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Year : 2019  |  Volume : 15  |  Issue : 9  |  Page : 196-207


Date of Web Publication28-Nov-2019

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How to cite this article:
. CNS. J Can Res Ther 2019;15, Suppl S2:196-207

How to cite this URL:
. CNS. J Can Res Ther [serial online] 2019 [cited 2021 May 16];15:196-207. Available from: https://www.cancerjournal.net/text.asp?2019/15/9/196/271705

 > Abstract: 121: Correlation study of histological and molecular diagnosis in adult glioblastoma multiformes patients Top

Rohini Khurana, Satyajeet Rath, Nuzhat Husain

Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Aims and Objectives: To evaluate frequency of 1p/19q Codeletion, IDH 1 mutation, ATRX deletion, MGMT gene methylation in Indian adult patients with glioblastoma multiformes (GBM) and to correlate individual markers and subgroups thereof with response to chemoradiation. Materials and Methods: Study design: Interventional Cohort study. Study setting: Tertiary hospital based study. Intervention: Chemoradiation with standard dose and fractionation. Clinical assessment of GBM patients at presentation: Symptoms and their duration recorded, detailed Neurological examination and Karnofsky performance scoring done. Extent of surgery and dose of steroids was recorded. Radiological Assessment: Gadolinium enhanced MRI to assess size of tumour and other features like edema, necrosis, calcification etc. Histological evaluation for confirmation of GBM was done. Molecular markers studied were Chromosome 1p and 19q deletion status done by Flourescence in situ hybridisation studies, IDH 1 mutation by IHC using mutation specific antibody, ATRX deletion by IHC, MGMT gene hypermethylation by methylation specific PCR. Treatment protocol was surgery (maximum safe resection) + RT to 60 Gy with concurrent Temozolamide + Adjuvant Temozolamide. On Follow-up monthly clinical assessment for 6 months and post treatment MRI at 12 weeks after chemoradiotherapy completion. Cases were divided into complete responders, partial responder, stable disease and progressive disease. Data Analysis: The relationship of various molecular markers as well different subgroup clusters with similar marker expression were compared in terms of response to treatment and overall survival. Observations and Results: Between January 2017 and April 2019, 44 cases diagnosed as GBM underwent four molecular studies. The median age (range) was 46.5 years (18-67 years); 21 (70%) were male. Presenting features included headache (95%), vomiting (65%) and seizures (48%). The median duration (mean, SD, range) of symptoms was 9 months (31, 19.8, 1-72). Median (mean, SD, range) diameter of disease was 5.0 cm (3.1, 3.2, 3.4-5.8) on gadolinium enhanced MRI. Median time (mean, SD, range) from the most recent surgery to start of radiotherapy being 1.5 months (2.8, 7.8, 5-6). Following immobilization patients were treated on a 6 /10MV linear accelerator. Median dose (range) was 60Gy (59.4-60 Gy) given in 1.8-2.0 Gy fractions, 5 fractions/week. In 44 patients of GBM, molecular markers were seen as 1p 19q was found codeleted in 7 patients, IDH 1 mutation found in 18 patients, ATRX loss found in 6 patients, p53 mutated in 18 patients. At a median overall survival of 22 months, there was progressive disease in 24 patients. Kaplan Meyer graph for overall survival and progression free survival showed improved OS and PFS for 1p19q positive subgroup. Conclusions: Codeletion of 1p19q in GBM is perhaps associated with a favorable progression free survival (p=.01) however longer follow up required to assess overall survival (p=.07).

 > Abstract: 130: Frameless stereotactic radiation treatments of benign brain tumors using dual imaging verification Top

Prathima Ramachandran, B. Krishnamoorthy Reddy, Subhathra Paulpandi, Prasanna Kumar, Vinay Manoor

Apollo Hospitals, Bengaluru, Karnataka, India, E-mail: [email protected]

Background: Stereotactic Radiotherapy (SRT) is the use of high energy photons to a focal area that ablates the growth of abnormal cells. The treatment requires high accuracy in spatial orientation & dosimetry. To acquire high precision in the pre-imaging era, patients were immobilized using a head-ring with screws driven into the skull which gave sub-millimetric precision. With the advent of reliable imaging modalities, there has been a paradigm shift towards non-invasive immobilization which has proven to give equal accuracy. Purpose: To assess the isocenteric accuracy of frameless immobilization techniques using Relocatable BrainLab head mask, ExacTrac's Stereoscopic X-ray Imaging, Novalis' Robotic couch & Cone Beam Computed Tomography (CBCT) in treating benign lesions. Patients and Methods: 13 patients (Females – 6, Males – 7) with benign conditions of the Central Nervous System, treated at our centre were studied. All the patients were immobilized using the 5-layered BrainLab head mask with a mouth-bite. A Computed Tomography (CT) of the brain was obtained with slice thickness of 1 mm with the mask in-situ with stereotactic BrainLab CT-localizer box. An RT-planning Magnetic Resonance Imaging (MRI) was done for all patients with 1 mm slice thickness and the CT & MRI images were fused and the Gross Tumor Volumes (GTV) were contoured. The mean GTV was 4.5cc (0.79-13.3cc). The GTVs were planned to a median dose of 25Gy (12-56Gy) in single or multiple fractions (1-30) (co-planar - 6, non-coplanar - 7). The treatment was executed on TrueBeamSTx with BrainLab Radiosurgery system. For patients with multiple fractions (n=7), treatment was given for 5 days a week. At the time of treatment delivery, patients were comfortably positioned on the Novalis' Robotic 6-Degree of Freedom (DoF) couch with their respective masks and initially, a kV-kV imaging was done. Sub-millimetric shifts were applied from the console, else the patient was manually re-positioned to align to the co-ordinates. Then, ExacTrac imaging was done & shifts in 6 dimensions were scrutinized and verified using bony landmarks. The resolution of this stereoscopic imaging permits up to 0.7 mm translational & 1° rotational accuracy. Final pre-treatment delivery verification was done by CBCT, that gave shifts in vertical, lateral, longitudinal & rotational. Once verified & rectified, treatment was delivered. ExacTrac imaging was done in all couch angles if the patient was planned a non-coplanar plan. Results: The mean isocenteric shifts noted in the 133 fractions by ExacTrac were Lateral:-0.08 mm ( SD=0.3 mm), Longitudinal: 0.2 mm (SD = 1 mm), Vertical:0.8 mm (SD = 0.7 mm), lateral: 0.06° (SD = 0.4°), Longitudinal:-0.03° (SD = 0.3°), Vertical: 0.21° (SD = 0.56°). The final shifts as verified by CBCT were Lateral:-0.06 mm (SD = 0.24 mm), Longitudinal:-0.02 mm (SD = 0.29 mm), Vertical:-0.1 mm (SD = 0.2) & Rotational: 0.07° (SD = 0.4°). The intrafraction shifts were noticed at Lateral: 0.06 mm (SD = 0.2 mm), Longitudinal:-0.05 mm (SD = 0.17 mm), Vertical: 0.07 mm (SD = 0.23), Lateral: 0.17° (SD = 0.32°), Longitudinal: 0.04° (SD = 0.28), Vertical: 0.08° (SD = 0.21°). Conclusions: Stereotactic Radiotherapy is increasingly becoming a treatment of care for intra-cranial benign lesions. Positional accuracy with frameless immobilization is a challenge especially with reproducibility of positioning in fractionated therapy. The presented 5-layered mask, Robotic couch, stereoscopic imager and on-board imager used in conjunction form an accurate repositioning system in the treatment of benign conditions of the CNS.

 > Abstract: 134: Intracranial extra-skeletal myxoid chondrosarcoma with EWSR1 gene fusion Top

Vinodh Kumar Selvaraj, Deleep Kumar Gudipudi

Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India, E-mail: [email protected]

Background: Intracranial extra skeletal myxoid chondrosarcoma is an extremely rare entity and are thought to arise from the choroid plexus, dura or in rare instances from the pineal region. They constitute a distinct genomic entity characterized by reciprocal translocation of fusion genes, most commonly EWSR1 in 22q12 with NR4A3 in 9q2q31.1. They are considered to have a high risk of local recurrence and potential for metastasis. Here we report a case of intraventricular myxoid chondrosarcoma in a young male, who underwent surgery and adjuvant radiation. Case Summary: A 27 year old male, evaluated for complaints of headache, seizures and pain in the neck, MRI whole spine was normal. MRI Brain showed a lesion in right lateral ventricle. He underwent right parieto occipital craniotomy with subtotal excision. Postop HPE was Ependymoma, WHO grade II. Referred to our institute for further management. Systemic examination was unremarkable. Postop MRI Brain showed no evidence of focal enhancing areas with post operative gliosis in right parietal lobe communicating with right lateral ventricle with dilated temporal and occipital horns. Blocks and slides review along with IHC revealed vimentin and CD99 positive while GFAP, pancytokeratin, CD 34, S100 negative, Ki 67 low. FISH for EWSR1 gene positive. Final possibilities were Myxoid Chondrosarcoma or Primary Intracerebral myxoid neoplasm with EWSR1 fusion. Discussed in multidisciplinary board and planned for adjuvant radiation. A total dose of 5400cGy in 30 fractions at 180cGy per fraction was delivered using 6MV photons with IGRT technique. Patient tolerated treatment well with grade 1 skin reactions and alopecia. At 9 months post radiotherapy, patient is asymptomatic and MRI Brain appears normal. Discussion: Based on literature review, 13 cases of intra cranial extraskeletal myxoid chondrosarcoma has been reported till date since its first description in 1972. This would be the 14th case overall and second case of intraventricular origin to be reported till date. Owing to its rarity and limited literature, there is no standard treatment guidelines available. Combined modality approach with surgery followed by radiotherapy provides good local control with low morbidity.

