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Year : 2019  |  Volume : 15  |  Issue : 9  |  Page : 214-232


Date of Web Publication28-Nov-2019

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How to cite this article:
. Gynaec-Onco. J Can Res Ther 2019;15, Suppl S2:214-32

How to cite this URL:
. Gynaec-Onco. J Can Res Ther [serial online] 2019 [cited 2021 Jul 31];15:214-32. Available from: https://www.cancerjournal.net/text.asp?2019/15/9/214/271709

 > Abstract: 118: Intracranial metastasis from carcinoma cervix: A case report Top

B. Naveen, Bhudevi Soubhagya N. Kulkarni, Gowtham Raj

VTSM Peripheral Cancer Centre – Kidwai, Gulbarga, Karnataka, India, E-mail: [email protected]

Introduction: Cervical cancer is one of the most malignant cancers affecting women, second only to breast cancer. Cervical cancer typically spreads locally via the lymphatic system to the pelvic and para-aortic lymph nodes, however it can metastasize to more distant organs—commonly the lung, liver, bone, and supraclavicular lymph nodes—via the hematogenous pathway. Presence of tumor cells in cerebral circulation does not necessarily lead to metastatic disease, it largely depends on the host's immune system, number of tumor emboli, tissue neovascularization, and characteristics of the tumor. Metastasis to brain has been reported to occur after spread to the lungs. This is supported by reports that the lungs are the most common area for metastatic cervical cancer; in addition, this pattern of spread is very typical in other types of systemic cancers, such as lung cancer, breast cancer, and melanoma. However, there were some reported cases of patients with intracranial metastases from carcinoma cervix without lung metastases. We are reporting a case of carcinoma cervix with multiple intracranial metastases. Case Presentation: A 38 years old female was presented in September 2017 with complaints of bleeding per vaginum since 3 months. Her general and systemic examinations were within normal limits. Pelvic examination revealed an ulceroproliferative cervical growth of 3*3 cm, with involvement of parametrium. A biopsy of the lesion showed moderately differentiated squamous cell carcinoma. MRI pelvis showed fat planes between lesion and urinary bladder as well as rectum were infiltrated by the lesion. After complete clinical and radiological evaluation, the disease was staged as FIGO stage-IVA. The patient was treated with concurrent chemoradiation. She received 3DCRT to pelvis to a dose of 50Gy at 2Gy per fraction for 25 fractions along with intravenous cisplatin at a dose of 40 mg/m2 per week for 3 cycles during the course of radiation therapy. After the completion of concurrent chemoradiation therapy she received Intracavitary brachytherapy ( ICBT) – HDR 6Gy for 2 fractions, patient defaulted treatment for 1month & she received 6Gy for 2 fractions Interstitial brachytherapy ( ISBT). The treatment was completed in january 2018 and the patient attained complete remission. The patient remained asymptomatic for 16 months after completion of treatment. In june 2019 she experienced gradual onset of difficulties in walking, headache, and vomiting. Multislice CT scan of brain showed multiple ring enhancing lesions present in left parietal lobe, right cerebellar hemisphere & right temporal lobe. perilesional white matter hypodensities noted in left parietal lobe. The metastatic workup, including computed tomographic (CT) scans of the thorax, abdomen, and pelvis, did not reveal other metastases. Histologic examination of the mass showed metastasis from squamous cell carcinoma consistent with known primary in the cervix. Palliative radiation therapy to whole brain to a dose of 30Gy in 10 fractions is planned. Conclusion: Intracranial metastases from carcinoma cervix are very rare & only a small number of cases have been reported.

 > Abstract: 129: Assessment of feasibility, compliance, response and toxicity in locally advanced carcinoma cervix patients undergoing chemoradiotherapy and adjuvant chemotherapy with gemcitabine and cisplatin Top

Varshu Goel, Kishore Singh, Arun Kumar Rathi, Gauri Gandhi, Alpana Manchanda, Anurita Srivastava

Maulana Azad Medical College and Associated Lok Nayak Hospital, Delhi, India, E-mail: [email protected]

Background: In India, the uncontrolled pelvic disease is the cause of death for most of the women with cervical cancer. Thus, locoregional control becomes of paramount importance to improve survival. Hence, there is a need to define novel agents over conventional cisplatin-based chemoradiotherapy. Purpose: To assess the feasibility, compliance, response and toxicity of gemcitabine and cisplatin as concurrent chemoradiation followed by adjuvant chemotherapy in LACC patients in Indian scenario. Methodology: Eligible chemotherapy- and radiotherapy naïve patients, aged 18-65 years, FIGO 2009 stage IIB to IVA LACC, ECOG performance status ≤ 2, with acceptable cardiac function and normal baseline hematological and biochemical parameters, were recruited after an informed consent to receive external beam radiotherapy 45-50 Gy in 25 fractions for 5 weeks with concurrent cisplatin 40 mg/m2 and gemcitabine 125 mg/m2 weekly, followed by high dose rate brachytherapy. This was followed by 2 cycles of adjuvant chemotherapy (ACT) : cisplatin 25 mg/m2 and gemcitabine 1000 mg/m2 on day 1 and day 8 given at 3 weekly intervals. Response assessment was done by RECIST 1.1/WHO criteria on CECT Pelvis imaging at the end of the chemoradiation and adjuvant treatment. Results: Between August 2017 and August 2018, 26 patients of biopsy proven locally advanced cervix cancer (FIGO 2009 stage IIB-IVA) with atleast one measurable lesion on imaging were enrolled. 20/26 (76.9%) were FIGO stage IIB and 10/26 (38.5%) patients had ECOG score 2. Complete or Partial Response (CR or PR) was seen in 21/26 (80.7%) patients at the end of the chemoradiation treatment. Concurrent dose schedule was modified to weekly cisplatin (30 mg/m2) followed by gemcitabine (75 mg/m2) for initiation, which could then be escalated as per tolerance to maximum of initially planned doses after an interim analysis of our first 10 patients. However, 6/26 (23%) patients interrupted treatment during CCRT in view of ≥ grade 3 acute hematological and gastro-intestinal toxicities, which was manageable in this trial setting. The treatment interruptions led to a delay in starting brachytherapy, and despite all efforts, the overall treatment time was prolonged (> 8 weeks) in 7/26 (26.9%) patients. 4 patients defaulted during chemoradiation and 1 patient developed lung metastases. Out of the remaining 21 patients, 19 completed both cycles of ACT with majority experiencing ≥ grade 2 anemia (57.7%) or ≥ grade 3 neutropenia (50.0%). There was one mortality during our study period after first cycle of adjuvant chemotherapy, probably attributable to treatment toxicity. After adjuvant CT, CR was achieved in 19/22 (86.4) patients. Conclusions: Despite 80% response rates, the combination of gemcitabine and cisplatin as concurrent with radiotherapy and as adjuvant chemotherapy was not well tolerated by our inadequately nourished and poor performance scored patients. In view of increased toxicity, there is a need to define optimal dose schedule for such regimens. To assess the impact on recurrences, a longer follow-up period is required.

 > Abstract: 144: Concurrent chemotherapy with HDR brachytherapy after treatment with chemoradiotherapy in cases of locally advanced carcinoma cervix: A study from rural area of maharashtra Top

Vandana Jain, Mayuresh Virkar, Namrata Bhagat, Chaitali Waghmare

Rural Medical College, PIMS, Ahmadnagar, Maharashtra, India, E-mail: [email protected]

  • This study aims to evaluate the efficacy, feasibility, tolerability, and toxicity of concurrent chemotherapy and brachytherapy for locally advanced cervical carcinoma (LACC)
  • The objective of the study is to quantify the potential to improve the locoregional control, disease-free survivals, normal tissue toxicities (acute & late side effects using common toxicity criteria (CTC) and RTOG toxicity Criteria), overall survival and decrease in the possibility of recurrences and distant metastasis.

Materials and Methods: 40 Patients of cervical carcinoma who satisfied the inclusion criteria were included in this study (Study period from Oct. 2016-Sept. 2019). Patients were evaluated by history, general, systemic and local examination and by hematological and relevant radiological investigations. All patients were given treatment as per protocol, EBRT(50Gy in25#) with concurrent weekly chemotherapy with Inj. Cisplatin (30mg/m2) followed by ICRT (3# ICRT of 7 Gy each) with concurrent chemotherapy with Inj. Cisplatin (30mg/m2). Response evaluation was documented with clinical and radiological evaluation on 1st month, 3rd month and thereafter every three to four-month follow up after completion of treatment till last follow up in September 2019. Thereafter, the prognostic outcome of each patient was assessed on the following parameters. Results: A total of 40 patients were enrolled in the study with appropriate inclusion and exclusion criteria in the Department of Radiation Oncology. Various parameters assessed are mentioned in Table 1. Median overall treatment time was 60 days. Similarly, the median tumor size was 8.9cm. The median ICRT dose was 21Gy. 36 patients completed treatment. There were no significant acute and chronic upper and lower gastrointestinal toxicities noted. The incidence of grade I and II skin toxicities were 78% and 10% respectively. The incidence of genitourinary toxicities with respect to Grade I and II were 72% and 12%. There were significant hematological toxicities noted in two patients (Total leucocyte counts were below 2000/cc) and the ICRT treatment was delayed for 4-6 days. The response to treatment on the first six months follow up on clinical and radiological assessment of disease has been mentioned in TABLE 2. Last, follow up results will be presented at the time of presentation. Conclusion: Combining brachytherapy with concurrent chemotherapy is not a standard recommendation, but worth experimenting given the radio-sensitizing effect of cisplatin on radiotherapy. In conclusion, brachytherapy with the addition of concurrent chemotherapy is effective and feasible with acceptable toxicity for various stages of cancer of the uterine cervix. Cumulative toxicity of cisplatin given with external radiotherapy and brachytherapy becomes the major concern with such an approach. Lastly, we had a very small number of patients for this study to come to a final conclusion. For all these reasons, further studies on concurrent chemotherapy with brachytherapy are required to arrive at any standard conclusion. Till then, this study upholds an interesting approach that can be regarded as feasible and tolerable for cervical cancer patients.

 > Abstract: 145: Clinical versus magnetic resonance imaging assessment of disease extent in carcinoma cervix patients undergoing chemoradiation Top

Ritika Ranjan, Satyajit Pradhan, U. P. Shahi, Ashish Verma, T. B. Singh, Deepak K. Singh, Rumita Singh

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

Purpose and Objective(s): Clinical staging in cancer cervix reveals more inaccurate diagnoses. Greatest difficulty is estimating tumour size, especially if disease is extending endocervically, and parametrial involvement. MRI provides better soft tissue delineation and could help in tumour size assessment. The purpose of this study was to evaluate the extent of clinical estimation of disease corroborating with MRI findings in cancer cervix patients receiving chemoradiation. Materials and Methods: The present prospective study, involving 38 histopathologically proven patients, was conducted during December 2017 to June 2019. Patients were evaluated both clinically and radiologically (by MRI) before external radiotherapy (EBRT), before Intracavitary application (ICR) and 3 months after treatment completion. MRI evaluation was considered as the gold standard. Disease extent in terms of thickness(AP), width(Transverse) and height (cranio-caudal) of primary lesion, vaginal, parametrial and nodal involvement, rectal and bladder involvement was evaluated. On pre ICR MRI evaluation, patients having no residual disease after EBRT were labeled as Group-1, while those with residual disease as Group-2. Results: On pre-ICR MRI, 26/38(72.72%) patients had no residual disease (Group-1) and 12/38(27.28%) patients had residual lesion (Group-2). Clinically, 10/38(26.31%) patients had residual lesions. Three months after treatment completion, all patients had complete response, both clinically and radiologically. Tumour thickness estimation was clinically less in 23/38(60.53%) and more in 15/38 (39.47%) patients. Among 23 patients with clinically estimated thickness less than MRI assessment, the percentage difference was <22% in 16 (42.10 % of 38) patients and >22% in 07 (18.42% of 38) patients. Among 15 patients with clinical measurement more than MRI measurement, in none the difference was >22 % (p=0.029). Transverse dimension was clinically less in 28/38(73.68%) and more in 10/38(26.32%) patients. Among 28 patients with clinical transverse measurement less than MRI measurement, percentage difference was <22% in 12(31.58 % of 38) and >22% in 16(42.10% of 38) patients. Among 10 patients with clinical measurement more than that by MRI assessment, in none the difference was >22 % (p=0.002). Cranio-caudal extent was clinically less in 34/38(89.47%) and more in 04/38(10.53%) patients. Among 34 patients with cranio-caudal estimation less than MRI measurement, the percentage difference was <22% in 20(52.63 % of 38) and >22% in 14(36.84% of 38) patients. Among 4 patients with clinical measurement more than MRI measurement, in none the difference was >22%. Clinically, 11 patients had no parametrial involvement and in 2(18.18%) the findings were corroborated by MRI. Clinical parametrial assessment corroborated with MRI findings in 16/38(42.1%) patients. Whereas, bilateral parametrium was detected clinically in 11 patients, MRI corroborated the findings in 10/11(90.9%) patients. Clinically, vaginal involvement seen in 23/38(60.52%) patients was corroborated by MRI findings. 9/38(23.68%) patients had bladder wall and 5/38(13.15%) patients had rectal wall infiltration. MRI detected pelvic lymphadenopathy in 52.63% patients. Conclusion: Clinical assessment underestimate size in all three dimensions especially cranio-caudally, compared to MRI. Clinical parametrial involvement did not always corroborate with MRI findings. MRI detects pelvic lymphadenopathy and also bladder and rectal wall involvement, which is not possible with clinical assessment.

 > Abstract: 151: Clinical prognostic factors and treatment outcomes for the survival in patients with small cell neuroendocrine carcinoma of cervix Top

Niketa Thakur, Sonal Patel

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

Background: Small cell carcinoma of the cervix is a relatively rare subtype in the spectrum of cervical malignancies. Small cell carcinoma, however, is far more aggressive compared to the more common variants such as squamous cell carcinoma, and these patients are more likely to develop lymph-node and distant metastasis. Knowledge of potential prognostic factors is important for the optimal selection of treatment modalities, monitoring of treatment response, and planning of follow-up. Keeping this in the background, we aimed to conduct this study. Aim: To evaluate the clinicopathologic aspects of small cell carcinoma of the uterine cervix. Methods: A retrospective review of 21 patients with small cell carcinoma in our institution from 2005 to 2014 was conducted to assess the survival and examine the associations between clinicopathological variables and overall survival (OS). Results: In the clinical group of 21 patients, the median overall survival was 6 months. Advanced FIGO stage, lymph node metastasis, neuroendocrine component, parametrial involvement, and palliative radiotherapy were associated with poor survival. Apart from this, double agent concurrent chemotherapy, use of neoadjuvant chemotherapy, surgery, prophylactic cranial irradiation, age>40, showed a trend towards better overall survival. Distant relapse (33.3%) was the most common cause of disease progression. Conclusions: Advanced FIGO stage, lymph node metastasis, palliative radiotherapy, neuroendocrine component were independent predictors of poor prognosis of small cell carcinoma cervix. Neo-adjuvant chemotherapy followed by concurrent chemoradiotherapy regimen similar to that of small cell lung cancer may be a potential therapeutic approach for small cell carcinoma cervix.

 > Abstract: 165: Dosimetric and clinical outcomes of computed tomography based high risk clinical target volume delineation for high-dose-rate intracavitary brachytherapy in carcinoma cervix: A retrospective audit Top

Arnab Kumar Ghosh, Anis Bandyopadhyay, Bidisha Bagchi

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

Purpose and Objective(s): Brachytherapy for carcinoma Cervix had moved from Point A based planning to optimization of dose based on HRCTV. Recent evidences support the use of MR sequences to delineate the HRCTV. Guidelines have been published by GEC ESTRO on HRCTV delineation based on Clinical Gynaecological examination and MR sequences in their EMBRACE studies. These have given significant clinical result in terms of local control. However, many centres in India still use CT based planning, which restricts HRCTV delineation as disease and Cervix can rarely be differentiated on a planning CT. Various studies have been done to develop CT based contouring guidelines from the available data, but solid evidence is not available on the clinical outcome when treatment is optimized to CT contoured HRCTV. The purpose of this study is to find out the relation between local control and dosimetry of HRCTV. Materials and Methods: 48 patients who presented at MCH in 2016, with initial FIGO stage IIB and have completed EBRT with 50Gy in 25 # with at least 4 cycles of concurrent weekly Cisplatin and had complete or partial response to EBRT were taken for study. All patients had completed CT based IC brachytherapy to 7 Gy in 3# with dose prescription at point A and optimizing dose to reduce bladder and rectal toxicity. HRCTV delineation was done on the treatment plan following guidelines from a novel paper by Viswanathan et al. The dosimetric data was collected from dose colour wash and DVH. EQD2 doses for EBRT+BT was calculated for point A and HRCTVD90. Follow up data on local recurrence was collected. Final interpretation was done using SPSS version 23. Results: The per fraction mean dose to point A, HRCTV D90, rectum and bladder is 6.80± 0.48 Gy, 7.47± 1 Gy, 4.19± 0.8 Gy and 5.61± 1.11 Gy. Mean EQD2 doses to Point A and HRCTVD90 is 78.66± 2.86 Gy10 and 82.46± 6.58 Gy10. On follow up 27% had local recurrence of disease. The mean point A EQD2 dose in the recurrent & locally controlled group is 78.63 & 78.67 Gy10 respectively (p not sig, independent t test) whereas the mean HRCTVD90 EQD2 in the two groups is 7.9 and 83.75 Gy10 (p-0.025, significant). Patients who received Point A EQD2>= 80Gy10 had similar recurrence with the ones receiving less than 80Gy10, median PFS being 31 and 30 months ( p- 0.787, log rank). Patients who received HRCTVD90 EQD2 >=80 Gy10 had 16.1% local recurrence whereas the recurrence was 47.1% in those who received <80 Gy10( p- 0.026), PFS being 33 and 20 months( p- 0.013, log rank). Conclusion: Dose prescription to a HRCTV contoured on a CT scan rather than conventional Point A prescription can significantly improve PFS and clinical results are comparable to corresponding MRI guided brachytherapy data available.

