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Year : 2019  |  Volume : 15  |  Issue : 9  |  Page : 303-313

Dr. MC Pant and Dr. MS Gujral

Date of Web Publication28-Nov-2019

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How to cite this article:
. Dr. MC Pant and Dr. MS Gujral. J Can Res Ther 2019;15, Suppl S2:303-13

How to cite this URL:
. Dr. MC Pant and Dr. MS Gujral. J Can Res Ther [serial online] 2019 [cited 2021 May 16];15:303-13. Available from: https://www.cancerjournal.net/text.asp?2019/15/9/303/271706

 > Abstract: A study on prognostic value of pathological response to NACT in cases of unresectable advanced ovarian cancer among patients attending Radiation Oncology Department, IPGME and R Top

Saikat Bhowal, Santanu Pal, Alok Ghosh Dastidar, Koushik Chatterjee

Department of Radiation Oncology, IPGME and R, Kolkata, West Bengal, India, E-mail: [email protected]

Aim: To study the prognostic value of pathological response to NACT in cases of unresectable advanced ovarian cancer. Materials and Methods: A hospital based retrospective study with 104 patients of advanced ovarian cancer (AOC) irrespective of histopathological type treated (from 2012-2014) with NACT i.e. Paclitaxel & Carboplatin followed by interval debulking surgery (IDS) {screened based on inclusion criteria i.e 25-85 years female matched by ± 3 years age range & exclusion criteria i.e any other malignancy} was conducted at IPGME&R, Kolkata. The analysis included only cases resected to no gross residual disease at IDS. Based on literature review, pathological response was classified as follows: complete (cPR) in the absence of residual disease, microscopic (micro PR) in the presence of microscopic tumor foci (maximum diameter ≤2 mm), and macroscopic (macro PR) when macroscopic residual disease was detected. Ethical clearance was obtained from ethics committee. Results: cPR was observed in 23 patients, microPR in 34 patients & macroPR in 47 patients.

  • Median progression free survival was 46 months in CPR, 18 months in microPR & 12 months in macroPR.(p= 0.02)
  • Median overall survival was 56 months in CPR, 32 months in microPR & 24 months in macroPR.(p=0.016)
  • cPR is an important prognostic indicator as per the multivariate analysis.


  • cPR is a rare occurrence in AOC patients receiving NACT
  • It is associated with a longer progression-free survival and overall survival compared with women showing no cPR even in patients receiving IDS with no gross residual disease
  • It might serve as an important prognostic tool.

 > Abstract: Twice weekly versus weekly computed tomography-based high-dose-rate intracavitary brachytherapy schedules in locally advanced carcinoma of the uterine cervix using iridium-192 source: A single institutional study from Eastern India Top

Barnini Ghosh, Debottam Barman, Bodhisattwa Dutta, Debashis Das, Snigdha Hazra, Asit Ranjan Deb

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

Background: Most of the cervical cancer cases present in the locally advanced stage. External Beam Radiation Therapy (EBRT) with concurrent chemotherapy in conjunction with Intracavitary Brachytherapy is the standard of care in such cases. Usually once weekly regimens of high-dose-rate (HDR) brachytherapy are used. Fractionation improves tumour cell killing. Hence, increasing the number of fractions may lead to better loco-regional control and lesser complications. Purpose: To compare the effectiveness, safety and toxicity profile of twice weekly HDR brachytherapy with conventional HDR brachytherapy in locally advanced carcinoma cervix. Methodology: Locally advanced cases of squamous cell carcinoma of the cervix, stages IIB to IVA, were selected. Following EBRT with concurrent chemotherapy, patients will were randomized into two groups for Intracavitary brachytherapy as follows –

Group A – 7 Gy per fraction, 1 fraction per week, total 3 fractions

Group B – 4.2 Gy per fraction, 2 fractions per week, total 6 fractions.

Response rates, Acute and Late Toxicities were analyzed by appropriate statistical methods. Results: Comparison of response rates between the two arms at 6 weeks post-treatment showed no significant difference. The control arm showed slightly lower rates of acute haematological and genito-urinary toxicities, but not statistically significant. No difference in acute GI toxicities between the 2 arms can be observed.

  • Late GI toxicities were significantly lower in the study arm.
  • Late GU toxicities were lower in the study arm but not statistically significant.

Conclusion: Our study suggests that the twice weekly regimen has similar outcomes compared to the weekly regimen with a better toxicity profile. However, larger sample size and longer follow up is necessary to validate the results.