 > Abstract: 141: Retrospective review of primary brain tumor: A single institutional study Top

Diptajit Paul, Rakesh Dhankhar, Vivek Kaushal, Anil Kumar Dhull, Baljit Singh, Rajeev Atri

Pandit B D Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Purpose and Objective(s): A number of previous studies, in different regions worldwide, have investigated the demographic profile, different treatment options and survival rates of patients with a brain tumor. The current study also focuses on same in patients of primary brain tumor attending Radiation Oncology Department, PGIMS, Rohtak. Our aim was to analyse demographic profile of primary brain tumor patients along with various treatment protocols and their responses. Materials and Methods: We retrospectively reviewed records of primary brain tumor patients who presented in Department of Radiation Oncology PGIMS, Rohtak from 2009 to 2012 for analysing demographic profile of the disease, different treatment schedules and their response evaluation. Results: Total 123-patients of primary brain tumors were identified, which constituted approximately 1% of total cancer patients in above institution. The median age at presentation was 41-years, third decade of life being the commonest presentation. The male to female ratio was 2.6:1. At the time of initial presentation, 61% patients had karnofsky performance status (KPS) >70 and 11% had KPS <30. 63% patients had a history of tobacco intake, while 53% were alcoholic. Mean duration of symptoms was four months. The most common presentation was headache (79%), vomiting (33%), seizure (27%) and altered sensorium (5%). 58% patients were locally advanced (WHO grade III & IV). Histopathologically, astrocytoma (50%) was the commonest subtype followed by glioblastoma multiforme (31%), oligodendroglioma (10%) and mixed gliomas (9%). Regarding treatment received by patients, 97% of patients underwent surgery and 88% received radiation therapy. Most common chemotherapeutic drug used with radiation was temozolomide. Radical and palliative radiotherapy was given in 84% & 4% patients respectively. Clinically the response at last follow-up was as follows: CR in 29%, PR in 41%, death in 23% and 9% patients lost to follow-up. Conclusion: Overall newly diagnosed cases of primary brain and spinal cord cancer was 1.6% of all cancers worldwide that closely resembles our study. Survival and prognosis of different subtypes of primary brain cancer were also similar as per data; whereas glioblastoma multiforme carries the worst prognosis, astrocytoma with lower WHO grade has good one. Clinical factors having significant role in prognosis of primary brain tumors include age, sex, smoking and alcohol habits, performance status, tumor location, extent of resection. Use of concomitant chemotherapy especially oral temozolomide with radical radiotherapy is highly recommended in locally advanced cases (WHO grade III and IV) particularly in glioblastoma. In low grade diffuse astrocytoma surgery followed by radical radiation is usually the standard treatment protocol. It is recommended to develop proper atlas of the cancer patients so that exact geographical plotting of the patients can be done to establish the accuracy of the scattered data. It is also recommended that different radiation therapy protocols should be explored alone or in combination depending upon the general condition and affordability of the patients so as to prolong survival and improve the quality of life. More studies in other institutions are recommended to conclude the demographic profile in primary brain tumor patients.

 > Abstract: 147: Clinical outcomes and dosimetric co-relation in Linac based X–knife radiosurgery for trigeminal neuralgia Top

Ashish Bhange, Shankar Vangipuram, Karuppusamy Arumugam, Dilip Nikam, Bhavya Patneedi, Hirak Vyas

HCG ICS Khubchandani Cancer Centre, Mumbai, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): Trigeminal neuralgia (TGN) also known as “tic douloureux” is the most common neuralgia with global incidence of 4-5/1 lac population. The patients typically presents with severe episodic lancinating, shock like pain sensation in area of trigeminal nerve distribution. Radiosurgery offers an excellent treatment option for medically refractory, post surgery failure or inoperable cases of TGN. Dosimetric parameters for plan evaluation of TGN radiosurgery are mostly based on global experience of Gamma Knife based radiosurgery. There is a paucity of Indian data on dosimetric parameters and its co-relation to clinical outcomes on Linac based X-knife radiosurgery for TGN. We report our clinical and dosimetric experience of refractory TGN cases treated at our institute with Linac based X-knife radiosurgery. Materials and Methods: Seventeen patients (male-12, female-5) of treatment refractory TGN were analyzed. Median age was 66 years (range 33-83 years). Dermatomal distribution (V1, V2, V3) was: 10 patients had either of 3 branches, 6 patients had 2 branches and 1 had all 3 branches affected. Nine patients presented with symptoms on right side while 8 had left side affected. Six patients had prior invasive procedures done for medically refractory indication. Eleven patients had vascular conflict with trigeminal nerve. Mean target volume localized via deformable image registration with heavily weighted T2 MRI sequences (CISS/FIESTA) or CT cisternography was 0.03 cc. All patients were planned with 6MV FFF beam and stereotactic cones (5 mm-13, 7.5 mm=4) to prescription dose of 79-85Gy to isocentre. Target dosimetric parameters: mean Dmax 81.6Gy (range 79-85Gy), mean marginal dose 57.9Gy (range- 48-77.7Gy). Mean distance of isocentre from brainstem was 5.17 mm (range: 3-7 mm). Brainstem dosimetric parameters were: mean Dmax-23.3Gy, mean V20% PD-0.024cc, mean V12Gy-0.09cc. All patients were followed up. Pain response and toxicity assessment was done as per Barrow Neurological Institute (BNI) scoring system. Patients were classified in three groups Excellent response (BNI Grade I), Good (BNI Grade II, III) and poor (BNI Grade IV, V). All the dosimetric parameters in the 3 groups were compared and co-related to clinical outcomes using appropriate statistical test in SPSS software. Results: At median follow up duration of 15 months, 8 patients had excellent outcomes (BNI Grade I) and 8 patients had good outcomes (BNI Grade II-III). One patient had poor outcome (BNI Grade V). Dosimetric parameters i.e. TGN target doses (Dmax and Marginal dose), brainstem doses (Dmax, V20% PD, V12Gy), size of cone, isocenter distance from brainstem were not co-related with statistical significance to clinical outcomes. Conclusion: We report our experience with excellent pain control for refractory TGN cases in 94% of cases treated at our institute. Linac based X-knife Radiosurgery offers an excellent outcome for refractory TGN cases when combined with precise treatment planning, dosimetric evaluation and robust treatment delivery. Upto our knowledge, herein we report first Indian Institutional data of clinical outcomes and its dosimetric correlation of Linac based X-Knife Radiosurgery.

 > Abstract: 161: Correlation of magnetic resonance imaging features with molecular markers in high grade gliomas or high risk low grade gliomas Top

Manan Sarupria, Shikha Goyal, Shyam Bisht, Deepak Gupta, Kushal Narang, Ishani Mohapatra, Jayesh Modi, Manoj Tayal, Tejinder Kataria

Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India, E-mail: [email protected]

Purpose and Objective(s): To improve the prognostic value of imaging in high grade gliomas or high risk low grade gliomas by determining correlation of magnetic resonance imaging (MRI) features with molecular marker (isocitrate dehydrogenase, IDH-1). Materials and Methods: Patients with histopathologically proven gliomas treated with adjuvant radiation therapy (+/- concurrent and adjuvant chemotherapy) in Division of Radiation Oncology from January 2017 to May 2019 were taken retrospectively. Patient demographics, signs and symptoms, preoperative MRI and histopathological reports were reviewed. IDH-1 Mutation status was correlated with MRI features (location, hemisphere, enhancement, proportion of enhancement>33%, tumor border delineation, diffusion restriction and significant midline shift >5 mm). Results: Out of total 49 patients (41 males, 8 females), 26 underwent gross total excision (GTE), 21 underwent subtotal excision (STE) and 2 patient had stereotactic biopsy. Twenty patients in GTE group, ten in STE group and two patient with biopsy were IDH-1 mutant. Others (18) were IDH-1 wild type. Out of 31 IDH-1 mutant patients, 2 were grade II (Oligodendroglioma-1, astrocytoma-1), 19 were grade III (oligodendroglioma-9, astrocytoma-10) and 10 were grade IV (glioblastoma). Out of 18 IDH-1 wild type cases, 4 were grade III (astrocytoma-2) and 14 were grade IV (glioblastoma). Frontal lobe tumors were 67.7% and 50% in IDH-1 mutant and IDH-1 wild type respectively. Right sided location was seen in 51.6% of IDH-1 mutant and 50% of IDH-1 wild type tumors. Tumor enhancement with contrast (Gadolinium) was present in 64.5% of IDH-1 mutated tumors and 94.4% of IDH-1 wild type tumors. Volume of tumor and volume of enhancement were analysed separately and proportion of enhancement was calculated (high enhancement proportion >/=33% or low enhancement proportion <33%). High enhancement proportion was seen in 12.9% of IDH-1 mutated and 55.5% of IDH-1 wild type tumors. Mass effect with tumor crossing midline was seen in 64.5% of IDH-1 mutant tumors while 72.2% of IDH-1 wild type crossed midline. Significant midline shift (>5 mm) was seen in 35.4% of IDH-1 mutated tumors and 50% of IDH-1 wild type. Tumor border delineation on T1 contrast was present in 29% of IDH-1 mutated and 38.8% of IDH-1 wild type cases. Diffusion restriction within the tumor was seen in 29% of IDH-1 mutated tumors while 88.8% of IDH-1 wild type showed diffusion restriction. Conclusion: There is some suggestion of differentiation between IDH-1 mutant and non-mutant gliomas based on imaging. IDH-1 wild type tumors shows significant presence of enhancement and more than 33% propoprtion of enhancement as compared to IDH-1 mutant tumors. Diffusion restriction appears to be significantly higher in IDH-1 wild type. Imaging features, could distinguish molecular subgroups of grade II and III gliomas on the basis of the updated WHO Classification, and the ability to distinguish these subgroups on initial diagnostic imaging may affect clinical decision making.

 > Abstract: 164: Frameless stereotactic radiosurgery using flattening filter free volumetric modulated arc therapy in brain metastasis Top

Deepanjali Patel, Ramesh Purohit, Hirak Vyas, A. R. Gupta, Kiran Chigurupalli, Menal Bhandari, Abhishek Arora, Apoorv Vashistha, Shalu Peter

Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India, E-mail: [email protected]

Purpose and Objective(s): Brain metastasis (BM) from solitary neoplasm is conventionally treated with whole brain radiotherapy (WBRT) or surgery. With advancement in imaging and treatment delivery systems, stereotactic radiosurgery has emerged as an effective treatment option. In this retrospective study we aimed at calculating the overall survival, efficacy and safety of Linear Accelerator based Frameless Stereotactic Volumetric Modulated Arc (VMAT) Radiosurgery (SRS) in developing nation scenario. Materials and Methods: Thirty two patients who met the inclusion criteria were enrolled in this study. All the patients presented with histopathologically proven solid malignancy with evidence of brain metastasis on imaging. All the patients underwent rigid immobilization for CT simulation. Following image fusion with Magnetic Resonance images patients were planned on MONACO planning system. Frameless SRS was performed using 6 MV Flattening Filter Free (FFF) photons on linear Accelerator with 6 Degree of Freedom couch using online image guidance. Patients were kept on regular follow up to document adverse events, local control and overall survival. Statistical analysis was performed using descriptive analysis and Kaplan Meier Survival curves. Results: In the median follow up of 10 months, all 32 patients were evaluated for each of 54 metastasis treated with SRS. Lung carcinoma was the most common primary neoplasm associated with BM. Sixty percent of patients presented with solitary BM. Median planning target volume (PTV) dose was 18Gy. Overall median survival after SRS was observed to be 10 months (range 2-44 months). Local failure was documented in 7 patients (local control of 80%) with a median time to recurrence of 4 months. Kaplan Meier survival analysis at 1 year shows predicted overall survival was 20% and local failure free survival was 60%. PTV dose of more than 18Gy and primary carcinoma of breast were found to be better prognostic factors for overall survival. No adverse events related to SRS were reported in this study. Conclusion: Frameless stereotactic FFF VMAT radiosurgery can be used as an effective, feasible and well tolerated treatment modality for treatment of brain metastasis even in a developing nation. Proper patient selection with correct treatment planning and delivery tools can provide excellent local control and has good overall survival compared to WBRT.