 > Abstract: 167: Prospective study on comparison of dosimetry, toxicity and quality of life in postoperative early carcinoma cervix with risk factors treated with vaginal cylinder versus 2 ovoid brachytherapy Top

Bidisha Bagchi, Anis Bandyopadhyay, Arnab Kumar Ghosh

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

Background: Very few cases of Carcinoma cervix are diagnosed at very early stage, being a disease of the poor world. When diagnosed early, can be managed by early surgery. Post-operative radiotherapy can significantly improve survival in selected groups as demonstrated by GOG92 and GOG 109 study. EBRT is usually followed by a boost dose by vaginal brachytherapy. Multiple trials have been demonstrated for the use of vaginal brachytherapy boost in endometrial cancer but no solid information is available as to its use in cervical cancer. Most common site of recurrence in post-operative cases is the vaginal stump. From our institutional experience with cylinder brachytherapy, we found that although it provides good target coverage, there is very low dose to vaginal apex and high dose to OARs. ABS guidelines provide some details of the alternative application of ovoid brachytherapy. The purpose of this study is to compare VC and 2 ovoid application in terms of dosimetry and toxicity if early information is available. Materials and Methods: 18 diagnosed cases who underwent Wertheim's hysterectomy and was eligible for Radiotherapy according to GOG92 criteria was taken for study. Patient received EBRT to 50Gy in 25 fractions without Concurrent chemotherapy and was taken for either Vaginal Cylinder or 2 Ovoid brachytherapy application. Application was done following institutional protocol and CT scan based target Volume delineation was done. Dose was prescribed to upper 4cm of vaginal vault at 0.5cm lateral to applicator surface to a total dose of 7Gy in 3# following Small W Jr et al. ABS guidelines. Dose coverage of Target an OAR was collected from TPS and analysed using SPSS version 23. EORTC QoL CX24 was used to assess QoL before, after and 3 months after procedure. Results: No significant difference was observed was observed between mean volumes of bladder, rectum and urethra in two arms. Mean mucosal D90 coverage for VC and 2 ovoid are 5.53± 1.06 Gy and 6.05±0.89 Gy per fraction respectively (p- 0.289). No significant difference in mean mucosal D100 coverage. Mean apical point dose was significantly higher in 2 ovoid arm (102.1% vs. 66.18%, p <0.001). Mean rectal 2cc and 1cc dose was significantly higher in VC arm (p- 0.005 and 0.035 respectively). The mean bladder 2cc and 1cc dose although higher in VC arm, was not significant (p-0.084 & 0.085 respectively). Urethral mean and 0.1cc dose was significantly higher in VC than 2 ovoid (p<0.001 & 0.001 respectively). There is some improvement in QoL score in the 2 ovoid arm. Conclusion: Vaginal Brachytherapy using 2 ovoid can be a good alternative to Vaginal Cylinder as it provides comparable target coverage, increased point dose to vault apex and decreased doses to Organ at Risks.

 > Abstract: 175: A study on clinical evaluation of postoperative carcinoma endometrium patients treated by external beam radiation therapy and vaginal cylinder brachytherapy as boost modality Top

Sahaj Palod, Virendra Bhandari, Priyusha Bagdare, Shalu Verma

Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): To study acute and late effects of radiation in carcinoma endometrium patients treated by external beam radiation therapy (EBRT) followed by boost with HDR vaginal cylinder brachytherapy (VCB). Materials and Methods: This study includes 30 patients of carcinoma endometrium undergone total abdominal hysterectomy and having high risk features on post operative histology report such as more than 50% myometrial invasion, lymphovascular emboli, cervical stromal involvement, positive or close vaginal resection margins, high grade tumor. These patients were given a dose of 50Gy in 25# by EBRT and then assessed for vaginal brachytherapy boost. The patients fit for VCB were given a dose of 5Gy in 2 # at interval of 1 week by a single channel vaginal cylinder chosen after anatomical assessment. VCB was done by cobalt 60 source based high dose rate brachytherapy unit. All the patients were followed up for a period of one and half year and all the acute and late toxicities noted. Results: The mean equivalent doses (EQD2) were calculated of both EBRT and VCB and evaluated. The EQD2 of D90 clinical target volume (CTV) is 69.54 Gray (Gy) (S.D2.18) The EQD2 of organ at risk such as bladder, rectum, sigmoid colon and B/L femoral heads was found to be 58.08Gy (S.D 1.23), 59.03Gy (S.D 1.23), 52.4Gy (S.D 1.72) and 48.5Gy (S.D 1.71) respectively. Among the acute toxicities grade I diarrhea was found in 63% and grade II in 20% patients. Amongst the urinary symptoms which were grade I only, urgency was found in 16% and increased frequency in 20%. 23% patient had grade I rectal symptoms. 33% had grade I skin toxicity. Vaginitis was grade I in 56% and grade II in 6% patients. Among the late toxicities, 39% patients had grade I and 3% had grade II dyspareunia. The most common one was grade I vaginal dryness which was found in 50% patients and grade II in 7% patients. 32% patients had grade I and only 3% had grade II vaginal stricture. Grade I skin toxicity was found in 25% patients and grade II in 10% patients. All the patients had good local control rates. Conclusion: After follow up of patients during and after the treatment, all the toxicities noted were grade I or II which were mostly self resolving or manageable with minimal intervention. No patients required treatment interruptions or hospitalization amenable to radiation induced toxicities. No grade III or IV toxicities were noted. Hence, this regimen is found to be acceptable in terms of radiation induced toxicities and local control.

 > Abstract: 178: Dose dense neo-adjuvant chemotherapy followed by chemo-radiation versus definitive chemo-radiation in carcinoma cervix: Overall survival data at 5 years Top

Shreya Kaundinya, Shashidhar Karpurmath, Geeta Narayanan, S. L. Pranitha

Vydehi Institute of Medical Sciences, Bengaluru, Karnataka, India, E-mail: [email protected]

Background: The standard of care for locally advanced cervical cancer is chemo-radiation. Role of neo-adjuvant chemotherapy is not clear yet. Dose dense, short-term neo-adjuvant chemotherapy (NACT) with early initiation of radiotherapy has shown survival benefit but randomised trials not available yet. This study was done for feasibility of NACT and for its comparison with the standard chemo-radiation (CTRT) and to assess the overall survival (OS) at 5 years. Objective: To assess the OS in NACT followed by Concurrent CTRT (arm A) vs Definitive CTRT(Arm B). Methods: Cervical cancer patients not randomly assigned into two arms. Arm A received 3 cycles NACT of paclitaxel and carboplatin weekly. All patients of arm A after NACT and arm B received EBRT on linear accelerator for a dose of 45-50Gy in 23-25 fractions with concurrent cisplatin 40mg/m2 followed by 3 applications of HDR intracavitary brachytherapy of 700 or 800cGy respectively. All patients were assessed clinically and radiologically with MRI after completion of CTRT and at follow up of 6 weeks. The patients were reassessed after 5 years to compare the OS in both arms. Results: A total of 15 patients treated in each arm. Stage IIB and IIIB constituted 93% of the patients, well matched in both the arms. The Complete response rate at follow up of 6 weeks after NACT was 73% compared to only 46.7% in arm B. At five years of follow-up, the OS was better in Definitive CTRT arm. Conclusions: Dose dense NACT is a feasible and effective option in treating cancer cervix. However, it did not improve the OS when compared to standard chemo-radiation. Limitations:

  1. Small sample size
  2. DFS data not available.

Clinical Practice Points: Dose dense NACT followed by concurrent CTRT showed better CR rates at 6 weeks of follow-up. However, it did not improve the overall survival. Definitive CTRT on the other hand, improved overall survival and remains the standard of care in carcinoma cervix. Regular follow ups and more number of patients are required to compare NACT versus Definitive CTRT in Cervical cancer.

 > Abstract: 184: Intravaginal cylinder brachytherapy with tandem in patients with carcinoma cervix not feasible for standard fletcher-suit-delclos application Top

Aamrutha Iyyapu, Aanusha Konakalla

GSL Medical Collage, Agannadhapuram Agraharam, Andhra Pradesh, India, E-mail: [email protected]

Intracavitary brachytherapy (ICBT) with intrauterine tandem and ovoids form integral part in the management of carcinoma cervix. Patients who are not suitable for ICBT, interstitial brachytherapy (ISBT) is the standard of care. However, as ISBT is technically challenging many centres are obliged to practice external beam radiotherapy (EBRT) boost intravaginal cylinder (tandem Þ cylinder) combination in such patients. Materials and Methods: We assessed the clinical features and treatment outcome in carcinoma cervix patients who were treated with chemoradiation followed by brachytherapy other than standard Fletcher-Suit-Delclos application by retrospective chart review from 2016-2019. EBRT was delivered with LINAC either by 2D or 3D conformal technique to a total dose of 45-50.4 Gy at 1.8-2 Gy per fraction over 5-5.5 weeks with weekly cisplatin 40mg/m2. Brachytherapy was delivered after a planned gap of one week to a total of 3-4 HDR sessions weekly at 5.5-7 Gy per session. In patients whose cervical os could not be sounded intravaginal cylinder was applied and in patients whose cervical os could be sounded, but vagina could not accommodate ovoids, tandem Þ cylinder was applied. X ray based planning was done on microselectron genie version 1.0 planning system, dose was prescribed to point A where tandem was used and 0.5 cm from surface where only cylinder was used. Overall survival was analyzed by kaplan-meier method. Results: 15 patients met the study criterion. Median age at presentation was 50 years. All patients had squamous histology. 2 are FIGO IIA, 7 are IIB, 5 are IIIB, 1 patient is IIIc1. Mean primary tumour size was 5.1cm (range 2-7.8cm). 1 patient had positive pelvic lymph nodes on imaging. Mean EBRT dose was 48Gy (range 45-50.4) and mean HDR brachytherapy dose was 20.8Gy (range 18 -24). Mean EQD2 was 78Gy. Mean cisplatin cycles were 5. Intravaginal tandemÞcylinder was used fpr all sessions in all patients. Mean overall treatment time was 69.3 days with less than 60days in 9 patients and more than 60 days in 6 patients. After a median follow up of 24 months, 2 patients expired due to disease progression. 1 patient developed radiation proctitis. 12 are alive without any evidence of disease. Conclusion: With declining brachytherapy practice in resource limited centres, the potential benefit of brachytherapy should always be utilised in the management of carcinoma cervix.

 > Abstract: 210: Dosimetric comparison of bone marrow and non bone marrow sparing with state of the art technique image guided volumetric modulated arc therapy in the treatment of carcinoma cervix Top

Abhishek Arora, Kiran Chigurupalli, Ramesh Purohit, Menal Bhandari, Deepanjali Patel, Apoorv Vashistha

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

Purpose and Objective(s): Aim of this study was to compare dosimetric parameters of bone marrow (BM) and non bone marrow sparing with state of the art technique image guided volumetric modulated arc therapy in the treatment of Carcinoma Cervix. Materials and Methods: The retrospective Dosimetric study was conducted on 10 consecutive patients of biopsy-proven invasive cervical cancer attending the outpatient department of Geetanjali cancer centre. For treatment planning, patients were scanned on a GE Optima-520, 16 slice fan-beam CT (FBCT) scanner with 2.5 mm slice thickness in the supine position on a customized vacuum cushion with simulation tattoos and alignment lasers. All the simulation scans were taken after following a bladder and bowel preparation protocol, aimed at an empty rectum and full bladder, starting prior to the initial planning scan and continuing throughout the treatment. The prescribed dose to PTV was 50Gy in 25 fractions (2Gy/fraction) and from second week of radiotherapy 50 mg/m2/week cisplatin chemotherapy was administered for five weeks. Two sets of plans were generated for all the 10 patients using VMAT in Monaco v 5.11.02(Elekta, Crawley, UK) treatment planning system. Keeping all constraints in mind planning optimization was performed with no compromise in coverage of PTV. Results: In the present study V5, V10, V20, V30 were all significantly lower in BMS-IG/VMAT plan. Maximum significance was noted at V20. Value of V40 is lower in BM-IG/VMAT plan, but statistically not significant. Conclusion: Treatment of carcinoma cervix is restricted as a result of toxicity of the surrounding normal structures and HT. HT could be significantly reduced by bone marrow sparing, which could be aided by IGRT/VMAT.

 > Abstract: 211: Computed tomography based analysis of dose contribution to pelvic lymph nodal stations from intracavitary brachytherapy in radical treatment of cervical carcinoma Top

Varsha Vempati, Shilpa Reddy Keesara, Kausik Bhattacharya, Prashant Upadhyay, Sayan Paul, Vijay Karan Reddy Palkonda, Vjay Anand Reddy Palkonda

Apollo Cancer Institute, Apollo Hospitals, Hyderabad, Telangana, India, E-mail: [email protected]

Purpose and Objective(s): In radical radiotherapy for cervical cancer, high-dose-rate (HDR) brachytherapy is used along with external beam radiation therapy (EBRT) to deliver a cumulative EQD2 of 80 to 90 Gy to the primary tumor and 54 to 60 Gy to gross pelvic nodes. However, there is less certainty regarding brachytherapy dose contribution to the pelvic lymph nodes. This poses a challenge as to how high a preceding EBRT dose should be prescribed to gross nodal disease, in order to achieve a cumulative tumoricidal effect. Hence, this study aims to quantify brachytherapy dose contribution to individual pelvic nodal groups, using computed tomography planning and to define the relationship between the Point A prescription dose and the dose delivered to various pelvic lymph node groups during HDR brachytherapy treatment of cervical cancer. Materials and Methods: This is an ongoing single institution prospective dosimetric study. Treatment data from 15 fractions of HDR brachytherapy of cervical cancer are reviewed. Various pelvic lymph node stations i.e Common Iliac, External Iliac, Internal Iliac, Obturator, Presacral nodes are contoured according to standard guidelines. Treatment planning done in Oncentra treatment planning system version 4.3 and delivered on Nucletron microselectron HDR brachytherapy. The dose-volume histogram parameters are obtained for all the pelvic node stations and are normalized as a percentage of the corresponding Point A dose. All nodal groups were divided into left and right sides, except the presacral nodal group. Results: Point A doses were Bilateral 7 Gy, Left 7 Gy, Right 7 Gy. Mean normalized D90 values as a percentage of point A for the various lymph node groups were as follows- Obturator: Bil 19.3% ± 5.2, L 19.6% ± 6.7, R 18.9% ± 6.3; External Iliac: Bil 8.3% ± 2.3, L 8.0% ± 2.0, R 8.5% ± 2.8; Internal Iliac: Bil 12.9% ± 3.8, L 12.6% ± 3.5, R 13.0% ± 2.3; Common Iliac: Bil 3.0% ± 0.7, L 2.4% ± 0.7, R 2.4% ± 0.7; and Presacral: 11.0% ± 4.4. With a brachytherapy dose of 7 Gy, the mean absolute EQD2 doses received by the Obturator, External Iliac, Internal Iliac, Common iliac, Presacral nodes are 1.3 Gy, 0.5 Gy, 0.8 Gy, 0.14 Gy, 0.7 Gy respectively. Conclusion: Our study demonstrates that pelvic lymph nodes receive substantial dose contributions from HDR brachytherapy in cervical cancer. This should be taken into account during EBRT planning, to calculate the boost dose required to the gross pelvic nodes to achieve good local control. This is only Interim analysis of the present ongoing study that aims to recruit total of 69 applications. More robust data is required to understand the Intracavitary Brachytherapy dose contribution to various pelvic nodal stations. By the time of presentation, more number of applications will be analysed and presented.