 > Abstract: A prospective study to see the feasibility, toxicity and efficacy of twice weekly interdigitated intracavitary brachytherapy in patients of carcinoma cervix stage IIB undergoing concurrent chemoradiation Top

Lekshmi R. Shenoi, Pritam K. R. Sardar, Sumana Maiti, Suparna Kanti Pal, Siddharta Basu

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

Introduction: For inoperable stage IIB Cervical carcinoma, the standard treatment is concurrent chemoradiation followed by intracavitary brachytherapy. To prevent accelerated repopulation, treatment should be completed within 8 weeks. In this study, we aim to further reduce the treatment time by interdigitating brachytherapy with concurrent chemoradiation. Aims and Objectives: To assess the response in terms of complete response, partial response, stable disease and progressive disease according to RECIST criteria, version 1.1 and acute toxicities according to the Radiation Therapy Oncology Group [RTOG] criteria. Materials and Methods: After undergoing pretreatment assessment with history, clinical examination, baseline laboratory investigations and imaging, patients with histologically proved squamous cell carcinoma cervix (FIGO stage IIB) without any evidence of distant metastasis were treated with concurrent chemoradiation with EBRT in a dose of 50 Gy in conventional fractionation and concurrent chemotherapy with i.v. inj.cisplatin 40 mg/m2 weekly. After 17 fractions of radiotherapy patients were assessed clinically for the feasibility for intra cavitary insertion. Patients received HDR brachytherapy twice weekly with a dose of 7.2 Gy/fraction in four fractions. No EBRT or chemotherapy were given on brachytherapy days. During treatment, patients were reviewed weekly clinically and with blood reports and thereafter 6 weekly for 3 months and 3 monthly till the end of the study. Results: 42 patients were included in the study. Mean age at diagnosis was 49.2±10.5 years, among them, 71.4% patients were post-menopausal and 28.6% were pre-menopausal. Most common histopathology in this study was moderately-differentiated squamous cell carcinoma (78.6%) followed by well-differentiated squamous cell carcinoma (14.3%). Average age of menarche of the patients was 12.9±0.9 years. Most of the patients in this study had a history of early age of marriage (16±1.9 years), early age of first child birth (17.2±2.1 years) and multigravida (3.7±1.2). Most common acute toxicity encountered was GI toxicity (78.6%) of grade 1 (42.9%) and grade 2 (28.6%). Followed by haematological toxicity (28.6%) of grade 1 and 2 (14.3% each) and skin toxicity (21.4%). Most grave toxicity was proctitis which was seen in 6 patients (14.3%). The overall response rate at 6 weeks post-treatment (complete response and partial response) was 100% with complete response (78.6%) and partial response (21.4%). The median duration of follow-up after initial 6 weeks post-treatment assessment was 6 months with minimum follow-up duration being 3 months-maximum 15 months.7 patients were lost to follow-up. Out of 33 complete responders, 2 patients developed recurrence (6.1%) after 7.5 months and 11 months after completion of treatment. Conclusion: To conclude, this study is feasible as the toxicities are limited and manageable. Most of the patients responded well without significant recurrence. For further conclusion, large number of patients should be included and compared to a control arm.

Abstract: Combined 3D-CT based interstitial and intracavitary brachytherapy in cervical cancer using a modified approach of template based interstitial brachytherapy along with central tandem of intracavitary brachytherapy applicator: A single institutional experience

Anish Dasgupta, Anis Bandyopadhyay, Souransu Sen, Bidisha Bagchi, Arnab Adhikary, Debabrat A. Mitra

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

Background: The standard of care in cervical cancer from stage IB and IIB onwards in concurrent chemo radiation followed by brachytherapy. Brachytherapy is most commonly given by the intracavitary method, using various applicators. However, in some cases, interstitial brachytherapy is preferred in place of intracavitary brachytherapy. In the modern scenario, combined interstitial and intracavitary applicators have been manufactured, as the combined modality may lead to better dosimetric coverage than either individual modality. Purpose: To compare the dosimetric data of interstitial brachytherapy against a hybrid intracavitary and interstitial method using interstitial template along with the central tandem of an intracavitary applicator by comparing the dose received by the organs at risk (OAR), Homogeneity Index, and. Methodology: Cervical cancer patients (F.I.G.O. Stage IIIB) without history of prior hysterectomy, after completing chemoradiation underwent a clinical examination and MRI scan. On the basis of this, those patients whose disease could not be adequately covered by intracavitary approach were selected for either interstitial approach or combined interstitial and intracavitary approach (with central tandem of intracavitary applicator and standard interstitial template with needles). Both MUPIT and Syed Neblett template were used. CT based planning was done for HR-CTV and OAR contouring (bladder, rectum). Dose prescribed was 7gy/fraction for 3fractions. Data was collected regarding the D2cc, D1cc, D0.1cc of OARs, D50, D90, V100, V150. Homogeneity index was calculated for both arms by the formula H.I.={ V100 - V150} / V100. Results: The median age of the patients were 52 years. 60% patients were treated by using MUPIT applicator, and 40% patients by using Syed Neblett applicator in either arm. A median of 14 needles were inserted for each application. The median D2cc, D1cc and D0.1cc of the rectum for combined arm and interstitial only arm was 576cGy, 622cGy, 697cGy and 484cGy, 548cGy, 693cGy respectively. The median D2cc, D1cc and D0.1cc of the bladder for combined arm and interstitial only arm were 631c Gy, 680cGy, 781cGy and 495cGy, 569cGy, 753.5cGy respectively. The median volume of HR- CTV contoured, was 46.5cc for the combined arm and 38.5cc for interstitial only arm. Homogeneity index compared by t-test. There was significant difference between the homogeneity index of the two arms. Conclusion: Combined interstitial and intracavitary approach leads to a very good coverage of tumour in cervical cancer.