 > Abstract: 172: A prospective randomized controlled comparison of hypofractionated radiotherapy with conventional radiotherapy in poor prognosis high grade glioma Top

Rakesh Ranjan, Sunil Choudhary, Abhijit Mandal, Ravi Shankar Prasad, Uday Pratap Shahi

Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): Median overall survival for patients with Glioblastoma Multiforme (GBM) with Recursive Partitioning Analysis Class (RPA) 4, 5 and 6 when treated with conventional protracted 6 weeks of radiotherapy with concurrent and adjuvant Temozolamide is about 12 months to 14 months. The study was conducted to compare Standard 6 weeks of radiotherapy (RT) with Short course RT in poor prognosis Glioblastoma Multiforme in terms of survival outcome, toxicity profile and quality of life (QOL). Materials and Methods: This study was conducted in a Tertiary Cancer Center, India between November, 2017 and June, 2019. Histologically confirmed patients of GBM belonging to RPA class IV-VI were randomized into two treatment arms:

  1. Conventional RT arm (CRT): 60 Gy/ 30F/ 6 weeks
  2. Hypofractionated RT arm (HFRT): 40 Gy/15F/3 weeks.

Patients in both the groups received concurrent and 6 cycles of adjuvant Temozolamide. Target delineation was done based on ESTRO-ACROP guidelines. Patients were treated with intensity modulated radiotherapy (IMRT) on 6 MV Linear Accelerator. Baseline MRI brain was done at 3 months of completion of RT. Quality of Life assessment was done using EORTC-QLQ30 questionnaire and BN-20 along with change in Karnofsky performance status (KPS) and neurological performance score (NPS) before the start of treatment and at 3 months of completion of RT. Overall Survival was the principal endpoint while acute toxicity and QOL were the secondary end points. Results: Eleven and ten patients could be recruited in CRT and HFRT arms respectively. The demographic profile in the two groups was well matched except for KPS and NPS. Most of the patients had gross tumor resection of the tumor in both the groups. Patients in HFRT arm had poorer KPS and NPS compared to the other group. Fifty percent of patients in 40 Gy arm belonged to RPA V-VI whereas it was only 9% in the other group. Median gap between surgery and start of RT was 6.9 weeks and 10.1 weeks in CRT and HFRT arms respectively. Three patients failed to complete the planned dose of RT. The median RT duration was 45 days and 19 days in CRT and HFRT arms respectively. Concurrent Temozolamide was well tolerated in both the arms. Two patients and one patient in CRT and HFRT arms respectively could complete six cycles of adjuvant Temozolamide. Median follow-up period was 6.2 months. Median OS was 12.5 months and 5.8 months in CRT and HFRT arms respectively (p = 0.164). Hematological toxicity was comparable in the two arms. There was significant improvement in QOL in terms of Physical scale, fatigue, and pain and communication deficit in 60 Gy arm compared to the other. Improvement in KPS was appreciated in seven and five patients in CRT and HFRT arms respectively. Conclusion: Concurrent Temozolamide is well tolerated with abbreviated course of RT. Short course HFRT in poor prognosis GBM offers equivalent survival compared to six weeks of CRT despite poorer KPS and NPS and delay in start of RT. However, QOL in patients who received HFRT was inferior as compared to CRT with regard to few parameters.

 > Abstract: 209: Metabolic regression velocity after stereotactic body radiation therapy for spinal metastases Top

Hirak Vyas, Shankar Vangipuram, Ashish Bhange, A. Karuppusamy, Bhavya Patneedi, Deepanjali Patel

HCG Cancer Centre, Mumbai, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): Stereotactic Body Radiation Therapy (SBRT), predominantly, causes indirect cell kill through (1) ceramide induced vascular apoptosis which starts few hrs after treatment & peaks around 3rd day (2) immunological alteration in the host tumor microenvironment, a process which starts around 3rd day post-treatment & peaks at 10-12 days. Routine Post SBRT followup imaging is advocated after 3 months. Present study evaluated the clinicoradiobiolgic response of single or multi-fraction spine SBRT post-treatment for spinal oligometastases with serial FDG PET-CT scans. Materials and Methods: 5 patients with localized spinal metastases with primaries from lung-2, breast-2, kidney-1 were included in proof-of-concept study. Patients were having lesions anywhere from C1 to L5, less than 5 cms paraspinal mass, >3 mm gap between edge of the lesion, 2 contiguous spine levels with <50% body involvement & No spinal instability. All patients underwent S board rigid fixation / body fix immobilization, advanced image guidance using 6 DOF corrections on C-arm Linac. Fractionation used for treatment was either 16 Gy in 1 Fraction or 24 Gy in 3 Frc based on the clinical scenario, goals of treatment & projected life expectancy. All patients underwent limited metabolic imaging Pre-treatment and Post-treatment PET-CT scans up to 3 months. Post SBRT serial PET-CTs scans were timed serially at 48 hrs, 10 days, 30, 60 and 90 days post treatment. PET-CT images were reviewed in order to determine the pre and post-treatment maximum standardized uptake value (m-SUV) of the lesion, including “complete resolution” of FDG avidity. Corresponding morphologic changes in the target lesions and surrounding normal bony were studied on the PET-CT images during the 3 month evaluation period. Results: All the 5 patients showed nearly consistent serial regression patterns in metabolic activity post treatment. The observed metabolic regression was between 60-65% (median 50%) at 48 hrs after treatment. 70% metabolic regression (median – 70%) was observed 10 days post-treatment. A median SUV increase of 1.7 was observed in all 5 patients in the first and second month scan when compared with 10th day post Treatment scan. At 3rd month 4 out of 5 pts had FDG non-Avid disease. During the evaluation period (first 3 months) there was no significant change in bony architecture but the paraspinal mass lesions morphologically decreased at 3rd month scan. Conclusion: Early metabolic response post Spine SBRT was seen at 48 hrs post treatment & maximum metabolic response seen at 3 months post SBRT. This is the first study reported in literature which looked into the serial metabolic trending in first 3 months post Spinal SBRT for spinal oligometastatic disease.

 > Abstract: 223: Astroblastoma: A rare case report Top

Shashank Joshi, Paramjeet Kaur, Ashok Chauhan, Abhishek Soni

PGIMS, Rohtak, Haryana, India, E-mail: [email protected]

Purpose and Objective(s): To report a rare case of astroblastoma in an elderly patient. Materials and Methods: We report the case of astroblastoma in a 58-year-old female who presented with complaints of multiple episodes of loss of consciousness from 3 months and right sided weakness and difficulty in speech from 2 months. Patient underwent craniotomy with gross tumor excision and presented to our department where on evaluation had a score of 13 (E4V3M6) on Glassgow Coma Scale. Post operative NCCT head was apparently normal showing post-op changes. Patient was planned and received post-op WBRT 60Gy/30# over 6 weeks by Cobalt-60 teletherapy machine with concomitant cap. Temozolomide 100 mg p.o. OD prior to radiation. Adjuvant chemotherapy with cap. Temozolomide 250 mg p.o. OD day 1 to day 5 was advised following chemoradiation. Patient tolerated chemoradiation well but reported after 2 months in poor general condition. CEMRI brain (post chemoradiation) was suggestive of local recurrence. Neurosurgery opinion was taken but patient was declared inoperable and was advised best supportive care with close follow up. Results: High gade astroblastomas and poor patient compliance have again proved to be a burden on the work of oncologist. As despite of such aggressive approach patient developed recurrence. Conclusion: Astroblastomas are rare primary brain tumors affecting children, adolescents and young adults and rarely found in elderly population. They are difficult to diagnose and manage and have an unpredictable course with a tendency of recurrence. Though treatment of astroblastoma is not well established because of its rarity, yet complete surgical resection plays an important role in its management, especially in low grade cases. Higher grades require adjuvant treatment with radiotherapy and temozolomide based chemotherapy because of higher recurrence rates and rapid progression as observed in our report.

 > Abstract: 248: Overall survival of glioblastoma and its correlation with postoperative gross tumor volume: A single institute based retrospective study Top

Biswajit Sarma, M. Bhattacharyya, A. K. Kalita, Partha P. Medhi, Gautam Sarma, J. Nath, Faridha J. Momin, Shashank Bansal, Ghritashee Bora, Luri Borah, Moumita Paul, Hima Bora, Prashasti Sharma, Dhiru Talukdar

Dr. B Borooah Cancer Institute, Guwahati, Assam, India, E-mail: [email protected]

Background: High grade Gliomas (Grade III, Grade IV gliomas) consist of 50% of all adult primary brain tumors with most common age of presentation being late adulthood. Factors which determine prognosis includes age at diagnosis, tumor histology, KPS, extent of tumor resection, duration of neurologic symptoms. The estimated survival of high grade glioma is 14 months after receiving standard treatment. In this study we retrospectively analyzed patients with high grade gliomas and tried to correlate overall survival with the Gross Tumor Volume after surgery. Purpose: To study the overall survival and its correlation with post-operativegross tumor volume in glioblastoma cases. Materials and Methods: Medical records of the patients registered in our hospital between January 2016 to December 2018 was analyzed. Tumor volume was collected retrospectively analyzing data from treatment planning system (XIO). Results: During the period of study a total 38 patients enrolled in our hospital. Median age of presentation was 51.5 years. 7 patients did not complete the treatment and died before starting or during the course of treatment. 31 patients completed the prescribed treatment, i.e. surgery followed by adjuvant radiation therapy and Temozolamide followed by maintenance Temozolamide. Out of the 31 patients Data of 3 patients could not be obtained and only 28 patients were available for final analysis. Overall median survival was 25 months. For male it was 25 months whereas for female it was 17 months (P value 0.15). For patients with age <50 year, median survival was 34 months and for patients with age >50 years overall median survival was 10 months only,(P value <0.025). Patient having gross tumor volume ≤ 70 cc had overall median survival of 34 months. Patient having gross tumor volume >70 cc had median survival of 25 months. HR 2.048 (95% CI, 0.5-8.3, P value 0.213). Conclusion: Gross tumor volume of > 70 cc was found to be a negative prognostic factor with survival chances half to that of patients with GTV of ≤ 70cc. Though the data is not statistically significant. Hence, more numbers of patients is required for result validation.