 > Abstract: 220: Comparison of computed tomography and magnetic resonance imaging based high risk clinical target volume contours at the time of brachytherapy in cervical cancer Top

Debanjan Kolay, Suman Mallik, Sayan Das, Jyotirup Goswami, Monidipa Mondal, Arijit Sen

Narayana Superspeciality Hospital, Howrah, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): To compare MRI and CT Scan as imaging modality in delineating the High Risk Clinical Target Volume ( HR-CTV ) in locally advanced cervical cancer during brachytherapy. Materials and Methods: 18 previously untreated patients with locally advanced cervical cancer ( Stage IIB – IVA ) suitable for radical treatment were included. All patients underwent EBRT to a dose of 50 Gy/25#/5 weeks along with weekly concurrent chemotherapy followed by intracavitary/interstitial brachytherapy using a magnetic resonance imaging compatible applicator to a dose of 8 Gy x 3# or 9 Gy x 2#. This was then followed by both computed tomography and magnetic resonance imaging. The HR-CTV was delineated on the brachytherapy CT and brachytherapy MRI scans along with the organs at risk (bladder, rectum, sigmoid, intestines) independently for each patient. The contouring on the computed tomography scan was done using only clinical findings and on the MRI scan using GEC-ESTRO guidelines. The discrepancy in volumes between the CT HR-CTV and the MR HR-CTV contours and the doses to the organs at risk were evaluated using two sided t-test. Results: The mean CT HR-CTV volume was significantly larger than the mean MR HR-CTV volume. The D50, D90, D100 HR-CTV CT doses were significantly lower than the D50, D90, D100 HR-CTV MR doses. However there was no significant difference in the volumes and doses to 0.1, 1 and 2 cc for the organs at risk. Conclusion: Magnetic resonance imaging remains the gold standard for delineation of the HR-CTV in locally advanced cervical cancer during brachytherapy but CT with clinical information can give comparable results which need to be studied further. CT based contouring can be comfortably used for delineation of the organs at risk.

 > Abstract: 221: A pilot study to see the feasibility, safety and efficacy of concurrent paclitaxel and cisplatin in patients of locally advanced carcinoma cervix being treated with radical chemo radiation Top

Susmita Biswas, Suman Misra

IPGMER and SSKM Hospital, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): (1) To assess tumour response at first follow up and subsequent follow up in terms of CR, PR, SD, and PD, according to resist criteria version 1.1 (2) To evaluate the toxicity – according to RTOG Criteria. Materials and Methods: In selected patients with histologically proved sq cell CA cervix (stage IIB to IVA ), without any H/O previous anti cancer treatment – pre treatment assessment was done with detailed clinical examination, radiological and laboratory investigation. Selected patients were treated with EBRT in a dose of 50 Gy in conventional fractionation and concurrent chemotherapy with intravenous infusion of inj. Cisplatin 40mg/m2 plus inj. Paclitaxel 30mg/m2 weekly one hour before EBRT. Patients received HDR brachytherapy twice weekly with a dose of 7 Gy/fraction in four fractions. During treatment patients were examined weekly clinically and with blood reports and thereafter 6 weekly for 3 months and 3 monthly till the end of the study. Results: 30 patients were included in the study. Maximum number of women were in the age group of 41 – 60 yrs (70%). 24 (80%) patients were post menopausal. Median age of marriage was 16yrs. 22 (73.3%) women had >2 children. Stage IIB was seen most commonly and moderately differentiated sq cell CA was common histopathology (60%). All patients were needed blood transfusion due to fall in base line haemoglobin % (grade II & III ). 9 patients (30%) and 4 patients (13.3%) experienced grade III GI toxicity (diarrhoea) and grade IV skin toxicity for which EBRT was temporarily stopped, but patients could be able to complete treatment. Almost all signs and symptoms of acute toxicity disappeared one week after completion of EBRT. At 6 weeks follow up CR was 93.3% and PR was 6.7%. no SD or PD. No recurrence was seen in study period. Despite the break in treatment (EBRT) the average treatment time was 60.67days. Conclusion: This study produced short term efficacy with relatively tolerable acute toxicities and feasibility. Study is limited by a small sample size and short follow up. Further observation is needed to ascertain its long term effects.

 > Abstract: 231: Dose volume analysis of acute gastrointestinal complications in cervical cancer undergoing definitive concurrent chemoradiation Top

Anup Kumar

RIMS, Ranchi, Jharkhand, India, E-mail: [email protected]

Purpose and Objective(s): This study aims to analyze the relation of small bowel dosimetric parameters with the incidence of acute gastrointestinal complications. Materials and Methods: The study analyzed 40 patients of stage IIB – IVA who underwent concurrent chemoradiation with 3DCRT and weekly cisplatin from June 2017 to June2018. Small bowel was contoured as the organ of risk. DVH parameters of small bowel subjected to analysis was mean dose, maximum dose, the total volume of organ receiving 20Gy, 40Gy and 45Gy (V20-45) and the volume of V20-45 to total volume(V20-45 ratio). Gastrointestinal toxicity was graded using CTCAE version 5.0 criteria. Association between dosimetric parameters and incidence of 1-2 gastrointestinal complications were evaluated. Results: Forty patients treated with concurrent chemoradiation were analyzed. Seven patients reported grade 1 while 3 patients reported grade 2 gastrointestinal complications. None of the patients reported grade 3 or higher gastrointestinal complication. Patients with gastrointestinal complications had greater V30-45 and mean dose as compared to those without gastrointestinal complication. Conclusion: Dosimetric parameters of small bowel should be evaluated to reduce the incidence of gastrointestinal complications.

 > Abstract: 232: Patterns of care and treatment outcomes for elderly women with cervical cancer Top

Sudharshan Gupta, P. V. Jeyaanth, Arvind S. Murthy, Jebakarunya Ramiredddy, Thomas Samuel Ram

Christian Medical College, Vellore, Tamil Nadu, India, E-mail: [email protected]

Purpose and Objective(s): To retrospectively study the patterns of care and treatment outcomes of elderly women with cervical cancer diagnosed and treated between 2014 to 2016 at our hospital. Materials and Methods: We retrospectively collected data of patients of age >60 years who were diagnosed to have carcinoma cervix from January 1,2014 to December 31, 2016 at Christian Medical College, Vellore. The patients clinical, histopathological, and radiological information were collected from electronic medical records. Details of external beam radiotherapy, brachytherapy and concurrent chemotherapy were analysed. Disease free survival and Overall survival were analysed using Kaplan Meier curves. Results: A total of 63 patients' data was collected. The median age was 64 years (range:60-91). Squamous cell carcinoma was the most common histology (95%) and the majority were FIGO stage IIB (46%). 41% patients received radiotherapy along with concurrent chemotherapy with weekly cisplatin(40mg/m2) followed by brachytherapy.48% patients received radiotherapy alone. 6% patients received neoadjuvant chemotherapy followed by chemoradiotherapy.3% patients received surgery followed by radiation. 2% patients received surgery followed by chemoradiotherapy. 59% patients received conventional radiation therapy in linear accelerator. 54%patients received concurrent cisplatin (40mg/m2) along with radiation, Of which 42% received 4 cycles of concurrent chemotherapy. 53% patients received Low dose rate,27%received High dose rate intracavitary brachytherapy.5% patients received vaginal cuff brachytherapy and 15% patients defaulted brachytherapy. At 6 week follow up 80%(49) patients had no disease clinically. Conclusion: Geriatric oncology is an evolving subspecialty in oncology. Standard treatment (EBRT with concurrent chemotherapy and brachytherapy) is a feasible option in the elderly cohort of cervical cancer patients.

 > Abstract: 245: A rare case of synchronous malignancies in cervix and nasopharynx Top

Rahul Misra, Rakesh Jadav, K. N. Srikanth, Manoj Kumar

HCG, Vadodara, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): To present a rare case of synchronous malignancies in cervix and nasopharynx. Materials and Methods: A 32/Female presented with c/o menometrorrhagia for 1 month. On per vaginal examination she had an ulceroproliferative lesion in cervix and upper vagina. On per rectal examination b/l parametrium were medially involved. After ultrasound and punch biopsy she was diagnosed as carcinoma cervix, squamous cell carcinoma. For metastatic work up PET CT was done. Pet ct confirmed the diagnosis as carcinoma cervix stage IIb and detected a second primary of ca nasopharynx (cT1N1). Usg guided fnac from cervical node showed squamous cell carcinoma poorly differentiated. Case was discussed in tumor board and it was decided to treat both the lesions by radical chemoradiation. After counselling the patient about the acute and late toxicities and taking her consent treatment was started. The nasopharyngeal lesion was treated to a dose of 66 gy in 30 fractions. The cervical lesion was treated to a dose of 50.4gy in 28 fractions. Both sites were treated by igrt and bladder protocol was followed for cervical malignancy. The patient also received concurrent weekly cisplatin at a dose of 40 mg/m2. The patient tolerated the treatment well with no treatment breaks. After completion of EBRT the patient was referred for brachytherapy for cervical malignancy. She received 2 sessions of intracavitary radiotherapy to a dose of 15 gy in 2 fractions. Results: Patient was kept on monthly follow up for 3 months with clinical examination being done at every visit. The patient had tolerated the treatment well and her acute toxicities had resolved within 1 month. At the end of 3 months a pet ct was done to assess disease status. Pet ct showed a complete metabolic response. Patient now has a DFS of 2 years and her 2nd annual PET CT was also normal. Conclusion: Synchronous presentation of malignancies in cervix and nasopharynx is a rare presentation. However, if treated aggressively with radical chemoradiation it may result in good prognosis and DFS.

 > Abstract: 247: Effect of anticancer treatment on the psychosexual life of cervical carcinoma survivors: A single institutional observational questionnaire based study Top

Nishana Paul, Partha Dasgupta, Kakali Choudhury

R G Kar Medical College, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): Carcinoma cervix is the 2nd most common malignancies in females. With around 83% of the global burden of cervical cancer residing in the developing countries, the picture in India is quite distressing. Though due to promising development in the field of radiation oncology, we manage to extend the life expectancy of the patients. But after treatment what happens to them? Sadly there are a small number of data on long-term treatment effects and their subsequent effect on quality of life(QoL) in cervical cancer patients. An increase in survival rates over few decades has lead to a greater proportion of patients living with the late adverse effects of cancer treatment. With multimodality treatment, the sexual quality of life of the patients are severely deranged. In a country like India, where discussion about sexual problems are still being considered as social taboo, more often the psychosexual problems of the carcinoma survivors are being neglected. In our institution we tried to evaluate the effect of radiotherapy on the psychosexual behaviour of the cervical carcinoma survivors. Materials and Methods: It was a single institutional observational interview based study. Study period was from August 2017 to May 2019. FSFI questionnaire: Female Sexual Functional Index -A multi dimensional self report instrument-presents the development of brief self report measure of female sexual function. The patients were interviewed at fixed time intervals, and the data were analysed at baseline, during treatment and post treatment. Total 58 patients were taken at first in study, among them 11 patients denied to answer the female sexual functional index score questtionares,9 patients lost to follow up, one died. 3 patients denied to give informed consent-so excluded from study. Results: The FSFI questionnaire looks in to six domains to explain the quality of sexual life of cervical cancer survivors, namely 1) desire 2) pain 3) lubrication 4) arousal 5) satisfaction 6) orgasm. The FSFI scores showed least values during radiation therapy as most of the patients showed abstinence during that period due to anxiety and social taboo. Desire, lubrication, pain showed most decreased values during radiation therapy, which gradually increased, but never achieved baseline values. Orgasm and satisfaction showed same trend, they were decreased as patients were going through a mental trauma and anxiety due to cancer treatment. As soon as the treatment completed the values returned to normalcy. Conclusion: From our study, we can conclude that the evaluation of the psychosexual quality of life in cancer patients could help improve treatment and also might even be a prognostic factor. We can also conclude that treatment with chemoradiation is significantly affected the quality of psychosexual function along with other physical problems. Hence, further studies are needed for more information and intervention to improve the problems.

 > Abstract: 252: Eortc QLQ CX24 quality of life in carcinoma cervix patients postebrt and brachytherapy Top

Antara Sanyal, Meenu Gupta, Mushtaq Ahmad, Sunil Kumar Saini, Upasana Baruah

Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India, E-mail: [email protected]

Purpose and Objective(s): Quality of life EORTC QLC CX24 in carcinoma cervix patient post EBRT and Brachytherapy. Materials and Methods: Application of EORTC QLQ CX24 questionnaire in out-patient follow-up cases of Carcinoma Cervix who have completed treatment approx 1yr ago.~60 patients - Data has been collected for 55 patients and is underway for compilation and completion. Results: Results and conclusions to be discussed with the study completion. Conclusion: Results and conclusions to be concluded after study completion.

 > Abstract: 268: Prognostic value of pretreatment hemoglobin level in patients with locally advanced cervical cancer Top

V. S. Haritha, Rajesh Jain, Chandra Prakash

Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): The purpose of this study is:

  • To investigate the prognostic value of pre- treatment haemoglobin(Hb) levels on the local control of disease in patients with international federation of obstetrics and gynaecology(FIGO) stage IIB– IVA cervical cancer
  • To evaluate the haematological toxicity arising from chemoradiation treatment in this group of patients
  • To assess the prevalence of anaemia in central India in a tertiary care hospital setup.

Materials and Methods: In this study we retrospectively enrolled patients with locally advanced cervical cancer who were treated at Shrimati Ujjam Ba Cancer Hospital, Jabalpur, Madhya Pradesh from January 2018 to July 2019. Results: We retrospectively enrolled 171 patients who completed treatment and came for regular follow- up. Factors such as pre- treatment and post- treatment Hb values, FIGO stage, age of the patient and outcome of treatment were analysed. Patients were categorized into three levels with Hb values >/= 12 g/dl, 10-12 g/dl and <10 g/dl.135 out of 171 patients had pre- treatment anaemia(78.9%) with 21% with Hb >/=12g/dl, 40.9% with Hb 11-10 g/dl and 38% with Hb <10 g/dl. On statistical analysis the pre- treatment Hb values of >/=10g/dl was found to be associated with lesser recurrence rates and entailed a better prognostic significance in disease free survival (p = <0.00001) compared to other factors like age of the patient(p =0.306) and FIGO stage(p=0.708). Haematological toxicity after chemoradiation was found in 105 out of 171 patients(61.4%) with grade 3 toxicity in 19 out of 171 patients(11.1%). Conclusion: We found that there was a strong relation between pre – treatment haemoglobin levels and the impact of anemia before treatment on the local tumour control in patients with locally advanced cervical cancer.

 > Abstract: 277: Comparison of organs at risk doses for two different dose prescription strategies in computed tomography based cervical cancer brachytherapy Top

Susan Mathews, Sharika Menon, Biju Azariah, Harsha Balachandran, Preethi George

Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]

Introduction: Image guided adaptive brachytherapy (MRI based IGABT) is the standard of care for Cervical cancer brachytherapy. Traditionally doses to organs at risk (OARs) are calculated using the ICRU-38 rectum and bladder points. For IGABT, OAR doses are assessed with dose volume histograms (DVHs) and the minimum dose to 2cc of OARs receiving the highest dose (D (2cc)) have been correlated with toxicity. Purpose and Objective(s): This study compares the Organs at Risk doses (D2cc OARs) for two dose prescription strategies - 7Gy to Point A & 8- 9 Gy to CTV in CT based cervical cancer brachytherapy and also assess correlation between D 2cc and ICRU point doses. Materials and Methods: At RCC Trivandrum, CT based Brachytherapy planning for cervical cancer is done the traditional way with slight modifications/ optimization of isodose to decrease dose to OARs after standard Point A prescription of 7Gy. Volumetric prescription and dose optimization was attempted by prescribing to CTV - which is the entire cervix and distal part of the corpus. Optimization is done to ensure 100% isodose coverage of CTV. The prescription doses for CTV were chosen from the equivalent doses tables proposed by Subir Nag and Gupta for 3 fractions of HDR. After 45 Gy EBRT, 8-9 Gy per fraction dose would deliver D90 of 85 Gy10 to the CTV. ICRU 38 bladder and rectal point doses were limited to ~7.5 Gy/fx and ~6 Gy /fx for limiting D2cc Bladder to75-80 Gy3 and D2cc Rectum to 65-70 Gy3. The D2cc doses delivered to bladder, rectum and sigmoid were retrospectively analyzed by contouring the OARs on the stored CT plan images. 129 CT data sets with 7 Gy Point A prescriptions and 139 CT images with CTV prescriptions were analyzed. Results: “Point A” prescription (7Gy) delivered a mean dose of 648.7cGy (SD-194.8, Range: 173-1198) to ICRU Bladder Point while the mean D2cc Bladder was 722.2 c Gy (SD: 128.6 Range: 289-1083). For CTV prescriptions (8-9 Gy) the mean doses were 566.3 cGy (SD: 142.6 Range: 224-938) to Bladder point and 721.6 cGy (SD 111.3, Range: 454-1040) for Bladder D2cc. The mean Rectal Point dose from 'Point A' prescription was 479.1cGy (SD: 129.2, Range: 223-836) and the mean D2cc Rectum was 452.4cGy (SD: 132.1 Range: 153-792). The mean values for 8Gy CTV prescriptions were of 536.7 cGy for Rectal Point (SD: 88.9, Range: 342-762) and 526.6 cGy for Rectum D2cc (SD: 98.89, Range: 280-760). There was no significant difference in D2cc values for Bladder and Sigmoid between the two prescription strategies. D2cc Rectum was significantly (P-0.001) different between plans. However this is not clinically significant as 526.56 cGy D2cc is well within rectal tolerance limits. The differences between ICRU point doses (Bladder & Rectum) and the D2cc values were statistically significant (P-0.001 & 0.004) for 'Ponit A' prescriptions. For CTV prescriptions the difference was significant for only the bladder dose (P- 0.001). Conclusion: Volumetric dose prescription for CT based cervical cancer brachytherapy is feasible and is a further step in the process of transition from 2D to 3D image guided Brachytherapy.