Abstract: A prospective study to compare the pathological outcome and acute toxicity profile in patients of resectable adenocarcinoma of rectum treated with short course radiotherapy followed by delayed surgery versus long course chemoradiotherapy followed by delayed surgery

Souransu Sen, Anish Dasgupta, Arnab Adhikary, Bidisha Bagchi, Anis Bandyopadhyay, Debabrata Mitra

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

Purpose of Study: Pre-operative treatment has emerged as the standard of care in the treatment of rectal cancer. Neoadjuvant therapy is associated with tumor downstaging, improved resectability and tolerance (both acute and chronic), and potential for expanded sphincter preservation options in the distal rectum. Both short-course RT and long-course chemoRT can be used as neoadjuvant therapy. The purpose of this study is to compare the pathological outcomes and acute toxicity profiles in patients of resectable adenocarcinoma of rectum treated with short course radiotherapy followed by delayed surgery versus long course chemoradiotherapy followed by delayed surgery. Materials and Methods: Biopsy proven patients of adenocarcinoma of rectum, who attended the Dept. of Radiotherapy, Medical College and Hospital, Kolkata between January 2018 and April 2019 and satisfied the inclusion and exclusion criteria, were randomised to one of the two treatment arms: Short-course radiotherapy (25 Gy/5#/5 days) or Long-course chemoradiotherapy (50.4 Gy/28#/ 1# per day/ 5 days a week with concurrent Capecitabine). After completion of RT all the patients underwent delayed surgery (4-8 weeks after completion of RT) in the form of either APR or LAR. After surgery, the resected specimens were analysed and the pathological outcomes in the form of tumour stage, tumour category, node category, tumour regression grade (using Dworak regression grade) and circumferential resection margin (CRM) status were recorded. The acute toxicities developed during and shortly after RT were also recorded. The pathological outcome data and the toxicity data were then analysed for any statistically significant differences in distribution between the two treatment arms. Results: A total of 46 out of 50 randomised patients were analysed for this study. The patients randomised to LCRT-delay arm had earlier ypT categories and a higher rate of pathologic complete response (pCR) (16.6% vs. 0%). Dworak Grade 4 regression was also higher in the LCRT-delay group (29.1% vs 0%). The rates of CRM positivity were lower in both groups and they were not statistically significantly different. The acute toxicity rates were comparable between the two groups except for incidence of neuropathy and hand-foot syndrome, which were higher in the LCRT-delay group. Conclusion: The results of this study points towards long-course chemoradiotherapy followed by delayed surgery being the better than short course RT followed by delayed surgery. However, the better toxicity profile of the SRT-delay arm makes it a feasible option in elderly patients or patients with significantly poor performance scores or with severe comorbidities. Long term follow up and survival data is needed to draw any meaningful conclusion.

 > Abstract: Comparision between the clinical outcomes of two hypofractionated palliative radiotherapy schedules in locally advanced inoperable head and neck cancers Top

Subhadra Choubey, A. K. Rathi, K. Singh, S. Arora

MAMC and LNH, Delhi, India, E-mail: [email protected]

Purpose and Objective: To compare clinical outcomes of two palliative hypofractionated radiotherapy schedules in incurable head and neck cancers. The primary aim of the study was to evaluate the response to treatment objectively (clinically) and in terms of subjective symptom relief. The toxicity of hypofractionated radiotherapy (as per RTOG criteria) was assessed and compared. Quality of life parameters of the patients undergoing treatment were evaluated using EORTC H&N35 Questionnaire. Materials and Methods: The study population consisted of 40 patients, all locally advanced (stage IVA/B) head and neck carcinoma. Twenty patients were randomised in each arm. Patients in arm A received 50 Gy in 16 fractions (Christie regime). Patients in arm B received 14 Gy in 4 fractions twice daily 6 hr apart, for 2 consecutive days repeated three times with 3-4 weeks gap (Quad shot). QoL questionnaires were filled for all patients. Results: Overall, 57.5% patients had improvement and 35% patients had no change in the performance status. However, there was no statistical significant difference between two arms in terms of performance status. The pain relief was reported in 78% of patients with significant decrease in pain score from pre-treatment score (p<0.0001). The median and mean of the pain scores when analysed post radiotherapy in both the arms and it was not statistically significant for the differences (p=0.196). Although, the mean subjective relief was greater in Christie arm (53.75%) as compared to quad shot arm (38%), but again not statistically significant (p=0.092). The median overall survival of our study population was 7 months. Also, there was overall improvement in quality of life (87.5%) in our study population including improvement in pain (78.13%), speech (62.5%) and global health status (87.5%) as reported by majority of patients who filled the QoL questionnaire. There was more (≥1 grade) toxicity recorded in Christie arm as compared to Quad shot arm ,[significant in skin (p<0.001), mucositis (p<0.001), salivary gland (p<0.001) and laryngitis (p<0.001) and non-significant for dysphagia (p=0.049) and anaemia (p=0.638)]. While the quality of life plays a major role in deciding efficacy of a palliative regime, there was no statistically significant difference between the two arms in our study. But there was significant improvement in global health status reported post treatment in overall population (p=<0.0001). Conclusions: Both the palliative regimes (Christie and Quad shot) are very effective for palliation in inoperable locally advanced head and neck cancer patients. Though the toxicities were more in Christie regime than Quad shot arm, the overall survival was numerically higher in Christie arm but not significant. There was significant improvement in quality of life of patients in both the arms but, the difference between the two was not statistically significant.