 > Abstract: 273: Prognostic significance of functional radiation resonse (DWI and MR spectroscopic) in case of postoperative high grade glioma with respect to isocitrate dehydrogenase mutation (1 and 2): A single institution prospective experience Top

Kushal Goswami, Anish Banerjee, Anirban Palit, Amitava Manna, Bhukya Swetha

Medical College and Hospital, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): The role of molecular status in prognosis of HG glioma has been established following WHO 2016 classification of CNS tumors. However as baseline of all Anatomic features of MRI is based on the CE T1 sequence done, the limit of the Functionally infiltrative portion of Grade III and glioblastoma is not definitively based on any one single MRI sequence, nor with any other Functionally based exam like FDG- PET, C11-MET, & FET. But MRI based functional imaging like MRS and DWI provides a component in a comprehensive yet to a cost benefited ratio. Our Study is aimed at comprehending the IDH mutative status of HG glioma with the baseline and the Functional (MRS and DWI) response pattern with respective to EFS and OS. Materials and Methods: 39 patients of Grade III Astrocytoma and Glioblastoma multiforme have been treated in our institution from September 2018-August 2019 Post operatively in a 3D conformal way. Based on an exclusion criteria of Biopsy (not included)


Non completion of adjuvant RT

we get to a patient population of 31 who have had MSR/SR followed by adjuvant radiation of 55.4GY/28# -60 GY/30 # as post operative dose. With concurrent and adjuvant temozolamide 21/ 31 of our patients were IDH+(1 or 2). Post operative Adjuvant Radiotherapy response were measured Functionally adjunct with IDH mutation. Good Response: ADC Min response (>10%) as measured in T2 Flair sequence (Change Pre RT and Post RT 3-6 Months) (GRI) and <15% response in MRS response criteria (CHO/Naa and CHO/ Cr ) whichever in higher.

  • Any one prognostically positive response (partial response)
  • Both lesser decrease (GRIII) (Poor response).

Based on the response pattern to RT and the Basic Genetic panel done on the post operative specimen we delineated 4 groups. Good Response with IDH+(12/31)(38.7%)) Progressive disease (functional ) with IDH +(9/31)(29.3%) Good response/ partial response with IDH wild type-(6/31)(19.3%) Poor response with IDH wild type-(8/31) (25.8%). Results:

  • MRS response score are overall equivalent to ADC min in response pattern (PFS=8.3 vs 8.9 months) (p=0.002 vs p= 0.002 with a 95 % CI (MRS) of (6.6-10.9) vs 95% CI (DWI) of 6.1-10.04
  • Overall functional response according to our definition combining DWI and MRS yields a PFS ( GR-8.2 m, PR-3.9 m, Poor response-3.1 month)
  • ntroducing IDH mutation among the Functional response pattern yields a mildly superior PFS for the the Good functional response pattern)(9.7 m vs 9 m) but also equivalently for the Poor response with PFS( 3.5 -4.2 m)
  • Using the following data we divided our pt population into 2 groups in terms of superior prognosis
  • GR with IDH mutant
  • Gd /PR withI DH mutant.

Any estimation of IDH mutant in combo with Functional response with (GR = 9.3 m, PR = 2.2 m & Poor response = 4.2 m) (p=0.007 with 95% CI (4.3-7.4). Estimation of EFS with respect to IDH mutation alone(Mutant=7.1 months, wild=4 months) (P=0.045 with 95% CI(4.3-7.4). Conclusion: While mutations of primary brain tumor has been proved to be of undoubted significance, our aiim in this study has been to make alliance of Functional response patterns and molecular genetics.

 > Abstract: 278: Encouraging experience of intensity modulated proton beam therapy in cranio-spinal irradiation Top

Utpal Gaikwad, Srinivas Chilukuri, Sapna Nangia, Dayanada Sharma, M. P. Naufal, Rakesh Jalali

Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India, E-mail: [email protected]

Introduction: To review patients treated with cranio-spinal irradiation (CSI) at our centre, South East Asia's first proton centre. All patients were treated using Intensity modulated proton beam therapy (IMPT). The aim is to share unique challenges faced during planning, plan implementation, dosimetric benefits and acute toxicities experienced by patients. Patients and Methods: Six patients, (3 adults and 3 paediatric, clinical indications) received cranio-spinal irradiation (CSI) using IMPT technique. Average PTV length 68 cm and PTV volume 2509 cc. For all patients whole body Vacloc made, planning CT cuts acquired as per institutional protocol. Clinical target volumes and organs at risk delineated as per standard guidelines using Raystation system Citrix version 7, once finalised by consultant, differential PTV margin generated, 3 mm for brain and 5 mm for spine. Intensity Modulated proton plan generated using, 4 or 5 fields, SFO technique and eight cm junctions with dose gradient technique to avoid dose feathering by junctional shift and achieving homogenous dose distribution. For dose calculations Monte Carlo algorithm used and robustness for 3 mm evaluated. Once plan finalised, patient specific QA performed before implementation of each plan. All patients underwent baseline neuropsychological and QOL assessment at baseline (pre – RT) then planned for subsequent assessment on follow up as per institutional protocol. Results: Dose prescribed for CSI was in the range of 19.8 GyE to 30.6GyE. Mean Conformity index is 1.1 and mean Homogeneity index is 1.02. Lens Dmean_avg 3.96 GyE, Parotid Dmean_avg 10.67 GyE, Bowel Bag Dmean_avg 0.18 GyE, Lung Dmean_avg 0.65 GyE, Kidney Dmean_avg 1.85 GyE, while heart, liver and gonads receiving no dose. Compared to adult CSI, pediatric CSI where whole vertebral body was included in CTV instead of spinal canal with nerve roots, as per standard guidelines, doses to OARs such as parotids Dmean_avg (0.44 GyE Vs 13.84 GyE), oesophagus Dmax_avg (0 Vs 33.34 GyE) midline mucosa Dmean_avg (2.05 Vs 7.78 GyE) kidney Dmean_avg (0.5 Vs 3.22 GyE) Bowel bag Dmean_avg (0.01Vs 0.36 GyE) are on higher side. Also among 6 patients only paediatric patients developed grade 2, grade 3 toxicities and over all treatment time was prolonged in them (No treatment gaps Vs 4 day's gap). Conclusion: With IMPT it is practically feasible to achieve good homogeneous conformal coverage and reduce radiation doses to organs at risk significantly, limiting acute and late effects, improving quality of life and therapeutic ratio for patients planned for craniospinal irradiation (CSI). At the same time it is important to adapt newer contouring guidelines for paediatric CSI patients and to plan dose gradient while radiating whole vertebrae, further limiting OAR doses.

 > Abstract: 283: Treatment intensification in “High risk-low grade gliomas” – Is “Pignatti criteria” enough? A case report and review of literature Top

Mansi Munshi, Sumit Basu, Bhooshan Zade, Vinay Babu, Sathiya Narayan, Amit Nirali, Pooja Moundekar

Ruby Hall Clinic, Pune, Maharashtra, India, E-mail: [email protected]

Background: Low grade gliomas are a heterogeneous group of brain tumors which vary in prognosis depending on the molecular pathway involved. Although treatment decisions on adjuvant therapy for this group is often guided by “Pignatti” criteria, increasing understanding of molecular expression (IDH1, MGMT, TP53, 1p19q) has helped to identify low grade gliomas that may be at a higher risk than others. These “high risk” low grade gliomas behave aggressively and warrant treatment intensification. Case Description: A 32-year-old mother of two, without any comorbidity presented with a history of progressive headache and personality change since the past 1 year. MRI Brain revealed a SOL measuring 1X2 cm, isointense on T1 and hyperintense on T2 & FLAIR weighted images with minimal perilesional edema and no post contrast enhancement. Gross total excision was done and histopathology showed Astrocytoma Grade II which was MGMT non methylated by PCR and IDH 1 & 2 wild using next generation sequencing. She was given adjuvant radiotherapy to a dose of 54 Gray in 30 fractions over 6 weeks, which she tolerated well. Discussion: Historically, the decision to give adjuvant radiotherapy in low grade gliomas, has been based on the “Pignatti criteria” which essentially incorporates tumor size & location, histology, age, and extent of resection. Molecular markers like IDH and MGMT have been shown to correlate better with survival than these traditional criteria. Treatment intensification with radiotherapy may benefit such “high risk” low grade gliomas, even in the absence of two or more “Pignatti criteria” factors. Recently, phase II trials for the use of temozolamide in this subgroup have shown a survival benefit too. Conclusion: “Pignatti criteria” is no longer enough to guide decision making for adjuvant radiotherapy in low grade gliomas and molecular analysis is highly recommended to identify individuals with aggressive tumors requiring treatment intensification with radiotherapy. Questions regarding dose of radiotherapy and optimal choice and duration for concurrent and adjuvant chemotherapy in this subgroup remain unanswered, however should be considered on a case to case basis.

 > Abstract: 305: Re-irradiation in primary brain tumours: Experience from a tertiary care centre Top

Mohammed Basalathullah, Monica Malik, Syed Fayaz Ahmed, Deepthi Valiyaveettil, M. Sindhu

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India, E-mail: [email protected]

Introduction: The advances in molecular diagnosis and therapy have resulted in a cohort of glioma patients with longer survival, which sometimes entails local recurrences and tumour progression. In the absence of standard guidelines and data from prospective trials, these patients undergo a one or more of the various salvage therapies. Re-resection, systemic therapy with irinotecan, temozolamide, bevacizumab, re-irradiation have all been employed in this setting. Objectives: This study was done to evaluate the feasibility and efficacy of re-RT in recurrent primary brain tumours, and to assess treatment outcomes and toxicities in these patients. Materials and Methods: Patient Selection and Treatment Technique: A total of 36 adult patients diagnosed with recurrent primary brain tumours and treated with re-RT at our institute from 2012-2018 were included in the study. Contrast enhanced magnetic resonance imaging (CEMRI) was routinely done for all patients and fused with the computed tomography images in the treatment planning system for target volume delineation. A prescribed dose and fractionation regimen, judged safe and suitable for the patient was decided by the treating physician. Concurrent temozolomide at a daily dose of 75 mg/m2 /day was administered for high grade glioma patients. All patients were treated with external beam radiotherapy with fractionated conformal radiotherapy, most commonly with intensity modulated radiation therapy (IMRT). Assessments of Outcomes and Toxicities: Physical and neurologic examination was performed at baseline and at follow ups and treatment outcomes were assessed by clinical examination and CEMRI. The primary endpoint was overall survival (OS), defined as the length of time from re-RT to any cause of death or the date of last follow-up when death had not occurred yet. Treatment related toxicities were assessed based on standard guidelines. Statistical Analysis: Data was analyzed using Statistical Package for Social Sciences v 26 software (IBM Corporation). Survival was obtained by Kaplan-Meier graphs. A p value of < 0.05 was considered significant. Results: We analyzed all patients (n=36) receiving re-RT for recurrent primary brain tumours during the seven year period. Median age of patients was 38 years (range, 18-54) at re-RT and included 45.6% females and 54.4% males. 58.3% patients had a Karnofsky Performance score of more than 70. 25 patients underwent surgical excision or biopsy at recurrence, out of which 10 underwent malignant transformation from low to high grade glioma. At re-RT 83.3% patients were treated with IMRT and 1 patient was treated with stereotactic radiosurgery and remaining with 3DCRT. The median time between initial and re-RT was 50.5 months (range, 11-163). Median initial RT dose was 55.12 Gy (range, 30.6- 63) and median re-RT dose was 50 Gy (range, 26.67-54). The median overall survival after re-RT was 7 months (range, 1-28 months). Most patients experienced only mild grade 1 and 2 side effects such as alopecia, headache, nausea. Two patient developed radiation necrosis out of which one patient required surgical intervention. Conclusion: Reirradiation in primary brain tumours is a feasible and effective modality in selected patients of recurrent gliomas.