 > Abstract: 281: Comparison of neoadjuvant chemotherapy followed by concomitant chemo-radiation with concomitant chemo-radiation alone in patients with locally advanced cervical cancer Top

Rishika Saxena, O. P. Singh, Veenita Yogi, H. U. Ghori, Vivek Tiwari, Manish K. Ahirwar

Gandhi Medical College, Bhopal, Madhya Pradesh, India, E-mail: [email protected]

Introduction: Carcinoma cervix forms a major bulk of all the cancer cases presenting at our centre. 95% of carcinoma cervix patients present with locally advanced cancer (FIGO stage IIB - IIIB). The role of neoadjuvant chemotherapy (NACT) has been investigated in order to improve the prognosis of patients with locally advanced cervical cancer. NACT before radiotherapy could potentially reduce tumor size and result in better dose distribution. Purpose: The aim of this analysis is to analyze the feasibility of neoadjuvant chemotherapy in carcinoma cervix and effect of NACT on response to ICRT. Materials and Methods: 100 histopathologically proven carcinoma cervix patients (Stage IIB to IIIB) were retrospectively analyzed. They were divided into two groups (A and B). Patients in group A received three cycles of Taxane based neoadjuvant chemotherapy followed by concurrent external beam radiotherapy (EBRT) then intracavitary radiotherapy (ICRT). Patients in group B received concurrent EBRT followed by ICRT. Both the groups were assessed for response evaluation and toxicity grading. Results: 74.5% in group NACT v/s 66.7% in group CTRT(p=0.01) had complete response to treatment. 25.5%(NACT) v/s 33.3% (CTRT)patients had residual pelvic disease. The delayed toxicities at 24 months or later after treatment completion in the neoadjuvant chemotherapy plus concomitant chemoradiation group versus the concomitant chemoradiation only group were gastrointestinal (2.2% v 3.5%, respectively), bladder (1.6% v 3.5%, respectively), and vaginal (12.0% v 15.7%, respectively). Conclusion: Neoadjuvant chemotherapy resulted in better clinical response and less residual disease with a similar toxicity profile, thereby suggesting NACT with concurrent chemoradiation to be a viable option for patients with locally advanced cervical cancer.

 > Abstract: 282: The prognostic significance of neutrophil lymphocyte ratio in cervical cancers treated with radiotherapy Top

B. M. Muhammed Ali Azher, Niketa Thakur, Sonal Patel Shah

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

Purpose and Objective(s): The elevated neutrophil to lymphocyte ratio (NLR) has been identified as a poor prognostic indicator in various malignancies. The progression of malignancies is manifested as alteration in blood counts which can be used as prognostic makers. In this study we tried to quantify the effect of NLR on disease free survival and overall survival in patients with cervical cancers. Materials and Methods: A retrospective analysis of patients treated with radiotherapy was carried out to estimate the pretreatment NLR. The NLR is correlated with overall survival and disease free survival in patients with FIGO Stage IIB to Stage IV and postoperative Cervical cancers. In analysis the association between NLR and survival was maintained in patients with stage II to IV diseases. There is a greater magnitude of correlation seen in advanced cervical cancers and a greater effect in overall survival is seen with concurrent chemoradiotherapy and radiotherapy. Results: The median cut off for high NLR is 3.5. The greater the NLR, the greater the stage and the outcomes are worse. In cervical cancer, significant association between NLR and OS is observed with locally advanced disease and in those who received chemoradiotherapy. Conclusion: High NLR is associated with adverse OS and DFS in patients with cervical cancers.

 > Abstract: 287: Isolated cardiac metastasis in a case of carcinoma cervix: A rare case report Top

Tasneem Nalawala, Niketa Thakur, Aastha Shah, Sonal Patel Shah

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

Introduction: Cardiac metastasis in a known case of squamous cell carcinoma of cervix is rare. Majority are diagnosed at autopsy. Incidence is <1.23% on autopsy. Metastatic sites in heart include epicardium, myocardium, endocardium and intraventricular tumour formation. Cardiac metastasis should be suspected in patients with recurrent pulmonary emboli without any evidence of deep vein thrombosis, inexplicable heart failure especially in patients with extensive pelvic lymph node metastasis. Early diagnosis may improve prognosis. Case Report: We report a case of carcinoma cervix International Federation of Gynecology and Obstetrics (FIGO) Stage IIIB treated with external beam radiotherapy 50 Gray in 25 fractions, 5 fractions per week with concurrent weekly four cycles of carboplatin followed by two fractions of intracavitary brachytherapy 7.5 Gray per fraction. Patient was on regular follow up and asymptomatic for four months post treatment. There was no evidence of local disease on examination and imaging. She complained of fatigue, weakness and shortness of breath. Total leucocyte count was elevated. Chest radiograph showed mild cardiomegaly. Patient was treated symptomatically. Cardiology opinion was sought. 2D echocardiography showed mild Mitral stenosis, Tricuspid stenosis, Aortic stenosis, 4*2 cm thrombus in right ventricular outlet, clot in right ventricle apex. CT pulmonary angiography was suggestive of metastatic lesion involving apex of right ventricle and intravenricular septum and multiple metastatic deposits in pericardium with thrombus in right descending pulmonary artery emboli. Patient was admitted under cardiology and actively managed for pulmonary emboli, but patient developed brain infarct and was kept on anticoagulants. However, patient's condition could not be stabilized even after two weeks of active management and she ultimately died of cardiac failure. Literature Review: We found 4 case reports of the same. Average survival after diagnosis was 12-23 months after the diagnosis.

 > Abstract: 288: Assessment and implication of rectal filling on vaginal motion in postoperative carcinoma endometrium patients Top

Rashi Agrawal, Prekshi Choudhary, Soobuhi Khan, Dinesh Singh, Sandeep Agarwal

Max Superspeciality Hospital, New Delhi, India, E-mail: [email protected]

Aim: In postoperative gynaecological patients, while delivering radiotherapy it is utmost important to minimize target motion to decrease margins. Hence certain bladder and rectum filling protocol are followed by each institute. During CBCT verification we observed that this motion was more affected by rectal filling. To verify our observation, we retrospectively analysed the vaginal movement and its relation with bladder and rectum filling. Materials and Methods: We evaluated post-operative carcinoma endometrium patients who completed their external beam radiotherapy treatment by image guided intensity modulated radiotherapy technique. We evaluated CBCTs of 15 carcinoma endometrium patients. Bladder and rectum both were contoured offline on each scan. To assess the motion of vagina, two reference points were selected. Posterior movement of bladder and anterior movement of rectum were noted on these points on each scan. Results: This is a retrospective descriptive study. Total 150 scans (135 KV- CBCT scans, and 15 planning CT) of 15 patients were studied. 66% patients had at least ten CBCT scans. 26% had more than 7 scans. On an average, 9 CBCT scans per patient were available for analysis. The bladder volume on planning CT (reference bladder volume) ranged from 51.4- 424.4cc. Mean reference bladder volume was 214cc. The rectum volume on planning CT scan (reference rectum volume) ranged from 32.6-123.5cc. Regression analysis reported that bladder wall changes has a non significant relationship with bladder volume among all the individuals. The significant rectum wall changes both at Point X and Y were observed among patient no 3.6, 8, 10, 14, 15 and only at Point X among patient no.4, 7, and 11. Rest of the patients showed no significant relationship between rectum wall and rectum volume in subsequent CBCT scans. Thus 60% patients showed relation between rectum volume and rectal wall movement. Conclusion: Although bladder volume is needed to decrease the dose to small intestine, we suggest to counsel patients more regarding rectum volume to decrease vaginal motion. However prospective data in large number is required to confirm these findings.

 > Abstract: 289: Comparison of thermoplastic molds and knee wedge as immobilisation devices for image guided pelvic radiation therapy using CBCT Top

Mridul Anand, Ankita Parikh, Sonal Patel Shah, U. Suryanarayan

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

Aim and Objective: Pelvic radiotherapy is generally performed with the use of an immobilisation and positioning device. The objective of the study is to ascertain and compare set up errors between the two positioning devices. Materials and Methods: A total of 35 patients of stage II and III cervical cancers were enrolled in the study and divided into 2 groups, one using knee wedge and the other using thermoplastic pelvic mask as an immobilisation device. Radiation was planned by 4 field box conformal technique. The random and systematic setup errors were then calculated for each patient in both the groups in the mediolateral(ML), supero-inferior(SI) and the antero-posterior (AP) directions. Results: The translational mean set up variation in the lateral, longitudinal and vertical direction is 0.17±0.24, -0.12±0.48 and -0.18±0.27 cm for thermoplastic pelvic mask and -0.03±0.26, -0.04±0.48 and -0.09±0.37 cm for knee wedge respectively. The systematic set up error and random errors were 0.24,0.48,0.27 cm and 0.31, 0.60 and 0.40 cm for thermoplastic mask and 0.26,0.48 and 0.37 cm and 0.38, 0.37 and 0.45 cm for knee wedge in medio-lateral, supero-inferior and antero-posterior axis respectively. The one way ANOVA test was applied to compare the set-up errors in between the three axis for both the immobolisation devices. To compare the positioning accuracy of thermoplastic mask and knee wedge, student t-test was applied. Both the tests were found to be insignificant(pvalue>0.05). Conclusion: Thermoplastic mask and knee wedge are equally effective as immobilisation devices for treating gynecological cancers with conformal techniques.

 > Abstract: 292: Female genital tract melanoma: Analysis from a regional cancer institute Top

Garima Pandey

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

Purpose and Objective(s): Malignant melanoma of genital tract comprises 3% of overall melanomas afflicting females. They are characterized by poor prognosis with 5-year survival of 0-25% and high incidence for distant metastasis. This study was performed to assess various clinical features, treatment options and management of genital melanomas. Materials and Methods: This was a retrospective analysis where records of patients with genital melanomas between 2005 to 2018 were reviewed to obtain demographic and clinical information, including age of diagnosis, presenting symptoms, performance status, pathology reports, treatment, follow-up and survival. Results: Between 2005 to 2018, 31 women were analyzed. The median age was 53.5 years (range 28.5-85). Vaginal bleeding was the commonest presenting symptom (80.6%) followed by discharge (29%), mass in vagina/perineum (19.3%), pain (16.1%) and difficulty in micturition (9.6%). The commonest site of origin was vagina (67.7%) followed by vulva (19.3%) and cervix (12.9%). Tumor diameter was more than 3 cm in 74.2 % (23/31). Out of 31 patients, only 16 opted for treatment. Four patients underwent surgery, 10 received primary chemotherapy and two needed palliative radiotherapy for heavy bleeding. The median survival in the treatment group was 5 months (2.5-28 months), almost similar to patients not receiving any treatment (5 months, 2-11). Conclusion: Genital melanoma are rare but aggressive tumors. Diagnosis is usually made with biopsy. No effective treatment strategy is yet available. However, surgery is the preferred first line treatment while radiotherapy and chemotherapy had been used in adjuvant setting.

 > Abstract: 299: Knowledge and awareness of carcinoma cervix, screening and vaccination strategies among relatives of cancer patients: A teritiary cancer centre study Top

Shiva Divya, Harjot Kaur Bajwa, Rohith Singareddy, Krishnam Raju Alluri

Basvatarakam Indo American Cancer Hospital, Hyderabad, Telangana, India, E-mail: [email protected]

Introduction and Background: Cervical cancer ranks fourth for both incidence and mortality among women worldwide. India contributes to 17% of the global burden of cervical cancer and it is the second most common among Indian females. The high incidence of 96,922 new cervical cancers diagnosed annually in Indian women contributes significantly. In spite of effective screening strategies for early detection of the precancerous conditions using cost effective methods and HPV vaccine administration there is a huge lack of awareness, which plays a main role of effective intervention. Objective: The objective of this study was to assess the knowledge and awareness about symptoms, risk factors, cytological screening and its acceptability, vaccination against human papilloma virus (HPV) and to know the sources of information and reasons for not undergoing screening and vaccination among men and women in our hospital. Materials and Methods: This is a cross-sectional study conducted on 130 men and women attending out patient department from May to October 2019 at Basavatarakam Indo american cancer hospital and research institute, Hyderabad. Two separate questionnaires were used to collect data from women (N=91) and men (N=39) after getting informed verbal consent. Results: In our study, majority of the participants 92(70.7% ) heard of cervical cancer and the source of information is through family(48.9%), neighbors (23.9%), doctors(16.3%) and mass media(10.86%). Out of those who heard of cancer, only 33( 35.86%) are aware of its symptoms and only 12(13%) are aware of one or more risk factors. Only 16(17.39%) are aware of existence of a screening method but only 4 have undergone the test in the past. After explaining the procedure and importance of screening to all the participants, only 24 females(18.46%) are ready to go for pap smear, 31 males(23.84%) would encourage females in their family for screening. In spite of this, 75(57.69%) are not ready for screening, the major reason stated as they do not have any symptoms by 33(44%), 26(34.6%) not being comfortable with the procedure,8(10.66%)need family members consent, 8(10.66%) due to other reasons. In total only 16(12.3%)respondents were aware of the HPV vaccine. After explaining the importance of vaccination,94(72.3%) would encourage their daughters/ females for vaccination but 36(27.69%) are not supporting vaccination still, 17(47.22% ) being afraid of side effects, 9(23.07%) have cost issues, 5(13.88%) are not being interested,3(0.08%) need family consent and 2(0.05%) due to other reasons. Conclusion: The low level of knowledge and awareness suggests a need to strengthen awareness programs. It is imperative that men and women gather adequate knowledge on cervical cancer for the success of any program to control the disease. Wide spread awareness about the disease must form an integral part of public health policy of government. A comprehensive cervical cancer control program must include awareness regarding prevention, screening, risk factors and treatment. While it may not be feasible to introduce all the interventions simultaneously, a long-term plan should be put in place to establish a comprehensive program.

 > Abstract: 304: Survival in uterine endometrioid adenocarcinoma after radiotherapy Top

Muthulingeshkumar Muthukarthikeyan, John M. Mathew, Divya Bharathi, Manavalan Manivannan, Jagadesan Pandjatcharam

JIPMER, Puducherry, India, E-mail: [email protected]

Purpose and Objective(s): Clinical outcomes of endometrioid adenocarcinoma depend on various prognostic factors. We intended to study the survival of these patients in our cancer centre. Materials and Methods: We analyzed the records of 106 patients of uterine endometrioid adenocarcinoma treated between January 2013 and December 2017 in our centre. Overall Survival (OS) was calculated by Kaplan-Meir survival analysis. The association of prognostic factors with OS was tested using log rank test for uni-variate analysis. Patients who did not reach the survival event and those lost to follow up were censored from analysis. Results: The median age was 55 years. Four patients were pre-menopausal. 58 % of patients had co-morbidities such as diabetes, hypertension or hypothyroidism. Based on ESMO-ESGO-ESTRO consensus risk stratification, 6(5%) patients belonged to low risk, 15(14%) intermediate risk, 2(2%)high-intermediate risk, 42(40%) in high risk, 3 (3%) each in advanced and metastatic risk groups and 35(33%) with unknown risk features. Radiation was planned in 70% of all patients as adjuvant, 13% as radical, 8% as neo-adjuvant and the remaining as palliative treatment. 81% had completed their planned course of radiation which comprised of 50Gy in 25 fractions of pelvic radiation with or without vaginal brachytherapy. 50 patients were treated with conventional two or four fields and 20 with 3D conformal techniques. Besides, 16 received only vaginal brachytherapy. 17 deaths were recorded and 36 patients had lost to follow up. The mean overall survival was 63.2 months (95% CI: 56.8 – 69.5) for all patients. Median Survival is 10 months for advanced/metastatic risk groups, 71 months for high-intermediate/high risk group and is not reached for low/Intermediate risk. Conclusion: Overall survival of uterine endometrioid cancers is poor in advanced and metastatic stages. The median survival of high-intermediate/high risk patients of endometrioid histology is around 5.9 years. In our study, a significant proportion of the patients had lost to follow-up.