 > Abstract: Head and Neck Cancer (Best Paper) Sinonasal tract malignancies and rare case study of intracranial extra skeltal myoxid chondrosarcoma Top

Vinodh Kumar Selvaraj, K. Raju

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

Background: Sino nasal tract can harbour a wide variety of malignant neoplasm, which can be epithelial, mesenchymal and lymphoid in origin. Owing to their peculiar epidemiology, complex anatomical location, diverse genetic and molecular alterations; they are extremely difficult to treat. The overall survival still remains the same over past two decades. Due to rarity of their occurrence, there are very limited number of studies and data on this group of malignancies. Methods: Between September 2011 to December 2016, 21 cases of Sino nasal tract malignancies were treated at our department. Charts were reviewed for standard demographic, tumour size and extension, histological features, treatment strategies, surgical approach, adjuvant therapies, outcomes and complications. Results: The median age was 50.3 years (16-77). There was a slight male preponderance with 57.1% (12). The most common presenting symptom was nasal obstruction followed by epistaxis. Thirteen cases were epithelial (62%) while 8 were non epithelial in origin (38%). Nearly half of the patients (10) had prior surgery, of which, 8 underwent re-surgery. Among all those who had upfront surgery (12), 25% received adjuvant chemo radiation (3) while 75% received adjuvant radiation alone (9). Inoperable cases were treated with definitive chemo radiation (5) with weekly or 3 weekly Cisplatin; radical radiation (3); and neo adjuvant chemotherapy followed by surgery and adjuvant radiation (1). The radiation dose ranged between 50.4 to 66Gy given over 28-33 fractions at 1.8-2Gy per fraction with Intensity modulated radiotherapy techniques. In spite of adapting a multi modality approach, residue/recurrence was seen in half of the patients (10) within 2 years (2-18 months) of treatment. The median DFS was 8.4 months in these patients. Progressive disease with metastasis was seen in 4 patients (19%), with bone being the most common site. Conclusion: Sino nasal tract malignancies still remain to have a poor prognosis. With newer molecular studies leading to further sub grouping of these malignancies, the survival is likely to improve with personalized multi modality treatment approach. Further studies on combining newer radiotherapy techniques with immunotherapy and radiosensitisers are warranted.

 > Abstract: Comparison of dosimetric parameters of 3-DCRT and intensity modulated radiotherapy in cancer breast patients undergoing adjuvant radiotherapy after modified radical mastectomy Top

Ankita-Mehta, P. Kumar, J. Nigam, N. S. Silambarasan, S. Navitha, A. K. Chauhan, P. Kumar

Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India, E-mail: [email protected]

Background: Adjuvant radiotherapy is required in most of the cases after modified radical mastectomy to prevent local and regional nodal recurrences. Late reactions are well known to occur in lung and heart using conventional tangential fields. Newer techniques like IMRT are being used to decrease the doses to these organs at risk and decrease the late morbidities. Purpose: To compare the various dosimetric parameters in Carcinoma Breast patients undergoing adjuvant radiotherapy after modified radical mastectomy (MRM) treated by 3 Dimensional Conformal Radiotherapy (3DCRT) and Intensity Modulated Radiotherapy (IMRT). Materials and Methods: 50 post MRM patients were selected and planned adjuvant radiotherapy who were randomized into two arms of radiotherapy techniques - 3D CRT and IMRT (25 each). The prescribed dose was 50 Gy in 25 fractions over 5 weeks. The CTV and Organs at risk (OAR's) were delineated based on RTOG guidelines. Two opposing tangential beams were used in 3 DCRT plans whereas four to seven beams, (mostly tangential) were used for IMRT plans. Dosimetric parameters were evaluated for PTV, Lungs, Heart, Opposite Breast and Esophagus. Results: The dosimetric parameters of PTV in terms of D95%, D90%, D50% and Dmean had no significant difference by both techniques, however IMRT had significantly better mean values of Dmin/D98% (40.74 Gy versus 30.81 Gy; p = 0.01) and Dmax/D2% (51.46 Gy versus 53.65 Gy, p < 0.001). Conformity index (1.07 versus 1.29, p=0.004) and Homogeneity index (0.22 versus 0.46, p= 0.003) were significantly better in IMRT arm. The dosimetric parameters of ipsilateral lung were significantly higher in IMRT arm in terms of mean dose (19.92 Gy versus 14.69 Gy, p < 0.001) and low/medium dose regions (V5, V10, V13, V15, V20; p < 0.05). However high dose regions (V40) were significantly higher in 3 DCRT arm (15.57 Gy versus 19.89 Gy; p = 0.02). In contralateral lung mean dose was significantly higher in IMRT technique (3.63 Gy versus 0.52 Gy, p<0.0001) along with low dose regions (V5, V10, V13, V15; p < 0.05) while V20 was comparable between both the arms. The heart dose was significantly lesser in left sided breast cancer patients in 3D CRT technique in terms of mean dose (17.20 Gy versus 8.51 Gy;p = 0.003), low /medium dose regions (V5, V10, V20; p < 0.05), and doses to partial/whole volumes (D33, D67, D100). The high dose regions (V25, V30, V40) were comparable between both the arms. The opposite breast received higher mean dose with IMRT technique (2.60 Gy vs 1.47 Gy, p=0.009) along with higher V5 (11.60 Gy versus 3.83 Gy; p =0.001). The dosimetric parameters of esophagus showed higher mean dose in IMRT technique (10.04 Gy versus 3.24 Gy; p < 0.0001). The high dose regions V35 and V50 were comparable between both the arms. Conclusion: IMRT technique was better in terms of conformity index and homogenous dose distribution with significant decrease in high dose regions in ipsilateral lung. 3DCRT showed lesser mean dose to lung, heart, opposite breast and esophagus. We may achieve a better dose distribution to PTV in 3D CRT plans if multiple subfields are used within tangential fields.

