21.04 Gy P = 0.609), Rectum D2cc EQD2 (45.77 ± 22.67 Gy vs 56.48 ± 20.32 Gy, P = 0.080) and Sigmoid colon D2cc EQD2 (38.08 ± 22.72 Gy vs 47.56 ± 22.16 Gy, P = 0.135) were in favour of portio applicator. Two in 25 patients of cylinder applicator arm had locoregional recurrence in pelvic nodes and vault as well as metastasis in liver. Acute bladder toxicity was more in cylinder arm (48% vs 40.7% P = 0.331) with increased late bladder toxicity (20% vs 11.1% P = 0.375) & late rectal toxicity (28% vs 7.8% P = 0.05) in cylinder arm. Acute GI toxicity was comparable in both arms (40.7% vs 40% P = 0.957). Conclusions: VBT is effective in ensuring better vaginal control, with fewer bladder & rectal toxicity with portio applicator with endometrial carcinoma of intermediate & high-intermediate risk.
Key words: Cylinder, endometrial cancer, portio, vaginal cuff intracavitary brachytherapy
Dosimetric study comparing IMRT and conformal pelvic radiotherapy plans in locally advanced carcinoma cervix
Gowtham Raja Adabala , Vibha Saluja, B. Paul Thaliath, R. R. Ghosh, Sonia Tiwari
Department of Radiotherapy, Kamala Nehru Memorial Hospital, Allahabad, Uttar Pradesh, India, E-mail: [email protected]
Objective: To compare conformal (4F) to IMRT in locally advanced Carcinoma Cervix for target volume coverage and dose to normal tissues. Materials and Methods: Ten proved cases of carcinoma cervix stage IIB & IIIB having histology sq. cell carcinoma were planned with both conformal and IMRT for 50 Gy/25 fr/5 wks. Two plans were generated for every patient; one using four field technique and one using 5 or 7 fields IMRT. Two techniques were compared using DVH for PTV, bladder, rectum and femoral heads. Results: Comparing different DVHs, mean values of PTV 95% and PTV 5% in IMRT 95.62% and 101.56% and for conformal radiotherapy were 95.36% and 103.08% respectively. IMRT plans were comparable to conformal radiotherapy in sparing the urinary bladder, mean of V35 for urinary bladder was 47.3 Gy for IMRT and 50.06 Gy for conformal. Mean of V60 for rectum were 42.7 Gy for IMRT and 49.44 Gy for box plan. For rectum IMRT plan was better to conformal plan as P value <0.005 is significant. Mean of V15 right and left femur were 36.7 Gy and 39.1 Gy for IMRT and 47.11 Gy and 45.77 Gy for conformal RT respectively. Dose to femur was significantly less with IMRT compare to conformal RT (P value <0.005). Conclusion: It is concluded that sparing of bladder comparable in both techniques. Dose to rectum was less with IMRT technique compare to conformal RT. Femoral heads can be significantly spared with IMRT. IMRT may prove to be a better treatment modality as far as rectal dose & femoral dose is considered.
Key words: Conformal radiotherapy, dose volume histogram, intensity modulated
Assesment of dose volume parameters for target and organs at risk in volume based intracavitary brachytherapy in carcinoma cervix: A prospective study
Ashutosh Das Sharma , Sonal Patel Shah, Ankita Parikh, U. Suryanarayana, Sunniya Gupta, sumit Goyal, R. K. Vyas
Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]
Aim and Objective: To analyse the efficacy of Volume based Intracavitary brachytherapy in Carcinoma cervix, in terms of Target coverage (HRCTV, IRCTV) and dose to the Organs and risk (OAR). Materials and Methods : Between December 2014 to January 2016, 60 patients of Carcinoma cervix (FIGO stage IIB and IIIB) were treated with volume based Intracavitary Brachytherapy, after external beam radiotherapy. External radiotherapy: 40 Gray/20 fractions for stage IIB and 50 Gray/25 fractions for stage IIIB. Brachytherapy dose: 7.5 Gy/3 fractions for FIGO stage IIB (n = 25) and 7.5 Gy/2 Fractions for FIGO stage IIIB (n = 35) Target volumes i.e. High risk Clinical target volume (HRCTV) and Intermediate risk clinical target volumes (IRCTV) and organs at risk i.e. urinary bladder, rectum, sigmoid colon were delineated on the CT images taken after the CT compatible brachytherapy applicator placement. Clinical target volume coverage was evaluated in terms of D 90, D 100, V 90, V 100. High dose volume in CTV was evaluated by V 200. For organs at risk, D 2cc , D 1cc , D 0.1cc were evaluated [Table 1]. Dose volume histograms were analysed for outcome measurement.