 > Abstract: 325: Brain radiotherapy with concurrent temozolamide versus brain radiotherapy alone for patients with brain metastasis Top

Anshika Gupta

MGM Medical College, Indore, Madhya Pradesh, India, E-mail: [email protected]

Background: Brain metastasis is seen in around 40% of all cancer patients. Whole Brain radiotherapy is the standard of care for the treatment of brain metastases, which has shown increased survival time by 3 to 6 months. The effectiveness of chemotherapy in brain metastasis is limited because most of the chemotherapeutic drugs cannot cross the blood-brain barrier. However, Temozolomide prodrug of procarbazine efficiently crosses the blood-brain barrier and shown effectively in other primary brain tumours when given concurrently with radiation. Thus we want to analyse the effect of temozolamide in patients of brain metastasis when given it with radiotherapy. Purpose and Objective: To compare brain radiotherapy plus concurrent temozolamide versus radiotherapy alone for patients with brain metastasis in terms of quality of life, adverse events and response over a period of 12 months. Materials and Methods: 30 patients presenting with brain metastasis in OPD of Dept of Radiation Oncology, GCH Indore were taken up for study. They were randomly allocated into two Arms. Arm 1 received concurrent temozolamide 75 mg/m2 for 5 days followed by 200 mg/m2 five times in a month for 6 months along with radiotherapy 10 fractions of 30 Gy. Arm 2 received radiotherapy of 10 fractions of 30 Gy. All the patients were assessed for toxicity during and after the treatment and QoL was assessed pre and post treatment using FACT- G and FACT-Br questionnaire. For statistical analysis, SPSS software version 25.0 was used and Paired 't' test was applied. Results: While assessing the response, complete response was 20% vs 10%, partial response was 20% vs 20% in Arm 1 and Arm 2 respectively and this difference was stastically significant (P value = 0.014), whereas objective and subjective response was 20% vs 10% each in Arm 1 and Arm 2 respectively. Addition of temozolamide leads to grade 1 nausea in 20% patients compared to 10% patients without temozolamaide. Similarily vomiting grade 1 vomiting was seen in 22.2.% patients in arm 1 compared to 20% in arm 2. QoL decreased from week 0 to week 24 in Arm1 but it was statistically not significant (p=0.328) but when compared with arm 2 at week 0 and week 24 where the difference was statistically significant (p=0.001). Conclusion: From our study results, complete response was found more in Arm 1. However, toxicity was more leading to morbidity of additional 10% but it was acceptable as it could be managed by symptomatic treatment. Hence, temozolamide can be beneficial in brain metastasis along with radiation. Therefore, further studies should be done for further evaluation with large sample size and more duration of study and longer follow up period.

 > Abstract: 330: High-dose neural stem cell radiation may not improve survival in glioblastoma Top

Saheli Saha, Rimpa Basu Achari, S. Moses Arunsingh, R. K. Baghami, R. K. Shrimali, Animesh Saha, Sanjoy Chatterjee, Indranil Mallick, B. Arun

Tata Medical Center, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): To evaluate the effect of radiotherapy dose-volume parameters of neural stem cell (NSC) compartment on progression-free survival (PFS) and overall survival after post-resection chemoradiation in newly diagnosed glioblastoma. Background: Glioblastoma is a heterogeneous tumour. The cancer stem cell hypothesis sheds some light on its heterogeneity. Studies have documented the presence of neural stem cells (NSC) with astrocyte-like characteristics in the adult human brain, represented by the subventricular zone (SVZ) of the lateral ventricles and the subgranular layer (SGL) of the dentate gyrus of the hippocampus. These cells possess specific lineage hierarchy and plasticity and are capable of self-renewal, multipotentiality and gliomagenesis. Post-resection care for glioblastoma remains partial brain conformal radiotherapy with concurrent and adjuvant temozolomide (TMZ), but with a median overall survival of only 14.6 months with most recurrences in and around the resection cavity. Magnetic resonance imaging (MRI) morphology has suggested that some glioblastomas may carry radiological signatures of their stem cell origin. Elective irradiation of the NSC compartment, aiming to eliminate potential stem cell rests and enhance survival, remains experimental with conflicting results. A competing therapeutic strategy is NSC sparing irradiation in selected patients and it aims to respect plasticity for repair, thereby improving neurocognitive outcomes. Materials and Methods: Sixty-one patients with unifocal glioblastoma were included. Ipsilateral (NSC_Ipsi), contralateral (NSC_Contra) and combined NSC (NSC_Combined) were contoured on radiotherapy planning computerised tomography datasets. NSC dose-volume parameters were correlated with PFS and overall survival. Serial magnetic resonance imaging scans were assessed to understand the frequency of pre- and post-treatment involvement of the NSC by contrast enhancing lesions (CELs). Results: Baseline involvement of NSC with CELs was seen in 67.2% and 95.9% had CELs and FLAIR abnormalities at progression. With a median follow-up of 14.1 months (interquartile range 9.4-20.6 months), median PFS and overall survival were 14.5 (95% confidence interval 11.6-17.5) and 16.2 (95% confidence interval 13.3-19.2) months, respectively. Poor Eastern Cooperative Oncology Group performance score, advanced recursive partitioning analysis class, unmethylated O6- methylguanine methyltransferase (MGMT) status, higher than median of mean NSC_Ipsi dose were associated with significantly inferior PFS and overall survival on univariate analysis. On multivariate analysis, unmethylated MGMT status, higher than median of mean doses to NSC_Ipsi and poor compliance to adjuvant temozolomide were independent predictors of inferior survival. Conclusion: In this cohort, 67.2% of newly diagnosed glioblastoma patients had NSC involved with CELs at presentation and 95.9% at progression. This might be an imaging surrogate of the current notion of gliomagenesis and progression from NSC rests. A high radiation dose to NSC_Ipsi was significantly associated with inferior survival. This could be a function of larger tumours and planning target volumes in those with pre-treatment NSC involvement. Methylated MGMT and good compliance to adjuvant temozolomide were independent predictors of better survival. Until further evidence brings hope for glioblastoma, elective, partial NSC irradiation remains experimental.

 > Abstract: 350: To study the effect of incidental radiation on pituitary gland function in irradiated paediatric central nervous system tumour patients Top

K. R. Anu, H. B. Govardhan, S. J. Divyashree, Merrin Shija, B. Kalyani, Sunny Paul Saritha, Ibrahim Khaleel

Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): To study the effect of radiotherapy on pituitary function in paediatric patients with central nervous system tumours. Materials and Methods: It is a prospective study, conducted between January 2015 – December 2018 at Kidwai Cancer Institute, Bangalore including 30 patients aged between 6 to 25 years. For all patients, baseline pituitary function tests such as TSH, FSH, LH, GH, ACTH and prolactin were obtained, followed by repeat measurements post RT, 3, 6 and 9 months. All patients were simulated and planned with IMRT as per institute protocol. The mean dose to the pituitary gland is tabulated and correlated with pituitary function. Results: Among 30 patients the most common tumours were anaplastic astrocytoma and medulloblastoma (28% each) followed by anaplastic ependymoma. The mean volume of pituitary gland was 0.3 cc (2-4cc). The mean of mean pituitary dose was 40Gy (10-45Gy). Altered pituitary function was observed in 6 patients in the mean duration 6 months (3-9 months). Conclusion: Significant incidental dose delivered to the pituitary gland may alter its function. In our study a mean dose of > 40 Gy to the pituitary gland showed alteration in its function in a mean duration of 6 months. This study highlights the importance of pituitary hormone testing so that appropriate interventions may be made in this developing age group. It also calls for practising pituitary sparing conformal radiation and need for long term follow up with larger sample size to substantiate our findings.

 > Abstract: 355: Prospective evaluation of response rate and toxicity profile of vascular lesions treated with robotic radiosurgery in a tertiary care centre in India Top

Arya Nair, K. Sruthi, A. Parasuraman, Ayya Durai, Suhas Udayakumaran, N. R. Sreehari, Anoop Thomas, K. Sajish, R. Anoop, K. U. Pushpaja, Ajinkya Gupte, Debnarayan Dutta

Amrita Institute of Medical Sciences, Kochi, Kerala, India, E-mail: [email protected]

Background: Evaluation of response to treatment and toxicity profile of vascular brain lesions treated with robotic radiosurgery in Indian patient population. Materials and Methods: Between May 2017 and Sep 2019, 55 patients, vascular brain tumours (AVM 35, 11 Glomus, 5 brainstem cavernoma, 4 vertebral haemangiomas) were prospectively accrued and treated with cyberknife radiosurgery. AVM & glomus tumour patients with residual/recurrent disease not suitable for surgery were accrued in the study. Brainstem cavernomas not amenable for surgery accrued. Vertebral hemangioms after stabilization was considered for Radical radiation therapy with SRS. Contrast CT simulation was done, fused with T1 contrast / T2 FLAIR MRI / MR angiography/ DSA for contouring and planning. Planning done with Multiplan (Volo) system and treated with CyberKnife M6 after optimization with Monte Carlo algorithm. PTV margin of 2 mm and dosage schedule depending upon volume & disease. Results: 35 AVM patients [Male 22 (63%), age 11 years, SM Gr I-II 29, SM Gr IV: 5, cerebellar: 7, frontal: 12, thalamic: 2, intraventricular: 2 ] treated with CK as per Flickinger model guideline. 29 patients received single stage SRS [22-24Gy: 17, 18-22Gy: 9, 16-18Gy: 3]. 17/35 (48%) had bleed prior to SRS, 10 (28%) had convulsions as presentation and 2 (6%) patient had deficit as presentation. After surgery, 3 patients had >3 years follow up and had complete obliteration of nidus. One patient was on long-term (>8 wk) follow up after SRS. One patient died with bleed at 8 months post-SRS. Six patients with SM gr IV AVM treated with 'staged' SRS. After contouring of entire nidus, the nidus is divided into two halves and treated with 18Gy/1fr to each halves at six months interval. At follow up, regression of nidus observed. Five brainstem cavernomas with intermittent episodes of micro-bleed with intermittent episodes of neuro-deficit was treated with SRS (15Gy/3fraction). All the 5 patients had significant clinical response after SRS with reduction in frequency of neuro-deficit episodes. Eleven patients with glomus tumour treated with CK (18Gy/3fr). Significant regression of symptoms (tinnitus) at post-CK follow up. Four patients with vertebral hemangiomas [Female 3 (75%), mean age 35 years, D3/D4 – 2 pt, L1-3 1 pt, L5 1 pt] treated with SRS (15Gy/1fr). At follow up, significant regression of symptoms and resolution of mass on MRI scan seen. Conclusions: Early follow up of patients treated with SRS shows low toxicity and significant symptomatic relief. Hemangiomas and glomus have early radiological and clinical response after SRS. Longer follow up of the same cohort will establish the efficacy of CK in our patient population. SRS is an option in selected benign brain tumour patients.