 > Abstract: 308: An indigenously built multichannel vaginal HDR applicator: Benefits and dosimetric comparison with the conventional single channel applicator Top

Sowmiya Sampathrajan, S. Senthilkumar, Kesavan Govindaraj

Vadamalayan Integrated Cancer Centre, Madurai Medical College, Madurai, Tamil Nadu, India, E-mail: [email protected]

Background: Endometrial cancer is one of the most common gynaecological malignancy. Vaginal cuff brachytherapy is a standard treatment option for postoperative endometrial and selective postoperative cervical cancer cases for women at high risk for vaginal recurrence. Single-channel vaginal cylinders are frequently used to treat the vaginal cuff, but they are limited in their ability to sculpt dose away from organs at risk (OARs). Multichannel applicators, through modulation of dwell times in various positions along the channels, improve the ability to optimize target coverage and to minimize dose to OARs. Purpose: The main purpose of this study was to develop an indigenous, cost effective multichannel applicator for HDR vaginal brachytherapy and dosimetric comparison with the conventional single channel applicator. Materials and Methods: The multichannel applicator is a solid cylinder made up of PMMA with 3 cm diameter, 13 cm length. It has a central channel surrounded by eight channels arranged equidistantly at the periphery in a single circle which is 0.5cm from the surface. We randomly selected 15 patients with endometrial carcinoma and treated them with conventional single channel applicator after obtaining CT scan, contouring CTV and organs at risk( OAR). 7Gy HDR Dose was prescribed to 0.5cm from vaginal surface and after treatment same patient was subjected to our multichannel application and CT scan images obtained. 3D inverse treatment plans were created with multichannel loading and the dose distribution of both plans compared with CTV coverage and also the rectum, bladder doses. Results: The DVH analysis showed statistically significant difference between single and multichannel plans in terms of target coverage, mean D95 of CTV was 93% and 96% respectively (p=0.0358), mean D100 of CTV was 86% and 92% (p=0.0229). Similarly dose to OAR's such as rectum was significantly lower, mean 2cc and V70 are 6.3 Gy Vs 5.5 Gy (p=0.002) and 7.2% vs 4.3% (p= 0.0073) respectively. On the other hand, bladder DVHs also showed difference but did not reach statistical significance, the mean 2cc were 4.9 Vs 4.7 Gy (p=0.728). Conclusion: Hence our Indigenous multichannel vaginal Applicator with 3D inverse treatment planning definitely has an advantage over single channel planning with improved target coverage and reduced dose to OAR'S especially rectum. It is a cost effective, in-house built applicator and hence be definitely of tremendous use in developing countries.

 > Abstract: 309: Dosimetric Comparison of geometric optimization versus inverse planning simulated annealing in patients of locally advanced carcinoma cervix treated with interstitial brachytherapy Top

Narayan Adhikari, Anurita Srivastava, Deepak Raj Sonkar, Kishore Singh

Maulana Azad Medical College and Associated Lok Nayak Hospital, Delhi, India, E-mail: [email protected]

Background: Brachytherapy constitutes an essential part of radiation treatment in cases of carcinoma cervix. Post teletherapy, cases not eligible for intracavitary brachytherapy undergo interstitial brachytherapy(ISRT). With availability of image based planning, several optimisation tools have found place in routine practice. IPSA is an optimization tool developed at University of California for high dose rate brachytherapy. Purpose and Objective(s): This study aims to dosimetrically compare ISRT treatment plans optimised with geometric optimization(GO) versus Inverse Planning Simulated Annealing(IPSA) in cases of locally advanced carcinoma cervix. Materials and Methods: ISRT treatment plans of 12 patients treated from 2017-2019 in our department were retrospectively analysed. ISRT is performed using MUPIT (Martinez Universal Perineal Interstitial Template) and treatment planning is done in Oncentra. Optimization is done by graphical or geometric methods for treatment and by IPSA for dosimetric comparison. Target volume(TV) and organs at risk(OAR) were delineated. Dose of 25- 30 Gy equivalent in 4-5 fractions were prescribed as per the tolerance limit of OAR to deliver sufficient dose to TV. Uniform cost function of dose constraints was applied to all IPSA generated plans with dwell time deviation constraint(DTDC) of 1 and 0 for case of comparison. The dosimetric parameters of GO versus IPSA were compared with repeated measures ANOVA. Statistical analyses were done in SPSS v25.1. Results: The mean values of TV85 for GO, IPSA-DTDC1 and IPSA-DTDC0 were 90.62%, 83.6% and 96.13% (p<0.001) respectively. Similarly mean values of TV100 were 74.51%, 67.23% and 80.48% (p-value <0.001), TV150 were 13.44%, 17.86% and 19.43% (p-value=0.002), TV200 were 5.38%, 7.70% and 8.96% (p-value<0.001) and D90 were 85.75%, 74.72% and 94.18% (p-value<0.001) for GO, IPSA-DTDC1 and IPSA-DTDC0 respectively. The mean values of dose homogeneity indices were 0.82, 0.73 and 0.76 (p-value=0.002), dose non-uniformity indices were 0.18, 0.27 and 0.24 (p-value=0.002), coverage indices were 0.74, 0.67 and 0.80 (p-value<0.001), overdose indices were 0.07, 0.11 and 0.11 (p-value<0.001), external volume indices were 0.28, 0.14 and 0.28 (p-value<0.001), conformity indices were 0.55, 0.56 and 0.60 (p-value=0.089) for GO, IPSA-DTDC1 and IPSA-DTDC0 respectively. The mean bladder D2cc were 74.06%, 64.66% and 71.34% (p-value<0.001), rectum D2cc were 70.54%, 63.84% and 70.69% (p-value<0.001) and urethra D0.1cc were 38.42%, 31.18% and 36.37% (p-value<0.001) for GO, IPSA-DTDC1 and IPSA-DTDC0 plans respectively. IPSA-DTDC0 had significantly better tumour coverage of both 85% and 100% isodose as well as D90 and coverage index, followed by GO and then by IPSA-DTDC1. However, 150% and 200% isodose volumes were significantly higher in IPSA-DTDC0 followed by IPSA-DTDC1 and then GO, leading in higher overdose indices. Dose homogeneity (highest dose homogeneity index and least dose non-uniformity index) was best for GO plan. GO and IPSA-DTDC0 plans had significantly higher normal tissue irradiation compared to IPSA-DTDC1 (external volume index). Conformity indices of all three plans were not statistically different. Doses to OAR were least in IPSA-DTDC1 plan. Conclusion: IPSA-DTDC0 gives better coverage but with significant high dose regions (CTV150 and CTV200) requiring careful evaluation of spatial location of these isodoses before implementation. IPSA needs to undergo comparative testing in larger studies before use in routine practice.

 > Abstract: 313: Efficacy of postoperative radiation therapy in carcinoma endometrium Top

Ramashish Kumar, Ashok Chauhan, Shailley Arora Sehga, Paramjeet Kaur, Abhishek Soni, Anil Khurana, Yashpal Verma, Anjali Bhola

PT B D Sharma PGIMS, Rohtak, Haryana, India, E-mail: [email protected]

Introduction: As compared to carcinoma cervix, the cancer of Endometrium is infrequently seen in Indian women. As per Globocan 2018 Endometrial cancer accounts for 13328 (1.27%) new cases in India. This study adds to the limited literature pertaining to demographic indices and treatment outcome in Carcinoma Endometrium. Materials and Methods: This retrospective study analyzed 97 patients of Carcinoma Endometrium attending the department of Radiation Oncology at Pt B D Sharma PGIMS Rohtak. The median age of the patients was 60 years. Of all the patients, 55% were from rural area and 45% are from urban area. It has been found that 5% patients were tobacco users. Most common histopathology was Adenocarcinoma (91%). Stage-wise distribution was stage I (58%), stage II (14%), stage III (18%) and stage IV (7%). Most of the patients i.e.89 (92%) underwent surgical treatment comprising total abdominal hysterectomy with bilateral salpingo-oophorectomy and out of these, 55(62%) patients had received External beam radiation therapy and 33 (37%) patients had received External beam radiation therapy as well as Vaginal cuff brachytherapy. Results: At follow up ranging from 1 month to 3 years with median follow up of 6 months, there were no recurrence in any of the patients receiving External beam radiation therapy as well as vaginal cuff brachytherapy. It has been found that 10% of the post-operative patients who did not receive any adjuvant treatment developed either loco-regional recurrence or distant metastasis. Conclusion: As per present study higher incidence were found in 5th decade of life, 55% of patients belonging to rural area and adenocarcinoma being the most common histopathology. At follow up there was no recurrence in any of the patients receiving External beam radiation therapy and Vaginal cuff brachytherapy.

 > Abstract: 319: Treatment pattern and survival outcomes in older women with cervical cancer Top

Sakshi Rana, G. Y. Srinivasa, Bhavana Rai, Divyesh Kumar, Sushmita Ghoshal, Arun Oinam

PGIMER, Chandigarh, India, E-mail: [email protected]

Introduction: Cervical screening programs in our and many other countries usually stop at the age of 65, and much of the focus is often on younger women. Although the older age group is becoming an increasingly prevalent portion, but the treatment disparities between older and younger age group are common. Elderly patients are a heterogeneous group in terms of performance status, comorbidities, access to healthcare and motivation to participate in screening programs. These factors are generally associated with the delay in the diagnosis and treatment could be further compromised due to the decreased ability to tolerate the radical treatment of concurrent chemoradiation. Management decisions, therefore need to be highly individualized. There is limited data on the patterns of care, treatment toxicity, and the outcomes in elderly patients with carcinoma cervix. Purpose: The study aims to examine the management of carcinoma cervix in elderly patients and the outcomes in terms of overall survival (OS), disease-free survival (DFS), and treatment-related toxicities. Methods: The records of all patients above age of 65 years treated for carcinoma cervix between January 2011 and August 2013 were reviewed retrospectively. Out of 300 patients, 48 patients were identified with age above 65 years. Prospectively data regarding treatment toxicity (CTCAE 4.0), treatment outcomes and parameters related to treatment was collected. Results: The results of 48 patients were identified, who were found to be ? 65 years age. The median age was 67 ( Range 65-76). 91% of patient belongs to the International Federation of Gynaecology and Obstetrics stage IIb–III b disease. All patients completed planned external beam radiotherapy. 66% of patients received radiotherapy alone followed by intracavitary brachytherapy (ICBT) and 25% received concurrent chemoradiotherapy followed by intracavitary brachytherapy (ICBT). Rest 9% received radiotherapy alone followed by supplementary radiotherapy. With a Median follow up of 88 months, 5 year OS and DFS was 75% and 78% respectively with majority patient dying without evidence of disease. Grade 2 or more late toxicities were: bladder 6%, rectal 10%, and vagina 20%. Conclusion: Elderly patients treated radically with concurrent chemoradiotherapy followed by ICBT have good disease control and better toxicity profile, but appropriate selection of patients is at-most essential in treating these patien.

 > Abstract: 340: Assessment of nutritional status of carcinoma cervix patients using patient-generated subjective global assessment score and its correlation with treatment outcome Top

Anjali Bhola, Ashok Chauhan, Paramjeet Kaur, Abhishek Soni, Shailley Sehgal

Pandit BD Sharma PGIMS, Rohtak, Haryana, India, E-mail: anjalibhola9[email protected]

Introduction: Carcinoma of uterine cervix is the fourth most common cancer in women worldwide and second most common cancer in women in India. Malnutrition negatively affects the patient's prognosis as it impacts disease progression, diminishes response to cancer treatment, increase risk of treatment complications, worsens quality of life, increases hospital stay and decreases survival rate. The scored PG-SGA is a validated nutritional assessment tool for cancer patients that records and summarizes weight changes, alterations in food intake, gastrointestinal symptoms and changes in functional capacity and physical signs of malnutrition. This study proposes assessment of nutritional status of cervix carcinoma patients by using Scored PG-SGA. Purpose and Objective(s): Assessment of nutritional status of carcinoma uterine cervix patients using PGSGA score and its correlation with treatment outcome. Materials and Methods: 60 previously untreated, histopathologically proven patients of cervix carcinoma, attending the Department of Radiotherapy were assessed for nutritional status using Scored Patient-Generated Subjective global assessment at time of presentation, at the end of treatment and three months after completion of treatment. Patients received external beam radiotherapy 50 Gy in 25 fractions over 5 weeks with concomitant cisplatin 40 mg/m2 intravenous weekly for 5 weeks. However, patient received supplementary EBRT 16 Gy in 8 fractions over 1.3 weeks or intracavitatory brachytherapy one week after completion of EBRT, three fractions of 7 Gy each, once in a week. Results: Before treatment, 55% patients were well nourished, 45% patients were moderately malnourished and none was severely malnourished. At the end of treatment, 3% patients were well nourished, 52% patients were moderately malnourished and 45% patients were severely malnourished. At third month of follow up, 67% patients were well nourished, 28% were moderately malnourished and 5% were severely malnourished. Mean PGSGA scores before concomitant chemoradiation, at end of chemoradiation and at 3rd month follow up were 8.08, 14.50 and 8.15 respectively (p-value <0.001). Complete response was seen in 90% of PGSGA stage A patients and 67% of PGSGA stage B patients and progressive disease developed in 3% of PGSGA stage A patients and 19% of PGSGA stage B patients. Six percent patients of PGSGA stage A had interruptions in treatment and 30% of PGSGA stage B patients had treatment interruptions. Conclusion: The study has noted a higher incidence of treatment related toxicities and treatment interruptions in malnourished patients. Treatment was better tolerated in well nourished patients and tumour control was better in well nourished patients. Degree of malnutrition increased shortly after treatment. Subsequently, degree of malnutrition substantially decreases during the first three months after treatment and nutritional status plays a role in the course of disease outcome.

 > Abstract: 346: Biomarkers of survival in patients with adenocarcinoma of the uterine cervix receiving chemoradiotherapy Top

Anil Khurana, Abhishek Soni, Yashpal Verma, Paramjeet Kaur, Om Parkash, Shailley Arora, Ashok Kumar Chauhan

RCC, Pandit B D Sharma PGIMS, Rohtak, Haryana, India, E-mail: [email protected]

Incidence of adenocarcinoma of uterine cervix is 10-20% of all uterine cervical malignancies and there is a trend of rising incidence because of nulliparity, obesity and HPV-18 infection. Concurrent chemoradiation is the standard of care for squamous cell carcinoma (SCC) cervix, however, patients with adenocarcinoma cervix respond poor to radiation and have inferior outcomes in comparison to SCC. Thus, biomarkers are of particular interest for their potential role in the design of personalized treatment strategies targeting individual malignant tumors. In cervical cancer, several biomarkers for RT-based treatment have been validated by patient survival or recurrence data. Purpose: Thus, this review investigates the impact of pretreatment immunohistochemical (IHC) biomarkers and clinical parameters on CRT based treatment in these patients. These biomarkers fall into categories according to biological function including hypoxia, cell proliferation, cell adhesion, immunogenicity, and evasion of apoptosis. Materials and Methods: Pubmed, Scopus, and Google Scholar were searched for publications related to biomarkers in adenocarcinoma cervix; and, relevant publications were included in the study. Results: The assessment of various biomarkers revealed that Myeloid cell leukemia-1 (MCL-1) and c-MYC overexpression played roles in inferior cancer specific survival (CSS) and pelvic relapse free survival (PRFS), respectively. In addition, co-overexpression of the two markers is associated with lower CSS. IHC results of the mentioned biomarkers are scored by a semi-quantitative approach used to assign an H-score to the tumor. The H-score takes into consideration the staining intensity in addition with the percentage of cells staining positively. Staining intensity is graded as 0, 1, 2, and 3 corresponding to negative, mild, moderate, and strong staining, respectively. The MCL-1 is an anti-apoptotic member of the BCL-2 family of apoptosis-regulating proteins, and is an independent factor for cancer mortality. MCL-1 overexpression has been reported in some hematological cancer and solid tumors. MCL-1 overexpression and the presence of pelvic lymph node metastasis are two prognostic factors for inferior CSS. Hb level of less than 10 gm/dl is associated with higher MCL-1 expression. The c-MYC oncogene is overexpressed in the majority of human cancers and contributes to the cause of at least 40% of tumors. Overexpression of c-MYC contributes to cancer radioresistance. The mechanism for inferior tumor control by c-MYC overexpression is not directly linked to the Warburg effect. However, external validation studies using an independent data set and a large sample size should be conducted to confirm this. Furthermore, the precise molecular pathway that MCL-1 or c-MYC overexpression confers to poor CRT-based outcomes could not be clarified through association studies between IHC biomarkers and clinical parameters. Additional molecular studies are recommended to elucidate the underlying biological mechanisms, as well as the interplay with other survival pathways. Conclusion: For patients with adenocarcinoma of the uterine cervix requiring definitive CRT, treatment outcomes can be stratified by the immunohistochemical biomarkers MCL-1 and c-MYC for cancer death and local failure, respectively. Co-overexpression of MCL-1 and c-MYC led to more cancer mortality.