Conclusion: Volume based brachytherapy can achieve adequate dose coverage of the target and limit the dose to the OARs as analysed from the dose volume histogram, which translates into better tumor control with minimal toxicity.
Comparision of 3D-CRT, IMRT and VMAT radiation therapy techniques for treatment of cancer cervix and analysis of acute toxicity in patients with co-morbidities
P. Vaishnavi reddy , P. P. Mohanty, B. Rama Krishna, Jagadish
Department of Radiotherapy, Yashoda Cancer Institute, Hyderabad, Telangana, India, E-mail: [email protected]
Objective: Prospective study on the Effect of co-morbidities on acute Gastrointestinal (GI) and Genitourinary (GU) toxicities in patients with cancer cervix treated with 3D-CRT, IMRT and VMAT. Materials and Methods: 75 patients with cancer cervix underwent whole pelvic RT with 3D-CRT, IMRT, VMAT, with 25 patients in each group. Patients received 45 Gy/25 fr to the whole pelvis (along with concurrent chemotherapy) followed by 3 fr HDR with 7 Gy per fraction. Acute GI and GU toxicity was assessed every week upto 8 wks using RTOG acute radiation morbidity criteria. Results: Absence of acute GI toxicity (grade 0) during RT in patients with diabetes mellitus (DM) was more frequently observed in IMRT and VMAT arm compared to 3DCRT arm (37.5% and 50% vs 12.5%, P = 0.081), and medication for diarrhoea (grade 2) was more frequently used in 3DCRT arm compared to IMRT or VMAT (84% vs, 8% and 8% P = 0.039). Grade 1 toxicity was similar in all three arms (40%, 40%, 20%, P = 0.678). Patients with DM and hypertension had more grade 1 and 2 toxicity in 3DCRT arm compared to IMRT and VMAT arm (60% and 40% vs 0%, P = 0.020). One patient in 3DCRT arm had grade 3 toxicity. Incidence of GU Toxicity is similar in all three arms in patients with DM (grade 1: 50%, 20%, 30%, P = 0.55, grade 2: 42%, 28%, 30%, P = 0.98) and in those with DM and hypertension (grade 1: 50%, 25%, 25% P = 0.32, grade 2: 33%, 33%, 33% P = 0.513). None had grade 3 toxicity. Conclusion: Patients with DM/ DM and HTN had decreased incidence of acute grade 1 and 2 GI toxicity in patients treated with whole pelvic IMRT and VMAT in comparison with those treated with 3DCRT. Incidence of acute GU toxicity was similar in all three groups.
Role of concurrent chemoradiation with weekly cisplatin and paclitaxel followed by hdr intracavitary brachytherapy in locally advanced carcinoma cervix
A. Preethi , N. V. Kalaiyarasi, R. Giridharan, P. K. Baskar, S. Madhumathi, K. Sanjal, K. Vijay
Department of Radiotherapy, Madras Medical College and RGGGH, Chennai, Tamil Nadu, India, E-mail: [email protected]
Introduction: Carcinoma cervix is the most common gynaecological malignancy in women. Concurrent chemoradiotherapy is an effective treatment program for locoregionally advanced squamous cell carcinoma of the cervix, with established benefits in both organ preservation and survival. Aims: (1) To assess the immediate locoregional response rates of locally advanced squamous cell carcinomas of the cervix treated with concurrent chemoradiotherapy using weekly low dose cisplatin and low dose paclitaxel and HDR intracavitary brachytherapy. (2) To assess the acute toxicity. Materials and Methods: This is a single arm prospective study in which 30 patients with cervical carcinoma of stages IB2-IIIB, presenting in Department of Radiotherapy, MMC&RGGGH, were given concurrent chemoradiation-50 Gy (200 cGy/25#) with weekly Inj. Cisplatin 30 mg/m 2 and Inj. Paclitaxel 30 mg/m 2 followed by intracavitary brachytherapy (8 Gy in 2#) and response was assessed, 6 weeks after completion of therapy. Toxicity was assessed using RTOG Morbidity scoring. Results: Clinically, there was complete locoregional response in 27 patients (90%), partial response in 3 patients (10%); complete response seen in 92.8% (13/14) and 84.6% (11/13) of stage IIB and IIIB respectively. Acute toxicities were observed but manageable. Diarrhea presented as grade I and II in 5 (16.7%) and 3 (10%) patients respectively. Grade I haematological toxicity was seen in 7 patients (23.3%) and grade II in 3 patients (10%) during the 5 th week of chemo-radiation. Grade I and II skin reactions were seen in 7 patients (23.3%). Conclusion: Thus, this study shows that including a taxane as radiosensitiser, in the standard concurrent chemoradiation with weekly cisplatin schedule, has shown better loco-regional response with acceptable toxicity, especially in locally advanced stages and with pelvic nodal involvement (IIIB).