 > Abstract: 3D conformal versus intensity modulated radiotherapy in head and neck squamous cell carcinoma: Comparative analysis of compliance, toxicities and dosimetric parameters Top

Kritika Mehrotra, P. Kumar, J. Nigam, N. S. Silambarasan, S. Navitha, A. K. Chauhan, P. Kumar

Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India, E-mail: [email protected]

Background: Newer radiotherapy techniques like 3-Dimensional Conformal Radiotherapy (3D CRT) and Intensity Modulated Radiotherapy (IMRT) are being used in treatment of Head and Neck Cancers. Various Radiotherapy techniques have advantages and disadvantages in terms of compliance, toxicities and dosimetric parameters. Purpose: The present study was done to compare the compliance, toxicities and dosimetric parameters in patients of head and neck cancers treated by3D CRT and IMRT. Methodology: Fifty patients of Head and Neck cancerswere planned chemo-radiation.They were randomised into two groups (25 each) based on radiotherapy planning technique: Group I-IMRT and Group II by 5 Field 3DCRT. All patients weredelivered 70 Gy in 35 fractions over 7 weeks along with weeklyCisplatin (35 mg/m2). Clinical Target volume and Organ at risk delineation was done according to RTOG 0225. Compliance was seen in terms of Overall treatment time and number of concurrent chemotherapyreceived.Toxicity was evaluated in terms of hematological (CTCAE v5.0) and radiation toxicity (skin, mucosal and salivary gland) by RTOG acute and late morbidity scoring criteria. Tumor response was assessed according to WHO criteria. Dosimetric parameters were calculated for Primary target volume (PTV)(V95, D95, Dmax, and Dmean) and Organs at Risk (Brainstem-Dmax, PRV Spine-Dmax, Opticchiasm-Dmax, Mandible-Dmax, Optic nerve-Dmax, Parotid gland-Dmean, Cochlea-Dmean, Mandible-Dmax, Lips-Dmean). Patients were followed during radiotherapy, on completion of radiotherapy and at 6 months post radiotherapy. Results: Compliance (Mean Overall Treatment Time-49 days, Mean concurrent chemotherapy cycles-5) is similar in 3DCRT and IMRT. No Grade III/IV hematological and radiation toxicities were seen during treatment and in follow up. There was no statistical difference in complete response between the two groups. Dosimetric parameters for PTV were significantly better in IMRT: V95 (94.9%vs 70.86 %, p <0.001), D95 (68.28 Gy vs 58.08Gy, p<0.001), DMean(69.4 Gy vs 65.27 Gy, p-0.004), Dmax(73.26 Gy vs 76.23 Gy, p-0.001). Doses to all organs at risk were within constraints in both 3D CRT and IMRT, though IMRT showed lesser doses. The doses were significantly lowerin IMRT for Right parotid (35.43 Gy vs 59.83 Gy, p<0.001), Left parotid (35.95 Gy vs 55.78 Gy, p<0.001), PRV Spine (37.5 Gy vs 43.4 Gy, p<0.001), Mandible (71.2 Gy vs 74.3 Gy, p<0.001) Left cochlea (9.62 Gy vs 19.14 Gy, p-0.02), Right cochlea (10.27 Gy vs 23.64 Gy, p- 0.0073) and Brainstem (37.67 Gy vs 39.11 Gy). Doses were better in 5 Field 3DCRT for Optic chiasma (3.02 Gy vs 2.14 Gy), Right Optic nerve (3.2 Gy vs 2.04 Gy), Left Optic nerve (4.58 Gy vs 2.18 Gy) and lips (23.28 Gy vs18.7 Gy) but no significant difference was seen. Conclusion: The present study reveals that IMRT plans give better dose distribution to PTV with lesser dose to parotid gland, PRV spine, Cochlea and Mandible. 3DCRT plans reveal lower dose to lips, optic chiasma and optic nerve. Addition of multiple subfields may improve the dose distribution to PTV in 3D CRT arm.