 > Abstract: 357: Assessment of prognostic factors and outcomes in medulloblastoma Top

Beulah Elizabeth, Monica Irukula, Fayaz Ahmed, Deepthi Nair, Prathyusha Eega

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India, E-mail: [email protected]

Purpose and Objective(s): Assessment of prognostic factors and outcomes in Medulloblastoma. Materials and Methods: Records of all the patients diagnosed with medulloblastoma from 2011- 2018 and who received craniospinal irradiation in our hospital were retrospectively analysed. Prognostic factors and overall survival of patients was assessed. SPSSv20 was used for the Kaplan-Meier survival analysis. Results: A total of 39 cases were included with age between 3 to 48 years and median age at diagnosis being 15 years. Males vs females ratio was 2.5:1, standard risk vs high risk 1.05:1, 26 classical variants, 10 were desmoplastic variants, 2 were large cell and one was small cell variant. 27 patients received concurrent and adjuvant chemotherapy and 12 patients did not receive chemotherapy. 2 patients had CSF metastasis. 4 pediatric patients who underwent GTE had recurrence. Extent of resection did not affect overall survival of patients. 5 year overall survival rate was 65.8%. Overall survival in patients who received adjuvant chemotherapy vs patients who did not receive adjuvant chemotherapy was 64% and 60% respectively. Children had 5 year overall survival of 77.7% and adults had 32.1%. Desmoplastic variants did better compared to classic variants. Conclusion: Surgery followed by concurrent chemoradiotherapy and adjuvant chemotherapy improves the overall survival. Children had better median survival and 5 year overall survival compared to adults. Desmoplastic variants did better than classical variants.

 > Abstract: 366: Great vessel motion mapping from 4D magnetic resonance imaging to 3D computed tomography? Implications for oligo metastatic spinal stereotactic body radiation therapy vessel constraint Top

Bhavya Patneedi, Ashish Bange, Shankar Vangipuram, Pradeep Bhaskar, Hirak Vyas, A. Karuppusamy

HCG Cancer Centre, Mumbai, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): 4D-MRI imaging offers good soft tissue details & a real time motion assessment. We hypothesize that the actual volume of the aorta and the dose received by it would be more than what it seems on a static planning CT-image due to the dynamic pulsatile motion of the great vessel. In this study, we made an effort to quantify the volume and dose variations of the aorta with the volumes marked on planning CT-scan Vs 4D-MRI scan based PRV generation in cases of oligo metastatic spine SBRT. Materials and Methods: Five patients of oligo metastatic spine SBRT (Lumbar 2; Dorsal 3) were chosen for this study. All patients underwent planning CT-scan using deep inspiratory breath hold (DIBH) technique with RPM device. All patients underwent 4D-MRI scan sequences (FIESTA 4 chamber view, contrast LAVA, DEFFICO sequences) using pulse gated technique with breath holding in the treatment planning position on 1.5T MRI machine. Breathhold 4D MR Scan mitigates respiratory motion and allows us to capture true pulsatile motion. Aorta was delineated in 2 clinical contexts (1) Aorta MRI: Aorta delineated in one of the 4D-MRI bins (4 chamber view) was deformably propagated onto the rest of the bins using intensity based deformable registration algorithm software and the PRV for the aorta was generated. The PRV Aorta MR volume was registered with BH CT-Scan and contours were mapped. (2) Aorta CT: On static BH planning CT-scan. The target volume and all other OARs were contoured on the Planning CT-scan and transferred to TPS for planning. The target coverage parameters and OAR constraints were achieved as per RTOG protocol. The PRV Aorta volumes on MRI and CT along with the D max and Threshold dose received by the respective PRV Aorta (Aorta MRI & Aorta CT) where assessed. These parameters were analyzed using Paired sample t test in SPSS software. Results: The median motion of aorta due to its pulsations was 2 mm (Range 1-2.5 mm). The PRV Aorta Volumes in MR were significantly more compared to CT (p value-0.008). Similarly, the D max and threshold dose received by the PRV Aorta MR as compared to CT were more and were statistically significant (p Value-0.05 and p Value-0.008 respectively). Conclusion: We noticed statistically significant change in the volumes and doses (max and threshold) of aorta contoured on 4D-MRI vs Planning CT-scan. As the tolerance limit of great vessel (aorta) for single fraction spine SBRT is higher than the maximum doses delivered to the target, these results may not hold any significance but this study may form a basis for future studies of SBRT in abdominal malignancies close to great vessels in terms of dose fluctuations due to their pulsations. This is the first study reported in literature and proof-of-concept to map the 4D MR motion on the 3D CT datasets & analyse the dose deformations.

 > Abstract: 373: Prospective study evaluating outcome, recurrence rate and retreatment incidence in 115 oligo-brain metastasis treated with robotic radiosurgery in a tertiary care centre in India Top

K. Sruthi, Debnarayan Dutta, Ajinkya Gupte, Ram Madhavan, R. Anoop, K. Beena, K. U. Pushpaja, Haridas Nair, K. Pavithran, Wesley Jose, Arun Philip

Department of Radiation Oncology and Medical Oncology, Amrita Institute of Medical Science, Kochi, Kerala, India, E-mail: [email protected]

Background: Evaluation of outcome, recurrence rate and retreatment incidence in oligo-brain metastatic patients treated with robotic radiosurgery in Indian patient population. Materials and Methods: Between May 2017 and Sep 2019, 115 brain metastases in 70 patients were prospectively accrued and treated with cyberknife radiosurgery. 'Oligo' brain metastasis patients with good performance status (KPS>80) and controlled primary disease were accrued in the study. Contrast CT simulation was done and fused with T1 contrast / T2 FLAIR MRI for contouring. Planning was done with Multiplan (Volo) system and treated with CyberKnife M6 after optimization with Monte Carlo algorithm. PTV margin of 2-3 mm and dosage of 12-30 Gy/1-5 fractions depending upon volume was given. Results: 70 patients with 115 lesions {mean age 56.3 yrs (29-82 years)}, the primary being breast in 30%, lung 43%, RCC 7%, other sites 20% were evaluated. Of them 8 patients had re-RT after WBRT. Brain metastasis were treated with SRS [1 Fr: 50 (71%), 3Fr-8 (11%), 5Fr-12 (18%)]. RT dose of 12Gy, 13-18Gy, 20-24Gy & 25-30Gy in 3, 12, 36 & 19 patients was given. Single GTV in 44 (63%), 2-3 in 19 (20%) & 4-5 in 7 (10%). Mean PTV volume was 29.9 cc (2.1-235 cc). Mean 12Gy normal brain vol was 37.5cc (4%), brainstem max dose 639 cGy, Optic chiasm max dose 202 cGy. The mean HI was 1.19, CI 1.25, MU 20573, Treatment time 56.8 min and number of beams for treatment was 229. At mean follow up 26.2 wks (2-105 wk) 55 (78%) had controlled brain disease, 14 (20%) had progression. Estimated mean OS was 72.3 wks (SE 6.9, 95%CI 55.7-85.8) [OS at 36 wks: 83%, 45 wks 71.2%, 60 wks 55.7%]. 'Out of-field' recurrence was in 12/15 (80%), 'In-field' recurrence in 1 (6%) & 2 (12%) had multiple lesions. Among 13/15 (95%) patient with brain recurrence received Re-RT [SRS 7 (53%), WBRT 6 (47%)]. Conclusions: Estimated mean OS, recurrence rate and re-treatment rate after SRS in Indian patients is acceptable. Recurrence rate at 6 months is 20%. 95% of patients with brain recurrence were treated with re-RT. Re-treatment with SRS possible in 53% of patients.

 > Abstract: 394: Prospective evaluation of outcome, recurrence rate and retreatment incidence in 91 benign brain tumours treated with robotic radiosurgery in a tertiary care centre in India Top

Shabin K. Sidhique, Debnarayan Dutta, K. Sruthi, A. Parashuraman, R. Ayyadurai

Amrita Institute of Medical Sciences, Kochi, Kerala, India, E-mail: [email protected]