Retrospective audit and stage wise comparitive analysis of factors affecting recurrence in cervical cancer patients presenting with local or distant metastasis following treatment: Single institutional experience
Upasana Mukherjee , Mousumi Das, Rajiv Lochan Jena, Poulami Basu, Praloy Basu, Arnab Adhikary, Arunima Gupta, Anish Bandopadhyay, Shyamal Kumar Sarkar
Department of Radiotherapy, Medical College, Kolkata, West Bengal, India, E-mail: [email protected]
Objective: Determine the factors affecting recurrence, failure patterns, toxicity, disease free interval and follow up pattern of cervical cancer patients treated with definitive or adjuvant radiotherapy with or without concurrent chemotherapy in the practice setting, in a tertiary care centre of Kolkata. Materials and Methods: Out of 1269 patients enrolled during study period of 5 years (2007-2012), 252 were eligible and included the study. Statistical analysis done using IBM-SPSS version 21. Results: Most common presentation was Stage II disease (52.4%) with median age 48 years. Most common histology being moderately differentiated squamous cell carcinoma. Median follow up time was 45 months. Average point A dose (HDR brachytherapy) was 7.6 Gy. Mean dose D 2cc rectum - 73.1 Gy & D2cc bladder 89.99 Gy. Toxicity observed was PR bleeding, dysuria. Rectovaginal fistula found in few cases. Recurrence was mostly local limited to pelvis (83.33%). Median disease free survival was 67 months (12-120 months). Advanced stage, non-squamous histology, treatment gap, brachytherapy type & dose was found to have significant impact on survival. In multivariate (cox regression) analysis, stage (HR-0.89) and brachytherapy dose (HR-0.74) were found to retain their effect on overall survival. Conclusion: Thus cervical cancer is curable if diagnosed and treated in initial stage. For patients presenting in locally advanced stage, treatment time& procedure is pivotal. Though LDR brachytherapy is replaced by HDR due to logistic problems, it was found superior in achieving longer DFS. Excellent response was observed at the cost of Grade II & III radiation toxicity in patients receiving dose at point A more than 7 Gy.
Treatment outcome of locally advanced carcinoma cervix (stage IIB-IIIB) with radical radiotherapy: A single institute retrospective study
Jyoti Poddar , Ashutosh Das Sharma, U. Suryanarayana, Ankita Parikh, Sonal Patel Shah, Sumit Goyal, Shikha Dhal, R. K. Vyas
Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]
Aim: To analyse the treatment outcome of locally advanced Carcinoma Cervix (Stage IIB-IIIB) treated at a single institute with radical radiotherapy (External RT and Brachytherapy). Materials and Methods: 212 patients of Carcinoma cervix IIB to IIIB (FIGO) treated during September 2010 to August 2012, were analysed and were followed up till July 2015. All these patients were treated at our institute with radical radiotherapy (external RT and brachytherapy ± Concurrent chemotherapy). External RT Dose - (a) 40 Gy/20# for FIGO stage IIB (b) 50 Gy/25# for FIGO stage IIIA-IIIB. Brachytjerapy Dose - (a) 7.5 Gy/3# for FIGO stage IIB (b) 7.5 Gy/2# for FIGO stage IIIA-IIIB. The patients were followed up for a median follow up period of 18 months. The range of follow up period was 3-58 months. Incidence of patients having residual disease at three months was calculated. Acute local reactions and significant immediate morbidity, late toxicity and distant metastases was noted. Incidence of recurrence and disease free survival was calculated. Results: 13/212 had residual disease and 10/212 had distant metastasis. 20/212 patients had local recurrence. The local acute reactions were manageable in all patients. 02/212 patients developed proctitis which was managed by steroid enema. Log rank test and Kaplan Meier survival analysis was done. Conclusions:Conclusions: Though the prescribed radiation dose for Carcinoma cervix is >90 Gray, for Indian patients where treatment tolerance, nutritional status and compliance are major logistic issues, a Dose of 75-80 Gray can produce significant results. Cervical malignancy shows Dose response relationship, so a higher dose can be delivered with a customized approach.