 > Abstract: A prospective comparative study of neoadjuvant concurrent chemoradiation with single agent capecitabine versus capecitabine-oxaliplatin combination in locally advanced adenocarcinoma of rectum Top

Arindam Chaudhury, Biswamit Bhattacharya, Premnath Dutta, Sanatan Banerjee

Department of Radiotherapy, Burdwan Medical College and Hospital, Bardhaman, West Bengal, India, E-mail: [email protected]

Background: Colorectal cancer is a major cause of morbidity and mortality globally. Rectal cancer represents a distinct disease entity that needs carefully optimized multimodality treatment strategies. Although surgical resection is the mainstay of treatment, preoperative neoadjuvant therapy with either short course radiotherapy (25Gy in 5 fractions) or long course chemoradiation (50.4Gy in 28 fractions) with concurrent 5–Flurouracil/Capecitabine based chemotherapy has emerged as the standard of care. Oxaliplatin is commonly used along with 5- Flurouracil/Capecitabine in the adjuvant or metastatic setting for Colorectal carcinoma although its role in the neoadjuvant setting as an add-on, remains questionable. Aim: This study aims to evaluate whether Capecitabine-Oxaliplatin combination is superior to single agent Capecitabine as radiosensitizer for neoadjuvant long course chemoradiation, in downstaging locally advanced rectal adenocarcinoma to achieve better treatment outcome. Methodology: This is a prospective, single-institutional, randomised, non-crossover study. Cases of histopathologically proven locally advanced Adenocarcinoma of rectum, attending the Radiation Oncology OPD of Burdwan Medical College and Hospital, from June 2017 to May 2019, were selected as per pre-defined inclusion and exclusion criteria, and segregated into the study and control arms by simple randomization method. Both arms were treated with neoadjuvant, external beam radiotherapy with 50.4Gy in 1.8Gy/fraction in 28 days over 5½ weeks along with concurrent Tablet Capecitabine (825 mg/m2/day) from Day 1 to Day 28 of treatment. Patients in the Study arm received additional intravenous chemotherapy with Inj.Oxaliplatin (85 mg/m2) on Day 1 and 14 of RT. Toxicities in both arms were assessed by appropriate methods and compared as per CTCAE v5.0. The patients then proceeded for definitive surgery. Post-operative histopathological reports were assessed for pathological response. The patients were regularly followed up and the treatment failures were documented. Results: Out of 32 patients in the study arm aged between 19-65 years (median 46.5 years), 15 (46.9%) were males and 17 (53.1%) were females. Out of 31 patients in the control arm aged between 24-66 years (median 45 years), 19 (61.9%) were males and 17 (38.1%) were females. Both the arms were statistically found to be age and sex matched. At the end of definitive surgery, 10 patients (31.3%) in the study arm versus 6 patients (19.4%) in the control arm, achieved pCR. The difference however, failed to show any statistical significance (p=0.387). During the study period, 5 patients (15.6%) in the study arm and 9 patients (29.03%) in the control arm had treatment failure (p=0.328). 14 patients (43.4%) in the study arm had grade 3 febrile neutropenia while only 3 patients (9.67%) in the control arm had so (p=0.005). 10 patients (31.25%) in the study arm and only 4 patients (12.9%) in the control arm had grade 3 diarrhea (p=0.15). 3 patients in the study arm, and 1 patient in the control arm had treatment related deaths (p=0.63). Conclusion: Addition of Oxaliplatin to neoadjuvant concurrent Capecitabine based long course chemoradiation in locally advanced adenocarcinoma of rectum causes improvement in pCR rates, and decrease in treatment failure rates, at the cost of significant increment in toxicities. The study protocol should therefore be tried in larger multi-institutional trials and considered only for patients who have preserved performance status and no or minimal co-morbidities.

 > Abstract: PD-L 1 expression in oropharyngeal cancers receiving definitive chemo-radiotherapy: A correlation with toxicities and response Top

Smriti Srivastava, M. Rastogi, K. Sahni, R. Khurana, R. Hadi, S. Sapru, A. K. Gandhi, N. Hussain, S. P. Mishra, A. K. Srivastava, A. Bharati, S. S. Nanda, S. Rath, H. B. Singh, K. Siddharth