 > Abstract: 358: A retrospective analysis of management and treatment outcomes in gestational trophoblastic neoplasia for a period of 5 years at a regional cancer center Top

Bijjal Atreya, G. J. Benjamin, Aarathi Ardha

Mehdi Nawaz Jung Institute of Oncology Regional Cancer Center, Hyderabad, Telangana, India, E-mail: [email protected]

Purpose and Objective(s): To analyze the management, treatment outcomes of the patients with Gestational Trophoblastic Neoplasia at a regional cancer center over a 5 year period from January 2012 – December 2016. Materials and Methods: We have done a retrospective analysis of 25 cases of gestational trophoblastic neoplasia registered at MNJ Institute of oncology and regional cancer center, Hyderabad, Telangana over a period of 5 years from January 2012 – December 2016. Our study reviewed the age distribution, the incidence of various types of Gestational trophoblastic neoplasia, the treatment received, risk stratification, their pre and post-treatment beta-HCG levels, incidence of pulmonary metastasis and the effect on fertility. Results: The most common age group for the presentation of GTN is 20-29 years constituting about 72%(18/25) of the study population, followed by 20%(5/25) who presented at an age <18 years. Among the types of GTN, 40% were diagnosed to have choriocarcinoma, 60% have molar pregnancy.12 patients received treatment with EMACO regimen, 5 patients received Methotrexate with Leucoverin rescue, Methotrexate +Actinomycin was given in 1 patient, EMACO was converted to Paclitaxel + Carboplatin in 1 patient, Methotrexate + Leucoverin was converted to EMACO regimen in 2 patients, Methotrexate + Leucoverin was converted to single-agent Actinomycin in 2 patients and no treatment could be given in 2 patients. Risk stratification showed 14 patients with high risk and 11 patients with low risk. Pulmonary metastasis is noted in 7 patients and in non-pulmonary metastasis, 1 patient has bone metastasis and 2 patients have brain metastasis. The mortality rate is 12%(3/25). At a median follow up of 19.5 months, the overall survival is 88%. Of the 7 patients who had lung metastasis at presentation, 6 patients were cured completely ; indicating that the presence of lung metastasis is not a bad prognostic indicator and that it can be resolved with chemotherapy. 20% of the study population(5/25) were able to conceive after the completion of treatment. The possibility of fertility preservation could not be commented on in 3 patients. Conclusion: We conclude that in our retrospective analysis of 25 patients with GTN, at a median follow up of 19.5 months, the overall survival rate is 88% and fertility is preserved in 20% of the study population. The beta-HCG levels dropped to normal levels in 86.9% of the patients treated with chemotherapy.

 > Abstract: 364: Synchronus primary neoplasm of ovary and cervix with different histopathology: A rare case report Top

Rajal Shah, Niketa Thakur, Sonal Patel Shah, U. Suryanarayan

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

Background: Synchronous primary neoplasms are defined when two or more neoplasms take place concurrently in the same patient. Synchronous malignancies of ovary and cervix are rare and generally entail poor prognosis. The optimal management is not well defined and varies from case to case basis. Case Report: We present a case of 55 year old women presented with postmenopausal per vaginal bleeding, per vaginal discharge and lower abdominal pain. Her initial ultrasonography done outside was 10*9*7cm cystic lesion in right ovary. Right salpingo-oophorectomy was done outside and histopathology was right ovarian serous cystadenocarcinoma with intact capsule which was also confirmed at our hospital by immunohistochemically. Routine physical examination and investigations were normal except bulky cervix on ultrasonography. CT Scan of abdomen and pelvis was normal with normal left ovary and post operative status at operated site with no evidence of any abnormally enhancing lesion. Interestingly, her endocervical curettage showed poorly differentiated squamous cell carcinoma which was also immunohistochemically proven. Then she underwent optimal staging laparotomy with transabdominal hysterectomy, bilateral salpingooopherectomy and bilateral pelvic lymphnode dissection. Histopathology was confirmative of squamous cell carcinoma of cervix pathologically stage IB. After surgical healing she was given external beam radiotherapy 50 gray in 25 fractions with concurrent chemotherapy followed by 2 fractions of intravaginal brachytherapy. Her follow up investigations are normal and currently she is on adjuvant chemotherapy. Conclusion: Since the incidence of synchronous malignancies in female genital tract is rare, we need to report such cases to identify embryological factors of carcinogenesis. Also it is necessary to thoroughly examine and look for synchronous malignancy if patient present with symptoms related to single malignancy.

 > Abstract: 368: Patterns of failure in node positive cervical cancer patients treated with radiotherapy Top

M. Geetha

Malabar Cancer Centre, Thalassery, Kerala, India, E-mail: [email protected]

Purpose and Objective(s): The objective of the study is to determine the patterns of failure in node positive cervical cancer patients treated with radiotherapy or chemo-radiation and to determine the grade III and IV toxicities associated with pelvic radiotherapy and extended field radiotherapy and, the association of various factors. Materials and Methods: This is a retrospective study done at the Department Radiation Oncology Malabar Cancer Centre on node positive cervical cancer patients treated with radiotherapy or chemo-radiation from Jan 2015 to Dec 2016. The patients included in the study were cervical cancer patients with positive pelvic and /or para-aortic lymph node who were treated with concurrent chemo-radiation or radiotherapy alone. Patients who were followed up at regular intervals at least for 1 year were included in the study. Radiation treatment was done with conformal 3D radiotherapy and extended fields were used to treat patients with positive paraaortic lymph nodes. Patients were treated upto a total dose of 45 Gy -50.4 Gy in 25 – 28fractions to the pelvis and nodes were treated upto a dose of 55 Gy in 25 -28 fractions with Simultaneous Integrated Boost (SIB) Technique. Concurrent chemotherapy was given with CDDP 40 mg/m2. After completion of CTRT intra-cavitary brachytherapy 6-7 Gy in 3-4 fractions were given. Radiation toxicities were recorded in the radiation charts as per CTCAE version 4.3. The data were captured from the case records. Results: 62 patients with node positive cervical cancer were analysed. 42% of patients had comorbidities. Majority of the patients were having squamous cell carcinoma (87.1%), with adenocarcinoma and adeno-squamous carcinoma in 9.7% and 3.2 % of patients respectively. Majority of patients were stage II(38.7%) followed by stage III (32.3% ) (AJCC 7th edition). At a median follow up of 33 months ( 15- 58.6 months) 11 patients had recurrence. Local recurrence and distant failure were 2 (3.2%) and 8 (12.9 %) respectively. Locoregional recurrence was seen in 1 (1.6%) patient.. Lung was the most common site of metastasis. Followed by supraclavicular region..3 year overall survival and disease free survival were 93.5 % and 82.3 % respectively at a median follow up of 33months. Univariate analysis showed that stage of the disease, residue at end of therapy (p-0.008) and chemotherapy drug (p-0.012) had a statistically significant association with DFS. No significant association was found between OS and any of these factors. Of the 62 patients grade III –IV toxicities are seen in 21(33%). Nine (13%) patients had acute toxicities and 12(19.4%) had late toxicities. Conclusion: Node positive cervical cancer is known to have poor prognosis and it is included in the FIGO stanging 2018. The current retrospective analysis shows that with aggressive management, the overall survival and disease free survival could be improved. But being a retrospective analysis, inherent flaws in the study may be attributed to better result. The diagnosis of nodal positivity is based on radiological findings and the pathological involvement is unknown. Hence the possibility of pathologically node negative diseases might have been included in the analysis. Prospective studies with pathological evaluation of nodes.

 > Abstract: 369: Point a or pointless? A question which is very revelant in 3D image guided brachytherapy Top

Harshitha Jain, Kirthi Koushik, M. G. Janaki, T. R. Arul Ponni, Mohan Kumar, Ram Alva

Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): In the recent years, we have seen that there has been a paradigm shift in the practice of brachytherapy from 2D to 3D image guided based. There has also been a shift from point based dose calculation and reporting to volume based. However, even with this transition, the most common practice of prescribing dose is still to point A in India. Is it time to let go of point A? In this study, we have prescribed dose to the volume and computed the dose to point A and correlated it with the survival. Materials and Methods: In this study, we retrospectively analyzed 44 patients treated with definitive chemoradiation in the year 2017 at Ramaiah Hospitals, Bangalore with a minimum follow up of 2 years. All patients received a dose of 45Gy/25Fr via external beam radiation therapy. Image guided ICBT was done and patients received a median dose of 26Gy in 3-4 fractions. The dose was prescribed to the high risk CTV (HRCTV). Point A dose was computed in these cases. A correlation of this was done with clinical outcome. Results: In the 44 patients that we analyzed, the mean HRCTV volume was 49.068cc (28.2 to 103.7cc). The mean coverage was 90%. The mean dose to point A was 3.7Gy (2.2 to 5.24). Two years post treatment, 35 patients (80%) were alive. One patient had recurrence and two died due to the disease. Four patients were lost to follow up. Three patients developed late grade 3 toxicity- two patients having grade 3 procititis requiring APC and one developed vaginal stenosis requiring dilation. Conclusion: The clinical outcomes in terms of local control and organs at risk toxicity validates the dosimetric advantage of image guided brachytherapy and volume based prescription. Time bid adieu to point A!

 > Abstract: 370: A comparison study of ICRU point doses and volumetric doses of organs at risks in brachytherapy for carcinoma cervix Top

Harshitha Jain, Kirthi Koushik, M. G. Janaki, T. R. Arul Ponni, Ram C. Alva, Mohan Kumar

Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): In cervical cancer patients undergoing intracavitory brachytherapy (ICBT), reporting with regards to the organs at risk (OAR) was done based on point doses in accordance to ICRU 38. With the wide acceptance of three dimensional image guided brachytherapy, the assessment of OAR is based on dose volume histogram. In this study we are assessing if there is a real shift in the paradigm by comparing the ICRU point doses to OAR with volumetric doses in ICBT patients. Materials and Methods: Using the HDR PLUS planning system, the doses to the OAR- bladder and rectum were retrospectively analyzed in 50 patients treated with definitive chemoradiation in the year 2018 at Ramaiah Hospitals, Bangalore. All patients received a dose of 45Gy/25Fr via external beam radiation therapy. Image guided ICBT was done and patients received a dose of 6-7.5 Gy in 3-4 fractions. The dose to the OAR were recorded in accordance with ICRU 38 and 89 in terms of point based(DICRU) and volume based (D2cc) respectively. Results: Mean rectal dose D2cc and DICRU was 4.45Gy (4.12-4.72) and 3.707(2.3-4.7) respectively. Mean bladder dose D2cc and DICRU was 4.16 Gy (3.85-4.47) and 3.71Gy (2.6-5.6) respectively. The mean dose ratios (D2cc/ DICRU) were 1.2 for rectum and 1.21 for bladder. DICRU correlated with D2cc for rectum (r=0.571, p=0.000) and DICRU correlated with D2cc for bladder (r=0.457, p=0.001). Conclusion: OAR doses assessed by DVH criteria were higher than ICRU point doses with significant correlation between DICRU and D2cc for rectum and bladder.

 > Abstract: 371: Bad application better than no application: A clinical experience Top

Harshitha Jain, Kirthi Koushik, M. G. Janaki, T. R. Arul Ponni, Mohan Kumar, Ram Alva

Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): In cervical cancer patients brachytherapy forms an integral part of the treatment. More often than not we come across patients who have not undergone “ideal” application. There are multiple problems which are faced by clinicians and a judgement to continue with the treatment or abandon the procedure has to be made. In this study, we reviewed cases treated with both ICBT in 2017 and enumerated the various problems faced and correlated it with the survival. Materials and Methods: In this study, we retrospectively analyzed 44 patients treated with definitive chemoradiation in the year 2017 at Ramaiah Hospitals, Bangalore with a minimum follow up of 2 years. All patients received a dose of 45Gy/25Fr via external beam radiation therapy. Image guided ICBT was done and patients received a median dose of 6-7.5Gy in 3-4 fractions. The cases where there were perforations, displacement of ovoids, rotation of the applicator were analyzed and a correlation of this was done with clinical outcome. Results: In the 44 ICBT patients that we analyzed, 5 had uterine perforation. The procedure was abandoned in one patient as the tandem perforated more than 1cm from the uterine wall. The other 4 patients were treated with the planned treatment with close vitals monitoring. The applicator was titled in 8 of the applications. In these cases the plan was optimized in order to achieve a mean coverage of 84%. At two years follow up, 35 (80%) patients were disease free, 2 patients died and one developed recurrence. With respect to toxicity- one developed vaginal stenosis and 2 patients had proctitis requiring intervention. Conclusion: Brachytherapy forms an important part of treatment of cervical cancer patients. Though we all aim for “ideal” application, we do come across these cases which dictate clinical judgement. With the advent of dose optimization, all patients should be given the benefit of brachytherapy provided the DVH parameters are within the acceptable limit.

 > Abstract: 377: The prognostic significance of neutrophil lymphocyte ratio in cervical cancers treated with radiotherapy Top

B. M. Muhammed Ali Azher, Niketa Thakur, Sonal Patel Shah

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

Purpose and Objective(s): The elevated neutrophil to lymphocyte ratio (NLR) has been identified as a poor prognostic indicator in various malignancies. The progression of malignancies is manifested as alteration in blood counts which can be used as prognostic makers. In this study we tried to quantify the effect of NLR on disease free survival and overall survival in patients with cervical cancers. Materials and Methods: A retrospective analysis of 300 patients treated with radiotherapy from 2017 to 2018 was carried out to estimate the pretreatment NLR. The NLR is correlated with overall survival (OS) and disease free survival (DFS) in patients with FIGO Stage IIB to Stage IV and postoperative Cervical cancers. OS and DFS were assessed by Kaplan Meier method. In analysis the association between NLR and survival was maintained in patients with stage II to IV diseases. There is a greater magnitude of correlation seen in advanced cervical cancers and a greater effect in overall survival is seen with concurrent chemoradiotherapy and radiotherapy. Results: The median cut off for high NLR is 3.5. The greater the NLR, greater the stage and higher the grade. And the outcomes are worse. In cervical cancer, significant association between NLR and OS is observed with locally advanced disease and in those who received chemoradiotherapy. Conclusion: High NLR is associated with adverse OS and DFS in patients with cervical cancers.

 > Abstract: 388: Adjuvant concurrent chemoradiation followed by chemotherapy for high risk non metastatic endometrial cancer: Preliminary analysis of toxicity and tolerance Top

Rajasree Rajan, Beena Kunheri, Thushar Tatineni

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

Background: Although women with endometrial cancer generally have a favourable prognosis, those with high-risk disease features are at increased risk of recurrence. The PORTEC-3 trial was initiated to investigate the benefit of concurrent chemoradiation therapy followed by adjuvant chemotherapy for women with high-risk endometrial cancer, and found to be well tolerated and beneficial in stage III endometriod and serous histology irrespective of the stage. We have initiated a study to evaluate the tolerance and toxicity of the treatment in our patients belonging to the Asian Subset. Aim: To assess the toxicity and tolerance of adjuvant concurrent chemoradiation followed by chemotherapy for high risk non metastatic endometrial cancer (HREC). Secondary endpoints are failure free survival and overall survival. Materials and Methods: 25 patients were enrolled into the study so far, and 20 patients who had completed the entire course of treatment were analyzed for the acute toxicities and tolerance during CTRT and adjuvant chemotherapy from December 2016 to August 2019. The patients were treated with radiotherapy to a dose between 45 to 48.6Gy in 1.8Gy/fraction over 25 to 28 days, 5 days per week. Chemotherapy during radiation was two cycles of cisplatin 50mg/m2 (week 1 and week 5), followed by 4 cycles of adjuvant chemotherapy – carboplatin AUC 5 & paclitaxel 175mg/m2. The primary endpoint being Toxicity analysis. Results: This is an interim analysis for acute toxicity and tolerance to CTRT and adjuvant chemotherapy. The median age of our patients was 62 yrs range (47 to 74 years). Acute Toxicity analysis showed that all the patients developed grade 1 & 2 toxicity during various stages of concurrent chemoradiation and adjuvant chemotherapy. During CTRT the major haematological toxicity was grade II Anemia (81%). Grade I Vomiting was seen in all patients undergoing CTRT and only very few patients had grade III vomiting (<5%). It was noted that 18 (90%) of the patients developed grade 1 & 2 Gastrointestinal toxicity during CTRT. The most common complaint was diarrhoea. The toxicities of CTRT resolved after completion of treatment without any persistence of acute side effects thereafter. During adjuvant chemotherapy, grade II neutropenia(69.6%) was a significant haematological toxicity observed. Treatment limiting peripheral neuropathy was seen in 2 patients, and hence could not take 4th cycle of adjuvant chemotherapy. All other patients completed the proposed treatment. Tolerance to CTRT and adjuvant chemotherapy in our subset of patients has been good and none of the patients had unforeseen treatment breaks due to toxicity during CTRT. This is concordant with the results of PORTEC III data of acute toxicity analysis. Long term follow up is required to assess the chronic toxicity and survival.