Locally advanced cervical cancer: Neoadjuvant chemotherapy followed by concurrent chemoradiation and targeted therapy as maintenance: A phase II study
Rony Benson 1 , Sushmita Pathy 1 , Lalit Kumar 2 , Sandeep Mathur 3 , Rabindra Mohan Pandey 4 , Subhash Chander 1 , Bidhu Kalyan Mohanti 1,5
Departments of 1 Radiation Oncology, 2 Medical Oncology, 3 Pathology and 4 Biostatistics, All India Institute of Medical Sciences, New Delhi, 5 Fortis Memorial Research Institute, Gurgaun, Haryana, India, E-mail: [email protected]
Objective: We evaluated the role of neoadjuvant chemotherapy (NACT) prior to chemoradiation (CRT), followed by Gefitinib maintenance in locally advanced cervical cancer. Methods: Twenty five patients of locally advanced carcinoma cervix were enrolled between July 2012 and May 2013. Patients received six weekly doses of NACT Paclitaxel (60 mg/m 2 ) and Carboplatin (AUC 2), followed by CRT and high dose rate intracavitory brachytherapy. Analysis of Epithelial Growth Factor Receptor expression (EGFR) was carried out by immunohistochemistry. Results: Twenty four of 25 patients completed the neoadjuvant chemotherapy and concurrent chemoradiotherapy. Post CRT, patients were started on gefitinib maintenance and twenty patients completed the intended 1 year of gefitinib maintenance. Complete and partial response rate post CRT was 96%. EGFR was moderately or strongly expressed in 86.3% of the patients. No significant correlation was demonstrated between the expression of EGFR and response to treatment. At a median follow up of 27 months 64% of patients continue to be disease free. Conclusion: Weekly neoadjuvant chemotherapy followed by chemoradiation is associated with high response rate in locally advanced cervical cancer. Gefitinib as maintenance therapy was well tolerated.
Key words: Cervical cancer, epithelial growth factor receptor, gefitinib, neo adjuvant chemotherapy
Dose optimization and plan evaluation in CT image based gynaecological interstitial brachytherapy using martinez universal perineal interstitial template
Jyoti Poddar , Ashutosh Das Sharma, Ankita Parikh, Sonal Patel Shah, Sunniya Gupta, Sumit Goyal, Shikha Dhal, U. Suryanarayana, Vimesh Mehta, Tarun Kumar, Harshavardhan Reddy, Atreyee Sarma, R. K. Vyas
Departments of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]
Aim: To study and document the various dose volume indices and parameters recommended by GEC-ESTRO, by dose optimization in CT image based gynecological interstitial brachytherapy using MUPIT. Methods and Materials: 35 patients of gynaecological cancer who underwent external radiotherapy and High Dose Rate brachytherapy using MUPIT, treated between 2014-2016 were recruited. The dose prescribed for Interstitial implant is 4 Gy/Fraction in four fractions (16 Gy/4#) treated 6 hours apart. Clinical target volume (CTV) and organs at risk (OARs) were delineated on the axial CT image set. Geometrical and graphical optimization were done for planning. Coverage Index (CI), dose homogeneity index (DHI), overdose index (OI), dose non-uniformity ratio (DNR), Conformity Index (COIN) and dose volume parameters recommended by GEC-ESTRO i.e., D2cc, D1cc, D0.1cc of rectum and bladder were evaluated. The mean value and standard deviation for each parameter was calculated. The Coefficient of Variation (CV) was calculated which was not significant for any of the parameters. Results And Conclusion: The coverage index (CI) was found to be 0.95 which shows that 95% of the target receives 100% of the prescribed dose. The COIN is 0.841 and DHI is 0.502. There should be a optimum balance between the CI, DHI, DNR and COIN for improving the quality of the implant. Dose optimization yields superior coverage with optimal values of indices. Clinical correlation, with DVH parameters may help in improving the quality of implants and identifying the hot and cold spots in the target and their clinical relevance. An institutional protocol may be formulated regarding the accepatability criteria of indices such that the use of optimization can be made uniform among all the users in the institution.