Purpose and Objective(s): Evaluation of outcome, recurrence pattern and re-treatment incidence in benign brain tumors treated with robotic radiosurgery in Indian patient population. Materials and Methods: Between May 2017 and Sep 2019, 91 patients with benign brain tumours (Acoustic schwannoma (AN) 42, Meningioma 49) were prospectively accrued and treated with cyberknife radiosurgery. AN and meningioma patients with residual/recurrent disease not amenable for surgery or early disease with good performance status (KPS>80) were accrued in the study. Contrast CT simulation done and fused with T1 contrast / T2 FLAIR MRI for contouring and plan. Planning done with Multiplan (Volo) system and treated with CyberKnife M6 after optimization with Monte Carlo algorithm. PTV margin of 2 mm and dosage schedule depending upon volume. Results: 49 meningioma patients [mean age 56.3 yrs (29-82 years), Male 16 (33%), skull-base 30%, falcine 22%, tentorial 18%, cavernous 10%) were treated with SRS [1 Fr: 21 (43%), 3Fr-4 (8%), 5Fr-23 (47%)]. RT dose of 12Gy, 13-18Gy, 20-24Gy & 25-30Gy in 7 (14%), 17 (34%), 7 (14%) & 18 (36%) patients respectively. Radical SRS in 22 (45%), post-surgery residual in 14 (29%) and recurrent disease after surgery in 10 (20%) patients. Mean actuarial progression free survival is 29.1 months (SE 1.5, 95% CI 26-32.2 months). 24 months PFS is 87.3%. 5/49 (10%) had radiological progression after SRS at maximum follow-up of 3 years. All 5 patients needed surgery after recurrence, 2 patients were grade II at progression with residual disease, re-treated with RT (50.4Gy/28fr, mean gap of 23 months). Two patient had controlled primary, but was on long-term steroid. 42 acoustic schwannoma patients [mean age 54 yrs, Male 20 (45%), Rt side 24 (57%), Bilateral 1 (2%)] were treated SRS [1 Fr: 28 (67%), 3Fr-8 (19%), 5Fr-5 (12%)]. RT dose of 11.5-12.5Gy/1fr, 18-21Gy/3fr, & 20-25Gy/5fr in 29 (70%), 17 (34%), 7 (18%) & 6 (15%) patients respectively. Radical SRS in 23 (55%), post-surgery residual in 4 (10%) and recurrent disease after surgery in 6 (11%) patients. At follow-up, 26 (62%) patient had significant regression of symptoms (tinnitus, vertigo), 17 (41%) had stable disease and only 3 (7%) had mild deterioration of clinical symptoms. Mean actuarial progression free survival is 27.1 months (SE 1.7, 95% CI 24.5-31.3 months). 20 months PFS is 84.7%. Only one (2%) patient had mild radiological progression after SRS, considered as pseudo-progression. One patient was on long-term (>8 wks) steroid. Conclusion: Recurrence rate after SRS in benign brain tumours are low (5%) at 3 years follow up. Re-treatment rate after SRS is possible with surgery. Recurrence rate at 3 year is 5% in meningioma and nil in AN. Additional dosage of steroids after SRS required in 4%. Skull base meningiomas with high MIB index recurs early. Post-CK there is significant improvement of tinnitus & vertigo in AN patients. SRS is an option in selected benign brain tumour patients.

 > Abstract: 400: Does gross total or subtotal resection affect the disease response and survival outcomes in gliomas? Top

Sowjanya Kondru, Goutham Reddy, Sandhya Rani Nipani, R. Srikanth, Aarathi Ardha

MNJ Cancer Institute of Oncology and Regional Cancer Center, Hyderabad, Telangana, India, E-mail: [email protected]

Background: Gliomas are the most common primary intracranial neoplasms in adults. Grading of gliomas is now done based on Histopathologic features along with molecular features like IDH (Isocitrate dehydrogenase) mutations, 1p19q codeletion, methylation profiling, ATRX loss, TERT mutation, BRAF V600E mutation, etc. Gliomas are managed with initial surgery for maximum possible resection of the tumour followed by adjuvant therapy with radiation with or without chemotherapy. Surgery plays a crucial role in both reduction of maximal tumour bulk and in alleviating tumor-associated mass effect and raised ICP(Intracranial Pressure). Initial surgery is always required for tissue diagnosis and pathologic analysis especially because molecularly targeted therapies are useful. Retrospective evidence for both high- and low-grade infiltrative gliomas states that maximizing the extent of tumor bulk removal potrays a better outcome as long as neurological function is maximally preserved. Purpose: Extent of surgical resection in gliomas can impact disease outcomes and patient survival. We in our study, aim to correlate whether the degree of resection has a bearing on the survival outcomes. Methodology: In this study we have retrieved data of patients diagnosed with gliomas and registered at MNJ Cancer Hospital in the year 2016-17. ECOG performance status of patients at initial presentation was studied. Factors like age distribution, sex ratio, grades of gliomas, initial extent of surgery and the adjuvant therapy received were analysed. The residual volume of tumour was measured in the post-operative MR imaging. Survival outcome after a median follow up period was calculated. Results: Patients were of all age groups youngest being 15 and the oldest being 65. Women were in the majority with 13 recorded cases. Patients with ECOG status 1 at presentation showed median overall survival of 25 months. performance grade 2 and 3 had median survival of 9 months, across all performance status median survival was 10 months. Patients with grade four tumor showed a median survival of 9 months, median survival in grade 2 and 3 being 26 months. All glioblastoma multiforme were found to show low overall survival of 10 months. All patients were operated with varying amounts of residual tumor tissue. Four patients who defaulted in adjuvant treatment were found to have a median survival of 8 months. We have noted 2 glioblastoma recurrences in previously treated low grade gliomas. Conclusion: Our study highlights the need for maximum possible surgical resection, especially in low grade gliomas as majority had better survival outcome. In high grade gliomas, the survival is irrespective of the degree of resection and is most importantly related to their performance status at presentation. Gross total resection is to be strongly considered in low grade gliomas as there is potential risk for conversion of the residual tumour to high grade gliomas, predominantly Glioblastomas.

 > Abstract: 406: Hippocampal avoidance in whole brain radiotherapy for metastases: Comparative neurocognitive and dosimetric assessment Top

Vibhay Pareek, Rajendra Bhalavat, Manish Chandra

NCI, AIIMS, New Delhi, India, E-mail: [email protected]

Purpose and Objective(s): Hippocampus is associated with formation and storage of new memory and irradiation of same during whole brain radiotherapy in brain metastases leads to decline in the neurocognitive function. Recent advancements in radiation delivery in form of IMRT, Hippocampal avoidance has been made possible. We analyze feasibility of hippocampal sparing and associated neurocognitive and dosimetric assessment. Materials and Methods: Between June 2016 to December 2017, 125 patients diagnosed radiologically and clinically with brain metastases were included in the study. Mini Mental State Examination (MMSE) and quality of life assessment with EORTC BN20 questionnaire were assessed along with dosimetry. Patients were assessed at baseline and followed by at 1, 3 and 6 months respectively. Factors were compared with the historical group with relation to quality of life especially neurocognitive functioning. Wilcoxon test for multiple comparisons was calculated to detect significant differences in global QoL scores. Results: Median age of accrued 125 patients was 48 years. Median D100% and Dmax to contralateral hippocampus was 7.1Gy and 16.7Gy. With IMRT, the doses to other critical structures were reduced. Patients treated with IMRT were found to have achieved desired dose constraints to hippocampus. Assessment of neurocognitive function between two groups, there was no difference at 1 month after treatment, however, difference was seen at 3 and 6 months favouring hippocampal avoidance. No difference noted in other aspects of quality of life between two groups. No severe toxicities (Grade 3 and 4) were noted in either group. Median survival in the HA-WBRT arm was found to be 10.1 months. Conclusion: Conformal avoidance of hippocampus during WBRT is associated with improved neurocognitive function and quality of life. IMRT has found to provide better dosimetric outcomes in HA-WBRT.

 > Abstract: 410: Ventricular – Subventricular zone involvement: A predictive factor for survival in glioblastoma Top

Vibhay Pareek, Rajendra Bhalavat, Manish Chandra

NCI, AIIMS, New Delhi, India, E-mail: [email protected]

Purpose and Objective(s): MRI imaging is an essential tool in diagnosing glioblastoma and it can give various anatomical details related to disease. It gives an assessment of involvement of disease with ventricular – subventricular zone (VSVZ), subgranular (SGZ) and corpus callosum (CC). This study aims at assessment of survival outcomes in diseases involving neurogenic zones and corpus callosum and the associated prognostic factors. Materials and Methods: We retrospectively analyzed 376 adult patients treated for histologically proven Glioblastoma. MRI studies were assessed for the tumor volume and its association with the neurogenic zones and corpus callosum. Age of patient, comorbidities associated, performance status, extent of resection and radiation doses received by these structures were evaluated. Overall (OS) and progression free (PFS) survivals were calculated and analyzed with multivariate Cox analyses. Results: Of the 376 patients, 121 had VSVZ involved, 62 had CC involved and 43 had SGZ involved and remaining 150 had cortical involvement and the latter served as controls. Overall median age was 60.4 years, median Karnofsky performance score (KPS) was 80 and median tumor volume was 34.7 cm3. Gross total resection (GTR) was seen in 50.6% and subtotal resection in 38.1% and rest were unresectable. On multivariate cox analyses, VSVZ was found to be an independent factor for poor OS and PFS. Besides, increasing age, lower KPS, less than GTR status were associated independent factors for reduced survival. Conclusion: Patients with GBMs contacting the VSVZ and SGZ neurogenic zones exhibit divergent clinical patterns of tumor recurrence and survival and VSVZ involvement are associated with early recurrences and lower survival. VSVZ has a rich stem cell and growth factor microenvironment and these structures can be considered as organs at risk in uninvolved disease for probably better outcomes.

 > Abstract: 414: Primary cerebral neuroblastoma: A rare case presentation Top

Vinodh Kumar Selvaraj, Deleep Kumar Gudipudi

Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India, E-mail: [email protected]

Purpose and Objective(s): Neuroblastoma is the most common extracranial solid tumor of childhood and accounts for 8%-10% of all pediatric cancer. It is extremely uncommon for neuroblastoma to present primarily as intracranial lesion. There is very sparse literature on the intracranial presentation and management of these tumors. Here, we report such a rare case treated in our hospital. Materials and Methods: 24 year male with no comorbids/habits, evaluated for complaints of headache and pain in left eye, was detected to have left occipital lobe mass in MRI. He underwent left occipital craniotomy and near total excision of the lesion. Post-op histopathological examination showed Neu N diffusely +ve, CFAP focally +ve, p53 -ve, suggestive of primary cerebral neuroblastoma. The case was discussed in our multi-disciplinary tumor board and planned for local radiotherapy followed by chemotherapy. He received EBRT to brain (occipital lobe), using 6MV photons, a total dose of 5040cGy given in 28 fractions, 180cGy per fraction in IMRT (RapidArc) technique followed by 8 cycles of lomustine and cisplatin. Post 2 years of treatment, patient is asymptomatic and follow up MRI done every 6 months showed no recurrence or progression. Results: There are very few case reports or series about primary cerebral neuroblastoma. It is considered to be an aggressive tumor with a relatively poor prognosis because of local tumor recurrence as well as leptomeningeal seeding. Surgical resection followed by adjuvant chemotherapy/radiotherapy has been tried as treatment options. Conclusion: Primary intracranial neuroblastoma is a rare disease with high chances of local recurrence. It should be borne in the mind as one of the differential diagnosis in pediatric/young adults. Surgical resection followed by adjuvant radiation and chemotherapy seems to offer good local and systemic control.