 > Abstract: 401: Outcomes of cervical cancer in HIV infected women treated with curative radiotherapy in the era of antiretroviral therapy Top

Bonala Sreenivasa Rao, Jayasree Kuna, B. V. Subramanian, Donapati Pradeep Kumar Reddy, Jilla Swapna, Pranabandhu Das, Veluru Chandipriya, K. V. L. Anusha, Prathipati Archana

Sri Venkateswara Institute of Medical Sciences, Tirupathi, Andhra Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): To determine outcomes of curative radiotherapy in HIV positive women with carcinoma cervix receiving ART. Materials and Methods: We did retrospective review of case records of cervical cancer patients registered from june 1st, 2015, to july 31st, 2019 at, Sri Venkateswara Institute Of Medical Sciences Tirupathi, Andhrapradesh. A total of 1150 cervical cancer patients were registered, of which 34 were found to be HIV positive treated with radical intent were included for analysis. The telephonic calls were made for some patients to retrieve complete information. Results: Total 34 patients were analyzed. All patients are on ART. All patients are given admission in the wards and closely monitored by daily rounds. The mean age of the cohort was 44 (30-52) years. The Median CD4 count was 350 (150-1100) cells/cubic millimeter. The tumor was large cell non keratinizing squamaous cell variant in 41% and all patients were staged as per revised FIGO and belongs to stage IIA to IIIC. All 34 patients received radical RT with external beam radiotherapy(EBRT) fallowed by high dose rate intracavitary brachytherapy (HDR- ICBT). The technique of EBRT was 2D in 7(20%), 3D-CRT in 18 (52.9%), IMRT 9(26.4%) of patients and the dose was 50 Gy in 25 fractions and the gross pelvic lympnodes were boosted to 54 -60 Gy. The concurrent weekly cisplatin during EBRT to a dose of 40 mg/m2 was given in selected patients. Out of 34, ten patients (30%) received chemotherapy of which eight (80%) received more than 3cycles. The HDR-ICBT was delivered by CT based planning prescription of dose to point A with a dose of 7Gy/fraction weeky for 3 fractions and inerdigitation of brachytherapy with EBRT done in feasible patients. Total 4(11%) patients defaulted after 1st ICBT due to longer travelling distance and overall treatment time is more than 8 weeks in five (14%) of patients due to ICBT being delayed due to social issues. There was no grade III, IV acute hematological, gastrointestinal toxicities. All patients got complete response clinically after 6 weeks of treatment. Five (14%) patients died and recurrences were 8% (one patient developed local recurrence, two patients developed lung metastasis). For the median follow-up of 18(2.9 to 47.4) months, overall survival was 85%. Conclusion: In the era of antiretroviral therapy, carcinoma cervix in HIV infected women should offer curative treatment. Curative radiotherapy alone or concurrent chemo-radiotherapy in selected patients is feasible and tolerable.

 > Abstract: 405: Impact of combined interstitial and intracavitary brachytherapy in locally advanced cervical cancer: A survival and toxicity profile assessment Top

Vibhay Pareek, Manish Chandra, Rajendra Bhalavat

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

Purpose and Objective(s): Advancements in role of imaging in brachytherapy in treatment of cervical cancers has seen further improvement in therapeutic ratio. We assessed the impact of combined interstitial and intracavitary brachytherapy in locally advanced cervical cancer in relation to survival outcomes and toxicity profile. Materials and Methods: A total 125 patients, histopathologically diagnosed as cervical cancer and staged as per FIGO staging, were enrolled for the procedure. After completing external beam radiation therapy (Median dose 50Gy), patients were evaluated for brachytherapy which involved CT based hybrid interstitial-intracavitary brachytherapy using Iridium-192 source and a novel template to facilitate therapy. Parametrial extent of the disease in these patients was judged to exceed the coverage limit of intracavitary brachytherapy alone. 'Manish Jupiter template' was used for guidance of parametrial needles to perform high-dose-rate-brachytherapy. Clinical feasibility, treatment outcomes and toxicity profile were assessed. The patients were followed up as per the institution protocol. Results: There were 57 patients (45.6%) in FIGO stage IIIB and 50 patients (40%) in stage IIB. The median EBRT dose was 50Gy and Brachytherapy dose received was 23Gy. The overall median EQD2 was 85Gy. After a median follow up of 30 months (Range 10 -50 months), local control rate was 95.2% and 11 patients (8.8%) developed distant metastases (9-Lung, 2-brain). Of the distant metastases, 7 were Stage IIIB and 4 had IIB disease. The median total treatment time was 69 days. No adverse events were caused by the procedure. Grade 2 and 3 rectal and bladder toxicities were 7.9% and 2.4% and 5.66% and 2.4% respectively. Disease free survival probability after 1 and 2 years was 94.1% and 93.53%. On multivariate analysis, stage of disease IIB, treatment duration less than 49 days and EQD2 of more than 85Gy were found to improve the rate of local recurrence and distant metastases. Conclusion: Hybrid brachytherapy with the novel template has shown to improve the therapeutic ratio in LACC by enabling a tumour specific dose escalation leading to improved survival outcomes without adding treatment related late morbidity. The procedure was more conformal with improved dosimetry and clinical outcomes.

 > Abstract: 407: Impact of counselling on patient reported sexual adjustment following chemoradiation and brachytherapy for cervical cancer Top

Vibhay Pareek, Manish Chandra, Rajendra Bhalavat

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

Purpose and Objective(s): The treatment of locally advanced cervical cancer with definitive chemoradiation (CRT) is associated with vaginal toxicity and altered sexual satisfaction. This prospective study compared patient-reported sexual adjustment, vaginal dosimetry, and physician-reported vaginal toxicity in patients with cervical cancer treated with CRT and brachytherapy (BT) following counselling for vaginal dilatation or resuming sexual activities with those who did not comply. Materials and Methods: Between 2016 and 2018, histopathologically proven and staged IB-IVA patients with cervical cancer receiving definitive CRT were enrolled in a feasibility study assessing the impact of compliance and its outcome in terms of sexual adjustment. Patients completed the validated sexual adjustment questionnaire (SAQ) and EORTC CX24 before BT (baseline) and during follow-up. Physician-reported vaginal toxicity was recorded. Dosimetric analysis was done with focus on rectovaginal point, mean vaginal dose, and D2cm3. Mean scores at baseline and follow-up assessments were calculated. A multivariable linear mixed-effects model was used to examine the association between total and individual scores (repeated measures) and covariates. Results: A total of 140 patients were assessed in the study and 75 patients complied with the counselling in terms of either resuming sexual activities or using vaginal dilators as compared to 65 patients who did not use any intervention in spite of the counselling. The diagnosis of cervical cancer and treatment negatively impacted sexual relationships in 66% and 68%, respectively. However, counselling and intervention helped improve the sexual adjustment over time (p = 0.023). There were no associations between sexual adjustment and the International Commission on Radiation Units and Measurements rectovaginal point dose or clinical vaginal involvement. Stage (p<0.001), age (p = 0.012) and diabetes (p = 0.037) were found to have an important association with delayed adjustments post intervention. Conclusion: Vaginal stenosis is an important late toxicity associated with radiation therapy and in India, counselling patients for resuming sexual relations can be a taboo. However, our study indicates good compliance among patients for use of intervention to prevent such complications and improved outcomes have been seen.

 > Abstract: 419: Comparison of two contouring methods of bone marrow and its relation with bone marrow toxicity in patients with carcinoma cervix receiving intensity modulated radiotherapy with concurrent chemotherapy: A pilot study Top

K. E. Greeshma

Malabar Cancer Centre, Thalassery, Kerala, India, E-mail: [email protected]

Purpose and Objective(s): The pelvic and adjacent bone marrow is a major organ at risk in patients irradiated for carcinoma cervix. Superior bone marrow sparing can be achieved with IMRT. Contouring of the whole bone which is inclusive of the marrow cavity containing active and inactive marrow is generally accepted as a surrogate for bone marrow. Identifying and conturing the active marrow is not possible unless special imaging modalities are used. Hence in general practice, the freehand contoured marrow cavity on simulation CT images is the best option to use as a surrogate for active marrow. This study compared volumes and DVH parameters for marrow contours using the 2 methods correrated it with grade 2 or higher hematological toxicity (HT) in cervical cancer patients treated with IMRT. Materials and Methods: Cervical cancer patients treated with IMRT to recieve 50GY to primary and electively treated nodes and 55Gy to clinically involved nodes in 25fractions were included in the study. Two sets of marrow volumes are contoured- the whole bone contours (W), and the freehand contours of the marrow cavity (F). In addition to the whole pelvic volume sets, 2 sets of subvolumes were created to identify the relatively important subvolumes as sacrum, ilium, ischium, lower pelvis lumbosacral spine and sacrum. All corresponding volumes in the 2 sets were compared for volume and DVH parameters for V10Gy, V20Gy, V30Gy, V40Gy and V50Gy. Grade 2 or higher hematologic toxicity was correlated with various factors including age, PTV volume, and DVH parameters for all volumes. Results: 23 patients were included in the study (mean age 55.5y). The mean PTV volume was 1604.5cc. The mean volume of whole pelvis (WP) was 1036cc and the mean free hand volume (FP) 434.2cc which is 41.9% of whole bone volume. The free hand volumes of subvolumes were 36-46 % of their corresponding whole bone contours. The V10, V20.V30.V40 and V50 volumes by whole bone contouring and free hand technique of the corresponding subsites were compared and was significantly different for V40 of sacrum, ilium, lower pelvis, and V30 and V40 of lumbosacral subvolumes. Grade 2 or greater HT occurred in 90.9% for TLC, 81.7% for ANC and 22.5% for PLC. Average reduction from baseline values were 72.8% for TLC, 76.2% for ANC and 59.3% for PLC, mostly occurring after 40 days into the treatment. No significant correlation could be found between grade 2 or grade 3 toxicities and different subvolumes (V10,V20,V30,V40,V50). Close to significant correlation was noted for Hb grade 2 or higher toxicity and freehand marrow cavity subvolume lumbo sacral (FLS ) V30 (p 0.058) and for platelet count and freehand marrow cavity subvolume lower pelvis (FLP) V30 (p 0.059). Conclusion: The DVH parameters of free hand marrow volumes rather than whole bone volumes correlated better with hematological toxicities though it did not reach statistical significance in the present study. Whether sparing of subvolumes of pelvis (FLP and FLS) rather than pelvis as a whole would result in lesser haematological toxicity needs to be validated in larger studies.

 > Abstract: 420: Endometrial carcinoma in a young female: An exception Top

Asmita Kulshrestha, Niketa Thakur, Sonal Patel

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

Background: Endometrial cancer affects mainly post-menopausal women with average age diagnosed as 60 years and being an extremely uncommon malignancy diagnosed in women less than 40 years with approximately 1–8% cases found to be reported in women under the age of 30 years, the youngest being 15 years. Objective: Report a case of endometrial adenocarcinoma occurring in a young female presented at our outpatient department for further management. Methods: A postoperative case of endometrial adenocarcinoma occurring in a young 29 year old nulliparous woman earlier treated for menorrhagia and lower abdominal pain since 2 months with previous normal menstrual history. Patient had undergone right side ovarian enucleation for a cyst that was negative for malignancy on cytology in the past. Following 3 years after which the patient underwent dilatation and curettage alongwith endometrial biopsy that revealed FIGO grade III endometrioid adenocarcinoma. Based on the present clinical presentation, imaging studies and positive histopathological report the patient was operated by staging laparotomy with radical hysterectomy, bilateral salpingo-oophorectomy and bilateral lymph node pelvic sampling after due informed consent. Results: An uncommon presentation of endometrioid adenocarcinoma in a young female of 29 years was managed according to the staging treatment protocol. The postoperative histopathological surgical diagnosis was established as endometrioid adenocarcinoma FIGO Grade 3 with stage IIIC1 and positive lympho-vascular invasion. Patient was planned post operatively for sequential chemotherapy followed by external beam radiation therapy with 50 Gy in 25 fractions. After response assessment intravaginal brachytherapy would be planned with the total duration of radiation therapy to be completed within 8 weeks. At present patient is undergoing treatment. Conclusions: Endometrial adenocarcinoma is a rare presentation in young women. Age at menarche has an inverse relationship with the risk of endometrial cancer. This is associated mainly due to unopposed estrogen exposure including certain conditions such as premenopausal anovulatory cycles polycystic ovarian disease and functional ovarian tumors. Another important risk factor found is nulliparous young females having a positive association between infertility and endometrial cancer. Also an inherited predisposition to endometrial cancer due to Lynch syndrome (hereditary nonpolyposis colorectal cancer syndrome) have been estimated in approximately 2%–5% of patients and for about 6% of all endometrial cancers, especially in young patients. The classic therapeutic approach is stage wise treatment constituting mainly of total hysterectomy and bilateral salpingo-oophorectomy with or without a pelvic or para-aortic lymph node dissection followed by sequential chemotherapy and external beam radiation therapy with or without intravaginal brachytherapy after complete response assessment. In younger patients with early stage endometrioid carcinoma fertility preserving options such as hormonal therapy with progesterone and LHRH (Luteinzing-Hormone-Releasing-Hormone) analogues is still a platform of research for approval of their clinical efficacy.

 > Abstract: 433: Risk scoring model to predict recurrence in locally advanced breast cancer treated with neoadjuvant chemotherapy Top

Joe Jose, Sushma Agrawal, Anjali Mishra, Gaurav Agarwal

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): Complete response (CR) to NACT portends favourable long term outcomes in LABC. There is a need for a tool to risk categorise patients for recurrence risk (RR), so that intensification of treatment can be offered to women with high risk of recurrence. Materials and Methods: A prospectively maintained database of LABC (between January 2007 to December 2012), who received NACT followed by definitive surgery, radiotherapy and endocrine therapy in endocrine sensitive disease wasretrospectively analyzed for clinico-pathological and treatment factors affecting disease free survival (DFS). A risk scoring model was developed on the basis of beta coefficients of identified independent risk factors for DFS. Results: The incidence of loco-regional relapse was 8% and that of distant metastases was 32% in a dataset of 206 patients at a median follow-up of 47 months (IQR 24-62 mo). The independent risk factors for recurrence wereindex Tstage [HR 1.8 (0.9-3.6)], N stage [HR 1.7 (0.4 – 4.7)], grade [HR1.8 (0.8-4.2)], age less than and more than 40 years [HR1.6 (0.4-0.9)], pathologic CR [HR 4.3 (1.7- 10.7)], intrinsic subtype [HR 2.2 (1.3-3.7)], and type of surgery (BCS vs MRM) [HR 2.2 (1.3-3.6)]. The ROC of the model for the prediction of recurrence was 0.67 (95 % CI: 0.61-0.75). The results of this model were validated by dividing the population into 3 risk groups: low risk (score less than 12), intermediate risk group (score between13-15), high risk group (score 16 or more). The chances of recurrence are 16% versus 34% versus 57% in low, intermediate and high risk group respectively. Presence of three risk factors implies low risk, five intermediate and more than five high risk. Conclusion: The risk scoring model developed by us predicts RR and can be used for selecting patients for treatment intensification in high risk category.