Key words: Dose volume indices, dose volume parameters, image based interstitial brachytherapy, MUPIT, optimization
Observational study of cone beam CT based interfractional urinary bladder filling variation during igrt in pelvic malignancies
Shah Manjari, Agarwal Sandeep, Chhabra Akanksha , Mishra Shiv, Shankar Ravi, Srinivasan Shashank, Chandra Ritu, Prekshi, Subramanian Bala, Agarwal Rashi, Singh Dinesh
Department of Radiotherapy, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India, E-mail: [email protected]
Background: Organ motion is a well-known fact in radiation therapy that limits its precision. It is well documented that for pelvic malignancies patients undergoing radiation therapy, there is correlation between target volume displacement and changes in bladder wall as much as 3 cm. The objective of this study was to observe inter-fractional bladder filling variation during Image guided radiotherapy after following bladder filling protocol. Materials and Methods: 26 patients of pelvic malignancies were enrolled including 9 cervical cancer, 7 endometrial, 5 prostate and 5 colo-rectal cancer patients. Total of 300 scans (26 Planning CT + 274 CBCTs) were performed and bladder was contoured in all scans. Bladder volume, transverse, antero-posterior and longitudinal diameter were measured in maximum dimension of the bladder. All these parameters were compared with the planning CT scan. Results: Patients showed variation in bladder volume with mean 184 cc and standard deviation 90cc and p-value was 0.761. With increasing bladder volume, its size increases with asymmetry in bladder wall. The mean diameter of bladder was 8.35 cm, 6.69 cm and 5.59 cm in transverse, antero-posterior and longitudinal diameter with standard deviation 1.039, 1.05 and 1.798 cm. Conclusion: Image-guided radiotherapy (IGRT) with verification of the organ position before the daily treatment after following bladder filling protocol has allowed for lessening of inter-fraction bladder wall motion and showed considerable benefits in terms of margin reduction on lateral side as there is less displacement on transverse diameter and more liberal margins should be considered in antero-posterior dimension and longitudinal dimension.
Dosimetric analysis of the effects of bladder filling on organs at risk dose in carcinoma cervix brachytherapy
Ashutosh Das Sharma , Jyoti Poddar, Sonal Patel, Ankita Parikh, U. K. Suryanarayan
Department of Radiotherapy, Gujarat Cancer and Research Institute, Ahmedabad, Gujrat, India, E-mail: [email protected]
Introduction: Brachytherapy is the crux of management of early stage as well as locally advanced cervical cancer. The purpose of this study is to find out a dosimetric correlation between the bladder filling and its effects on the dose received by OARs during CT guided HDR brachytherapy in carcinoma cervix and to derive a conclusion as to limit the dose to OARs by maintaining the optimum bladder protocol. Materials and Methods: 30 patients (70 ICRT applications) of carcinoma cervix (stage IIB, IIIB, IVA) treated with EBRT followed by CT based HDR brachytherapy our institute between July 2014 to Jan 2016 were randomly selected from the database and studied retrospectively. Bladder filling data was collected for 72 applications and was correlated with the dose received by bladder and rectum. Results: A statistically significant positive correlation was found between bladder volume (30cc to 160cc) and dose to bladder (D2cc D1cc D.1cc). Conclusion: Bladder distension does increase the dose to bladder wall. Keeping the bladder empty during all phases of brachytherapy would definitely reduce the probability of late bladder toxicity further, adding to the benefits of image guided brachytherapy in cervical cancer.
Key words: Bladder volume, D2cc Bladder, image guided brachytherapy
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