 > Abstract: 418: Modified recursive partitioning analysis and treatment outcomes in glioblastoma multiforme: A single institutional study Top

Anu George, Ram Alva, Kirthi Koushik, M. G. Janaki, Arul Ponni, Mohan Kumar

M.S. Ramiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): Despite recent advances, prognosis and outcome in glioblastoma multiforme(GBM) remains poor. Original recursive partitioning analysis (RPA) of patients with malignant glioma produced six prognostic groups(I-VI). Recently a modified RPA model combining classes V and VI, resulting in three distinct prognostic groups have been validated which is simpler to use for the physicians. The aim of our study was to classify GBM patients based on modified RPA system and correlate it with survival outcomes. Materials and Methods: A retro-prospective evaluation of 27 GBM patients, treated at our institution from Jan 2016 to Jan 2019 was done. All newly diagnosed GBM cases were considered for this study and data regarding patient, tumour and treatment characteristics were documented in structured format. All patients were classified according to modified RPA classification into Class III, IV or V based on 4 factors, Age, KPS score, Extent of surgery and neurological function. The OS and PFS was estimated by using the Kaplan–Meier curves. The survival differences between the RPA classes were studied using the log-rank test. Results: A total of 27 patients were analysed, among which 13 (72 %) were males and 5 (28 %) were female. Median age of the study group was 59 ( range 30 -70 ). 2 patients(7.7%) had a biopsy alone, 16 (61.5%) underwent partial excision and 8 (30.8%) underwent complete excision. All patients received adjuvant radiation using IMRT technique with concurrent and adjuvant temozolamide. On univariate analysis Age < 50 and KPS score >70 were prognostic factors associated with a better overall survival (p value 0.03 and 0.04 ). Duration of temozolomide, extent of surgery, neurological function was not statistically significant, but better OS and PFS was observed in patients who received temozolomide for 6 months or more, those who had complete resection of tumour and who had good neurological function. Based on modified RPA classification, 2 (7%) patients belonged to RPA class III, 12 (46%) patients in RPA class IV and 12 (46%) in class V in our study. Median OS and PFS in our study group were 18 months and 9 months. The median OS in RPA class III, IV and V were 24, 15 and 9 months respectively (p value 0.001). The progression free survival in class II, IV and V were 23, 9 and 6 months respectively(p value <0.0001). The 1 yr and 2 yr OS was 30 % and 11 % in class IV, 15 % and 3 % in class V. Conclusion: The factors such as Age<50, KPS score >70, complete or partial excision, good neurological function were found to be favourable prognostic factors and modified RPA classification had a significant correlation with survival rates. Our study sample had a slightly better overall survival rates across all RPA classes which might be attributed to > 6 months adjuvant temozolamide in majority of patients and newer techniques like cyberknife to treat recurrences.

 > Abstract: 425: Dosimetric comparison of coplanar volumetric modulated arc therapy with non-coplanar volumetric modulated arc therapy for treatment of brain tumors Top

Sagar Raut, Debanjan Sikdar, T. S. Aathira, Nidhi Sharma, Sweety Gupta, Deepa Joseph, Rajesh Pasricha, Manoj Gupta, Ganesh Patel

AIIMS, Rishikesh, Uttarakhand, India, E-mail: [email protected]

Purpose and Objectives: Radiation therapy to primary and metastatic brain tumours is delivered by different modalities of External beam Radiation Therapy (EBRT) like 3D conformal external beam radiotherapy (3D-CRT), Intensity modulated radiotherapy (IMRT) & VMAT. Compared with conventional fixed-field IMRT, VMAT can generate precise conformal dose distribution through rotational delivery accompanied by variability of the multi-leaf collimator (MLC) position, dose rate, and gantry rotation velocity, thereby improving the dose distribution, reducing the dose to normal tissues, and shortening the delivery time. Noncoplanar arcs are generally used to improve PTV conformity and homogeneity and an additional degree of freedom for potential additional gain in quality of treatment. Noncoplanar beam trajectories for VMAT are less common as the availability of treatment machines handling these is limited. This study was planned for comparing the dose distribution to the planning target volume (PTV) and organs at risk (OAR) of c-VMAT and nc-VMAT and to find which of these can maximally reduce doses to OARs without compromising prescribed tumor dose. We also looked for various potential factors which could affect dosimetric parameter of optimum plan. Materials and Methods: This is single institute cross sectional study of brain tumor patients. After immobilisation, patients underwent a planning contrast CT & MRI scans which were co-registered and fused using image registration software (Monaco V5.11, Elekta Medical system). GTV, CTV, PTV & OARs were contoured using RTOG guidelines. Two different treatment plans were created using inverse-planning methods incorporating dynamic MLC. A simple coplanar (PLAN-A) and non-coplanar arcs (PLAN-B) using VMAT technique. Dose-volume histograms (DVHs) for PTVs and OARs were generated. Each plan was evaluated based on ICRU-83 plan evaluation criteria which included analysis of homogeneity index, conformity index, maximum dose (PTV-Dmax), minimum dose (PTV-Dmin), mean dose PTV (PTV-Dmean) and doses to OARs. Tumor volume, size, location & distances from OARs were also recorded and analysed. Results: A total of 40 plans of 19 patients (20 plan A & 20 plan B) were evaluated (One patient had 2 lesions which were planned & analysed separately). There were 9 female and 10 males with good KPS (Around 70 % between 80-90). Most patients were of gliomas (68%) followed by brain metastasis (21%).

Doses to OARs in plan A&B including Point dose to optic chiasm (23.72 & 25.86 Gy, p-.93), right optic nerve (14.49 & 13.47 Gy, p-.78), left optic nerve (18.18 & 17.90 Gy, p-.82), brain stem (22.49 & 21.71 Gy, p-.92) were similar. Mean dose to right and left eyes, lens, right & left cochlea and remaining brain (brain-PTV) were also not significantly different in both the plans. Conclusions: Both the techniques are comparable in term of doses to PTV & OARs. For an individual patient, factors like minimum set-up time ease of reproducibility on daily basis and other logistic issues may help in selecting the optimum technique.

 > Abstract: 453: Impact of time to initiation of radiotherapy on survival after resection of glioblastoma Top

Chinmaykumar Prajapati, Maitrik Mehta

Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): Analysis on the effect of timing of postoperative radiotherapy (PORT) on survival in patients with primary glioblastoma (GBM). Materials and Methods: Patients with newly diagnosed primary GBM between March-2017 and April-2018 in our institution were retrospectively analysed. The population was trichotomized based on the time interval from surgery till initiation of RT (< 28 days, 28–33 days, > 33 days). The adjuvant radiotherapy 60 Gy in 30 fractions was offered with concurrent Temozolomide 75 mg/m2 followed by 6 cycle adjuvant Temozolomide 150 mg/m2 Kaplan-Meier was used to compare progression free survival (PFS) and overall survival (OS) between the groups. The age, grade, performance status, neurological deficits and presence of residual tumor were analysed. Results: 51 patients met the inclusion criteria. Between the three groups no significant difference in PFS or OS could be demonstrated. Residual tumor volume (RTV) and midline structures involvement were identified as independent prognostic factors of PFS. Patients starting RT after a prolonged delay (> 42 days) exhibited a significantly shorter OS. Conclusion: A prolonged delay (> 42 days) may be associated with worse OS. RT should neither be delayed, nor forced, but should rather start timely, as soon as the patient has recovered from surgery.

 > Abstract: 472: A case report and literature review of a rare brain tumour- hemangiopericytoma Top

Syed Yasar, P. B. Anandrao, P Guru Sai Ratna Priya, Gajjala Naveen Reddy

G.S.L. Medical College, Rajahmundry, Andhra Pradesh, India. E-mail: [email protected]

Background: Hemangiopericytoma (HPC) is an extremely rare hypervasculartumor of mesenchymal lineage. It tends to recur and to develop distant metastases even many years after primary surgical resection. The management of recurrent and metastatic disease is not always so well defined. A complete surgical resection does not eliminate the high risk of local recurrences that occur in the central nervous system, often in the same surgical bed hence adjuvant radiotherapy is indicated in these cases. Case Report: A 28 year old female patient came to our hospital on October 2018 with chief complaint of headache since one year which was more during night, relieving with analgesicslater she developed one episode of seizures on September 2018. She was evaluated with base line investigations and MRI scan which showed intracranial space occupying lesion of 6.5*6.75*5.8 centimeters in right temporoparietal lobe with significant perilesional edema and mass effect suggestive of High grade Glioma. Methodology: Gross tumour resection of the tumour was done on October 2018 at our hospital. Histopathological examination showed Poorly differentiated highly mitotic primary CNS malignancy most probably Hemangiopericytoma. IHC Markers [GFAP, EMA, CD34, VIMENTIN, CD99, PR, CHROMOGRANIN A] suggestive of Hemangiopericytoma. FOLLOWING SURGERY Adjuvant radiation WAS PLANNED and delivered to a total dose of 59.4GY in 33 fractions, 5 fractions per week on LINAC VERSA HD with 6MV Photons from 9th April to 28th May 2019. Results: Patient tolerated Radiotherapy well AND she is on regular follow up. At six months followup patient is asymptomatic and stable. Conclusion: Intra cranial Hemangiopericytomas are extremely rare and aggressive malignant CNS neoplasms. Management recommendation includes Gross tumour resection followed by adjuvant radiotherapy. Close surveillance is required for these patients due to the aggressive nature of the tumour and its propensity for recurrence or metastasis.

 > Abstract: 475: Hypofractionated radiation therapy in elderly patients with newly diagnosed glioblastoma with poor prognosis Top

Akash Rajesh Pandya, Rajan Yadav, U. K. Suryanarayan, Ankita Parikh, Maitrik J. Mehta, Pooja Nandwani Patel, Sonal Patel Shah, Niketa Thakur, Amit Kichloo, Sakina Mankada, Rajal Shah, Heena Rathod

Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose: To evaluate the outcomes of hypofractionated radiation therapy (HFRT) given to elderly patients with newly diagnosed glioblastoma with poor prognosis. Endpoint was progression-free survival (PFS) rate. Materials and Methods: Patients with newly diagnosed glioblastoma, age ≥75 years, Karnofsky performance scale (KPS) score ≤60, treated with HFRT to a dose of 30 Gy/10 fractions were evaluated retrospectively. Results: Twenty seven patients were treated, with a median age of 78 years. Concurrent and adjuvant temozolomide chemotherapy (TMZ-CHT) was administered in 6 (22.2%) and 13 (48.1%) patients received only adjuvant TMZ-CHT. The median 6-month PFS and 12-month PFS were 38.4%, and 15%, respectively. No increase in steroid drugs was required during radiotherapy treatment and a reduction was possible in 10 (37%) patients. Patients with KPS=60, RPA V, neurological status stable or improved after surgery and who underwent HFRT with concurrent and adjuvant CHT, had better outcomes. Conclusion: HFRT can be considered for selected elderly and frail patients with newly diagnosed elderly glioblastoma as a feasible and effective treatment with limited morbidity.


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