 > Abstract: 439: Treatment outcome and toxicity in stage IIB carcinoma cervix patients treated with a different dose schedule: An institution based retrospective study Top

Rajal Shah, Niketa Thakur, Sonal Patel Shah, U. Suryanarayan

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

Background: Carcinoma cervix is one of the most common cancers of Indian women with very high morbidity and mortality burden. Although India probably is the leading country in number of the carcinoma cervix patients treated with combination of external beam radiotherapy and brachytherapy, there is presumed diversity of practice in fractionations regimens among various centres across the country. Purpose: The present study was conducted to evaluate current different practice pattern of management of carcinoma cervix stage IIB patients at our hospital. Primary end points were to know progression free survival, loco-regional control and treatment related toxicities. Methodology: A retrospective analysis of 100 patients of carcinoma cervix FIGO stage IIB (parametrium involved medially) treated with conventional external beam radiotherapy 40 GY in 20 fractions with concurrent chemotherapy followed by 3 fractions of 7.5 GY intracavitory brachytherapy from January 2015 to December 2016 was done. Patient's age, histopathology, co-morbid conditions, menstrual and obstetric history, external and brachytherapy details, concurrent chemotherapy and overall treatment time were noted. Disease free survival, complication following radiation therapy and last follow ups were noted. Results: Mean age of patients was 45 years.95% patients were of squamous cell carcinoma, 4% were adenocarcinoma, rest were poorly diffentiated. Out of these,10% patients had co-morbid conditions like hypertension and/or diabetes,5 % patients were sero-positive. Overall treatment time for all patients was around 8 weeks. Around 65% patients were disease free till last follow up done in 2019. Median follow up was 30 months. Rest of the patients developed either loco-regional recurrence or distant metastasis for which they were given re-irradiation or palliative chemotherapy accordingly. Any severe acute treatment related complications with radiation therapy were not seen. Around 2% of patients developed grade 1 or 2 bladder related and 5% of patients developed grade 1 or 2 rectal related late toxicities which were managed conservatively. Conclusion: The most common radiation therapy dose for carcinoma cervix FIGO stage IIB in various institutes in India is 46 GY in 23 fractions or 50 GY in 25 fractions with concurrent chemotherapy followed by 3 fractions of 7 GY or 2 fractions of 9 GY intracavitory brachytherapy. In our institute we prescribe 40 GY in 20 fractions with concurrent chemotherapy followed by 3 fractions of 7.5 GY intracavitory brachytherapy. Thus we give more dose locally by brachytherapy since many years. In view of similar treatment outcome and limited treatment related late toxicities, this dose schedule can be considered as an alternative standard approach. However, studies of more numbers of patients are required to validate this data.

 > Abstract: 440: Comparison of dosimetric data of bone marrow between standard intensity modulated radiotherapy and bone marrow sparing intensity modulated radiotherapy in carcinoma cervix Top

Samir Kumar Mohanta

A.H. Regional Cancer Institute, Cuttack, Odisha, India, E-mail: [email protected]

Purpose and Objective(s): The purpose of the present study was to analyse the Dosimetric data which the Bone marrow receiving in using two different modalities of Intensity Modulated Radiotherapy (IMRT) in cervical cancer patients. Materials and Methods: Biopsy-proven Squamous cell carcinoma of cervix patients were taken for study. Most of the belongs to FIGO stage IIIB and Stage IIB and few are Stage IB Post-Operative. Whole Pelvic bone along with lumbosacral spine (LS Spine), Bilateral Femoral Head, Upper 1/3rd femoral bone was contoured as a surrogate marker for bone marrow. All 40 patients were treated using Intensity Modulated Radiotherapy (IMRT) in two arms each having 20 patients. Arm A is treated with (Standard-IMRT) and Arm B with BMS-IMRT. All patients were contoured for Bone marrow and one Arm has given bone marrow constrains. Dose-Volume Histogram (DVH) were generated for both arms and parameters like V10,V20,V40, Mean dose, Maximum Dose, Minimum Dose, Total Volume were then compared with each other using Student Unpaired T test. PTV was not compromise in both the arm. Results: Compared with Standard IMRT there is no statistically significant difference between the mean value of volume receiving 10Gy,20Gy and 30Gy, Mean dose, Maximum Dose, Minimum Dose, Total Volume of bone marrow in BMS-IMRT. Statistical p value was calculated for both arms and are as given. For V10 p value=0.8,V20 (p=0.74), V40 (p=0.14), Mean Dose (p=0.96), Maximum Dose (p=0.37) Minimum Dose (p=0.6), Total volume (p=.16). Conclusion: In our study it is found that there is no statistically significant difference in dosimetry between two groups. So Bone marrow sparing IMRT is not superior as compared to Conventional IMRT plan in reducing the dose to bone marrow neither in 10Gy volume or 40Gy volume. However larger sample size and Multivariate analysis is required to get a definite conclusion.

 > Abstract: 442: Effectiveness and feasibility of reirradiation using conventional external beam radiotherapy in gynaecological cancers: An institution based retrospective study Top

Tejal Chaudhari, Sonal Patel Shah, Niketa Thakur

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

Objective: Pelvic reirradiation is a local treatment with radiotherapy in patients with loco-regional recurrence of pelvic tumours previously treated with radiation therapy. Locoregional recurrence following chemoradiation and intracavitary radiotherapy is the most common pattern of failure in management of gynaecological cancer of cervix, endometrium and vagina followed by para-aortic and pelvic lymph node recurrence. Purpose: This study is aimed to evaluate effectiveness and feasibility of reirradiation using conventional external beam radiation and intracavitary brachytherapy in gynaecological cancer. Methods: Fifteen patients with recurrent primary gynaecological malignancies of the cervix, endometrium and vagina with prior radiation history were included in this retrospective study from 2010 to 2019. All patient underwent reirradiation using conventional external beam radiotherapy plus weekly platin based chemotherapy and intracavitary brachytherapy. Results: Out of 15 patients, 10 were of cervix, 4 of endometrium and 1 of vagina have been treated with pelvic reirradiation were included in this retrospective study. All 15-patient reirradiation tolerated well. Grade III skin reaction were observed in two patients, during the course of radiation therapy. 10 patients responded very well with complete reduction in tumour size, bleeding and pain and 3 patients with partial response. Remaining 2 patients with stable disease could get only symptomatic relief from pain and bleeding, while residual disease was persisting on clinical examination on 1st follow up. Late complications developed in four patients were: radiation proctitis, 2 patients; cystitis, 1 patient and intestinal obstruction, 1 patient. Conclusion: The pelvic reirradiation after previous definitive treatment was found to be effective and feasible in symptom relief and local tumour control with acceptable toxicity. As minimal data is available on the toxicity of additional radiation therapy, this approach would be considered only when there is no other alternative for effective therapy and in the face of progressive and severe symptoms.

 > Abstract: 448: Prognostic nutrition index and its significance in advanced ovarian cancer Top

Garima Pandey, Pariseema Dave, Shilpa Patel, Ava Desai

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

Objective: The prognostic nutrition index (PNI) had been shown to be prognostic in various gastrointestinal and head neck malignancies. The aim of this study was to investigate the significance of PNI in advanced epithelial ovarian cancer with respect to clinical characteristics, short term treatment related morbidity and response to platin based chemotherapy. Methods: We prospectively investigated 150 patients who underwent primary debulking or interval debulking surgery for advanced epithelial ovarian cancer between august 2017 to September 2019 at our institution. All patients received 6 cycles adjuvant or neoadjuvant chemotherapy with carboplatin and paclitaxel. Pretreatment PNI was calculated as serum albumin (g/L)+0.005×lymphocyte count (per mm3). The optimal PNI cutoff value for disease free survival (DFS) was identified using ROC curves for DFS. Clinical characteristics and PNI were compared with chi-square or Fisher's exact tests, as appropriate. The impact of PNI on DFS was analyzed using the Kaplan–Meier method and Cox proportional hazards model. Results: Of 150 patients, 105 underwent interval debulking and 45 underwent primary debulking. The median PNI was 49.1 (32.6-62.6). ? The 41.1 cutoff value divided patients into the high PNI and low-PNI groups. No significant correlation was found between pre-treatment PNI and age of patient, FIGO stage, CA125 level, residual disease after surgery, platinum resistance or DFS. However, low PNI was associated with increased rate of postoperative complications (p=0.02), chemotoxicity (p=0.03) and poor quality of life (p=0.008). Conclusion: This study did not find any co-relation between pretreatment PNI with DFS and platinum resistance but low PNI was significantly associated with increased rate of postoperative complications, chemotoxicity and poor quality of life.

 > Abstract: 450: Primary ovarian lymphoma case: A rare presentation (0.5%) overall of other malignancy involvement Top

Viraj Modi, Maitrik Mehta, Sonal Patel, Pooja Nandvani Patel, Niketa Thakur, Jyoti Poddar, Ankita Parekh, U. Suryanarayana Sir, Maitrik Mehta

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

Background: Overall NHL is about 4% of all malignancy. Primary lymphoma of ovary is very rare (0.5%) as compared to secondary involvement( 7-26%). The most common variety of primary ovarian lymphoma (POL) is Diffuse Large B- Cell (DLBCL). Bilateral POL is even rarer. Purpose: Involvement of ovary by NHL is a rare entity. Which poses diagnostic difficulty. A case of primary NHL ovary is being presented owing to its rarity. Methodology: A 44 year old female presented with complain of bleeding & white discharge per vagina, abdominal pain and backache for 3 months and weight loss for 1 month. On physical examination a 15x10 cm smooth, firm, mobile mass was palpable in left hypogastric and iliac regions of abdomen. Per rectally a mobile mass was palpable. P/V was normal CT scan of abdomen and pelvis revealed 94x95x91 mm3 and 94x46x67 mm3 lesions on left and right sides respectively along with a lytic destructive lesion on left pubis, ischium and acetabulum. Bone scan showed osteoblastic lesions at left acetabulum, left ischium and left pubis. All routine blood investigations, pap smear, cxr, and chest CT, tumor markers Chorioembryonic antigen and CA 19-9 were normal in blood levels. Bone marrow and csf cyto were normal. CA125 was raised to borderline value of 38.5 U/ml. Biopsy fromright adnexal mass showed poorly differentiated carcinoma. On immunohistochemistry (IHC) was positive for CD20, leucocyte common antigen (LCA) and 50-60% positivity for MIB1 and negative for AE1 CK7 and CD2 suggestive of High grade non Hodgkin's lymphoma, B-cell type. The patient was diagnosed as primary ovarian lymphoma, Ann Arbor stage IV. Patient was administered as single cycle of CVP as cyto reductive chemotherapy in September 2017 followed by 4 cycles of R-CHOP till October 2017. Post chemotherapy CT scan of abdomen and pelvis showed residual masses sized 48x38x57 mm3 and 31x15x42 mm on left and right sides respectively. Lytic lesion with 14 mm soft tissue component was seen on left ischium, acetabulum and head of femur. Two more cycles of R-CHOP with intrathecal methotrexate were given to the patient till Jan 2018. Involved Field Radiotherapy (IFRT) to pelvis and all the involved bones was considered after 21 days of completion of chemotherapy. Radiotherapy dose of 40 Grays in 20 fractions at 200 cGys per fraction for 5 days a week over a period of 4 weeks was delivered with antero-posterior and postero-anterior portals in supine position till March 2018. Radiation treatment was uneventful. A PET-CT of April 2018 showed 36x43 mm and 16x24 mm masses in left and right adnexa respectively and a lytic lesion on left ischium, acetabulum and femur head. There was no uptake of 18-FDG by the lesions. A follow up USG abdomen and pelvis was done on October 2019 was normal. Patient is on regular follow-up and symptom free. Conclusion: NHL of ovary and pelvic bones could be treated on the lines of other Extranodal NHL as due to the low incidence no definitive treatment guidelines are available.

 > Abstract: 454: Demographic and clinicopathologic profile of carcinoma cervix: A retrospective study from Rajiv Gandhi Cancer Institute and Research Centre in New Delhi, India Top

Himanshi Khurana, Swarupa Mitra, Abhinav Dewan, Inderjeet Kaur Wahi, Sumeet Aggarwal, Soumitra Barik, Kiran Dobriyal, Maithili Sharma, Abhiramasundari Vivekanand, M. Jwala

Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India, E-mail: [email protected]

Background: Cervical cancer is the second most common cancer in women and in developing countries it remains the major cause of death from cancer. Cervical cancer ranks second in incidence and mortality after breast cancer in lower Human Development Index settings. The aim of this study was to evaluate the demographic details, histology, age, stage, clinical profile and the treatment modalities of cervix cancer patients registered in Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India. Methods: This is a retrospective study of the case records of the patients diagnosed with carcinoma cervix from January 2012- December 2018. Results: The total number of the patients who were registered in the institute was 2240, out of which 1101 (49.65%) received the treatment (Surgery/Chemotherapy/Radiotherapy/Best Supportive Care), while the rest of 1139 patients came for second opinion and took treatment elsewhere. The prevalence of cervical cancer among gynecological malignancy was 52%. 50.8% patients were from Delhi followed by 16.20% from Uttar Pradesh and 13.16% from Haryana. The median age at registration was 54. Abdomen Pain, Discharge P/V and Bleeding P/V were the most common symptoms in about 84.8% of patients. Staging information was available for 71.33% of the treated patients, of which Stage I comprised 21.1%, Stage II 31.06 %, Stage III 23.6% and Stage IV 6.6%. The most common histologic variants were Squamous Cell Carcinoma (83%) and Adenocarcinoma (7.60%) and only 1% with other variants like Small Cell Carcinoma, Clear Cell Carcinoma and Adenosquamous Carcinoma. About 53.8% patients had Moderately Differentiated (Grade II) tumors. Out of 1101 patients, about 736 patients have received RT, of which 463 patients (42.05%) took the upfront RT+CT. 176 patients were given the Post Operative RadioTherapy, 67 patients took Only RT, while 30 patients took Neoadjuvant treatment followed by RT. There are total 368 patients that had undergone Surgery of which 174 patients were treated with only Surgery, 105 patients had undergone Surgery followed by the adjuvant treatment. While in 89 patients Surgery followed the neoadjuvant treatment. 17 patients were treated with the Best Supportive Care. Conclusion: The incidence of cervical cancer is still unacceptably high at our centre. Organised cervical cancer screening needs to be adopted for early diagnosis.

 > Abstract: 467: A case report of malignant melanoma of ovary Top

Isha Shah, U. Suryanarayan, Sonal Patel Shah, Niketa Thakur

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

Primary malignant melanoma of ovary is extremely uncommon. Primary malignant melanoma of ovary is challenging to diagnose. Most of the cases get reported when metastasis develops. A 37 year old patient presented with bilateral adnexal mass. On ovarian biopsy, it showed adeno carcinoma. On Immunohistochemistry work up it turned out to be Malignant Melanoma of bilateral ovaries. IHC showed HMB 45, MELAN A and VIMENTIN markers positive. No other primary elsewhere detected. Patient was on chemotherapy with stable disease. Progression free survival was 1 year and 4 month. Subsequently patient developed brain metastasis and treated with whole brain radiotherapy. Patient expired during the therapy. This event draws our attention at how the malignant melanoma of ovary mimics primary ovarian tumors in clinical presentation. CT scan and HPE reports may not be conclusive in the differentiation of ovarian malignant melanoma and other epithelial ovarian malignancies. Here the keynote is to include Immunohistochemistry typing in the final diagnosis.

 > Abstract: 470: Vulval metastasis from adeno: Carcinoma of cervix Top

Himanshi Jain, Maitrik Mehta, Ankita Parikh, Sonal Patel Shah, Pooja Nandwani Patel, U. Suryanarayan, Niketa Thakur, Jyoti Poddar

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

Purpose and Objective(s): Cervical cancer is the third largest cause of cancer mortality in India accounting to nearly 10% of all cancer related deaths in the country. Adenocarcinoma makes up 10% to 20% of all cervical cancers. Cervical cancer patients may develop metastasis (local as well as distant), more so in advanced stages of the disease. Cutaneous metastasis of cervical cancer is very rare, at a minimal range of 0.1-1.3%. Cutaneous metastasis is common at the abdominal wall, vulva and anterior chest wall and mainly presents as an asymptomatic dermal or subcutaneous nodule, ulcer or plaque. However, vulval metastasis is a rare entity. Hereby we report a case of adeno carcinoma cervix with vulval metatstasis(skip metastasis). Methodology: A 37 year female presented with complaint of lower abdominal pain for 4 months associated with white discharge per vagina. Clinically, on inspection, two ulcerative lesions were seen on inner side of labia majora and introitus. On per vaginal examination ulcero-infiltrative lesion was palpated involving whole of cervix and vagina upto introitus. On per rectal examination a hard central bulge and bilateral parametrium involvement upto lateral pelvic wall were palpated. On further investigations biopsy from the cervix showed adenocarcinoma- endocervical type and biopsy from right labia majora lesion showed fragments of squamous epithelium without stroma with endocervical adenocarcinoma. Ct-scan abdo pelvis showed 40 * 48 mm lesion involving cervix, involving uterus and vagina and and bilateral parametrium and 25*16 mm inguinal node on left side. The patient received curative external radiotherapy (50gy/25#), with extended field including pelvis and inguinal region, with concurrent 5 cycles of weekly cisplatin (50 mg) chemotherapy. As the patient showed poor response to external radiotherapy, external boost radiotherapy 10gy/5# was given. Patient did not receive any brachytherapy. The patient is now on monthly follow up. Conclusion: The purpose of this case report is to draw attention towards the extreme rarity of this case.


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