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

Background: The Programmed Death Receptor Ligand 1 (PD-L1), is a cell-surface glycoprotein expressed on cancer cells, macrophages, T cells and other tissues. The interaction of PD1 and PD-L1 can suppress the cytotoxic CD8 T-cell mediated immune response.. The association of PD-L1 expression with head and neck cancer has been established in various studies. But the definitive association of this expression with the response obtained with chemoradiotherapy and the associated toxicity is still debatable. Aims and Objectives: To access the correlation of toxicity and response with PD-L1 expression in oropharyngeal cancers receiving definitve chemradiation. Materials and Methods: Our study was a prospective observational study in squamous cell carcinoma of orophaynnx (stage II-IVA,(AJCC 8th). PDL1 expression in biopsy specimen was assessed using Immuno-histochemistry. Definitive radiotherapy (RT) of 70 Gy in 35 fractions at 2 Gray/fr, each, in two phases was given by linear accelerator using 3 Dimensional Conformal radiotherapy technique with concurrent chemotherapy (Cisplatin 35 mg/m2 weekly). Patients were weekly assessed for acute toxicities as per RTOG criteria. Response assessment was done 3 months post RT with WHO response assessment criteria. Grade ≤2 vs >2 toxicities and complete response versus partial response or stable disease were correlated with PDL1 expression using Chi square test. P value of < 0.05 was considered statistically significant. Results: 40 patients were enrolled with a median age of 55.5 years (range 26-75). 90% patients had history of tobacco abuse & Base of tongue was most common subsite (58%). 15/40 patients were positive for PD-L1 in tumor cells. Among these, 8 were also positive for PD-L1 in TILs (Tumor infiltrating lymphocytes) and 4 were co-positive for P16. 37% of low and intermediate grade tumor were PD-L1+ve and 80% of high grade tumors were PD-L1 +ve (p = .05). Median RT dose was 70 Gy and median RT duration was 49 days. None of the patients had grade IV or above toxicity. Overall grade >2 toxicity was 50% oral mucositis, 45% dysphagia & 28% laryngeal toxicity. Radiation toxicity in terms of oral mucositis, dysphagia was more in PD-L1 -ve patients in comparison to PD-L1 +ve patients [Table 1]. At a median follow up of 10 months (range 3-18) overall survival was 96% in the PD-L1 –ve arm and 80% in PD-L1 +ve arm (p=0.04). Conclusion: PD-L1+ve is strongly correlated with high tumor grade. Patients with PD-L1 positivity have lower radiation toxicity and may have poorer survival compared to PD-L1 –ve patients.
Table 1: Relation of toxicity and treatment response with PDL1 expression

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 > Abstract: Dosimetric feasibility and clinical outcome of image guided interstitial brachytherapy using two different fractionation schedule in cancer cervix Top

Janmenjoy Mondal, Abhishek Basu, Bidyut Mandal, Debjit Ghosh, Diptimay Das

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

Background: Cervical cancer is the second most common cancer in women of India with around 60,000 annual mortality. Interstitial brachytherapy (ISBT) is used wherein standard intracavitary brachytherapy (ICBT) or intravaginal brachytherapy is expected to result in inferior local control due to suboptimal dose distribution within the lateral parametrial tissues or for bulky cervical cancers. There is scarcity of data regarding different fractionations in ISBT. This single Institutional, retrospective study was done to compare dosimetry & clinical outcomes using two different dose fractionation. Materials and Methods: 60 patients were recruited between 2014-2017 & treated with ISBT using Syed–Neblett Template by iridium 192 with Gamma Med plus HDR afterloader unit. They were allotted in 2 arms (n= 30) & received 9 Gy ×2# and 7 Gy ×3 # respectively. All patients received 50Gy/25# whole pelvis EBRT by Theratron 780C. Coverage Index (CI), Dose homogeneity index (DHI), Overdose index (OI), Dose non- uniformity ratio (DNR), D90Target and 2cc EQD2 of OARs were calculated and correlated with toxicity, locoregional control & survival. Statistical Analysis: Unpaired T test & Chi- square test were used to compare numerical & categorical variables, using IBM SPSS, V23 . PFS & OS were calculated using Kaplan–Meier analysis, and log-rank test was used for comparison. Results: Mean EQD2 for bladder (75.33 vs 77.29 Gy) & Rectum (69.59 vs 69.30 Gy ) were comparable. With a median follow up period of 38 months, 3 yr local control rate was 50% vs 43.30% (p = 0.72) and 3 yr OS was also similar 83% vs 80% (p=.8). Other Dosimetric parameters & toxicity profile between two groups were not significantly different. Conclusion: 9Gy ×2 # is a reasonably good alternative for treating locally advanced CA cervix. Robust Prospective RCTs are warranted to validate.

 > Abstract: A prospective randomised comparative study of two palliative radiotherapy regimens in advanced squamous cell carcinoma of head and neck region Top

Dhananjay Mondal, Biswamit Bhattacharya, Rajat Bandopadhyay, Pradip Kumar Maiti

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

Background: Squamous cell carcinoma of head and neck constitutes about 30-40% of all cancer burden in this country. Unfortunately, majority presents with advanced stage or recurrence after initial definitive therapy. Earlier, the initial treatment of patients with locally advanced stage III or IV (M0) was mainly surgery and/or radiation therapy. Radiotherapy alone has been the “traditional” single treatment for patients with unresectable and/or inoperable locally advanced head and neck cancers, and still relevant despite advent of better chemotherapeutic drugs and monoclonal antibodies. Objectives: The study aimed to compare which of commonly used palliative schedules i,e 30 Gy in 10 fractions in 2 week or 20 Gy in 5 fractions in 1 week in terms of treatment outcome and toxicities encountered. Materials and Methods: From February 2018 to May 2019, 61 patients with histopathologically proven advanced (stage III, IV) squamous cell carcinoma of head and neck region were recruited. They were divided into a ARM A [who received External Beam Radiotherapy with 3Gy /fraction, five days a week for 2 weeks upto total dose of 30 Gy and ARM B who received radiotherapy with 4Gy/fraction, five days a week for 1 week upto total dose of 20 Gy, the two groups were comparable in terms of age distribution, sex distribution, ECOG performance status, stage, primary site and histological grade. Results: Overall response (CR+PR) was achieved in 61.28% patients in the ARM A which was comparable with other studies. The ARM B, although a lesser proportion of patients achieved overall response (56.66%), could not yield a statistically significant inferior outcome in terms of the same parameter. 3.22% patients achieved Complete Response (CR) in the ARM Awhile 3.33% patients achieved Complete Response (CR) in the ARM B (CR). However, this result could not be validated with a statistical significance. The lack of statistical significance may probably be a reflection of the relatively small sample size of the present study. Palliation of symptoms like PAIN CONTROL was studied in both arms according to visual analogue scale. It was found to be comparable in both arms. In ARM A moderate to significant pain control was 90.31% whereas in ARM B was 93.33% tough slightly higher in ARM B that is statistically insignificant. Other symptom control was also comparable. Average duration of pain relief in ARM A is 7.34 months vs 7.96 months in ARM B, the slight difference is not statistically significant. The acute and late toxicities like mucositis and xerostomia were comparable. Conclusion: Hypofractionated RT regimen with both schedule of 30Gy in 10 fractions in 2 weeks and 20Gy in 5 fractions in 1 week are effective palliative tools for controlling symptoms and disease in patients with advanced head and neck cancers where curative treatment options is unsuitable. Even in patients with moderate-to-poor performance status, there were significant symptom control and tumour responses in most patients similar to other published series. Thus, hypo-fractionated palliative RT is a good option for disease control, palliation of symptoms with manageable toxicities.

 > Abstract: Epidemiology of lung cancer in Eastern India with focus on histopathological subtypes and smoking history: A single rural tertiary center experience Top

Madhusudhan Perumandla

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

Background: Lung cancer has variable epidemiologic pattern according to the geographic region. Worldwide we are observing important changes in incidence trends amongst men and women, histology, and incidence in non-smokers. Indian epidemiological data on lung cancer is scarce, more so from the eastern parts of the country and rural scenario. Aims: We aim to study the epidemiological patterns of lung cancer in India, and find out whether global trends in changing patterns of epidemiological profile of lung cancer is also applicable for Indian population. Materials and Methods: We enrolled all the patients attending Radiotherapy OPD of Burdwan Medical College and Hospital having histopathological diagnosis of lung cancer between 2017 and 2018. Demographic data, smoking history, place of residence, histology, stage at presentation, and treatment details were collected. Data was entered and analyzed in SPSS. Results: There were 484 patients, with a median age of 59.5 years (Range: 33 to 79 yrs), of which 132 (27.3%) were non-smokers and 352 (72.7%) were smokers. The male-to-female ratio was 4.7:1. 12.4% of patients had small-cell carcinoma; of the 87.6% patients with non-small-cell carcinoma (NSCLC), the most common histology was adenocarcinoma (44.6%), followed by squamous cell (38.4%). 4.5% of patients were diagnosed by cytology, therefore were diagnosed as NSCLC, without further histopathological sub-typing. Most patients (53%) were in Stage IV at presentation. Lung followed by bone were the common sites of metastases. The majority of the patients (49%) received palliative chemotherapy. Conclusion: Majority of rural Indian patients with lung cancer are smokers. India is not an exception to the global trend of rise in the incidence of adenocarcinoma. The proportion of small cell carcinoma of lung patients in our series is slightly more than other Indian data, which needs to be collaborated by further multi-centric studies.

 > Abstract: A retrospective analysis of epidemiological pattern of nonHodgkin's lymphoma in a tertiary care center of Eastern India Top

Arundhati Mondal, Biswamit Bhattacharya, Premnath Dutta, Sanatan Banerjee

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

Background: Non-Hodgkin's Lymphomas (NHL) is diverse in its presentation, morphology, histology, and immunophenotyping. Indian data is lacking regarding epidemiologic pattern of disease. Aim: The aim of this study is to analyze the clinicopathological features and assess treatment modalities utilized and their outcomes in patients with NHL and also the outcome with involved field radiotherapy (IFRT). This is a retrospective observational study from prerecorded hospital data. Materials and Methods: Cases of primary extranodal NHL attending the radiotherapy outpatient department of our institute during the last 2 years (July 2017-June 2019) were taken for this study. Hospital recorded data were taken and analyzed regarding the demography, clinical features, histopathological features, and treatment modalities and their outcomes. Result: Total 106 patients were identified with mean age of 47.6 years (Range: 14- 78 yrs). There was a definite male preponderance (Male:Female ratio being 2.8:1). Most common histopathological sub-type was Diffuse large B cell lymphoma (54.7%). 45.3% patients had extranodal involvement with stomach, nasopharynx, and testis being the most commonly encountered extranodal sites in our series. Most common stage at presentation was stage II (49.05%). 67.9% patients were CD20 positive, thus were candidates for Rituximab. Almost all patients (102 out of 106, 96.22%) received chemotherapy while only 15% patients received involved field radiotherapy. Conclusion: Immunohistochemistry is essential in all cases to identify the subset which would respond excellently to rituximab (CD20 positive). Role of IFRT is shrinking in the management of NHL due to advent of better options of systemic therapy and now considered only in patients having residual disease following systemic therapy.

 > Abstract: Dosimetric analysis and toxicity comparision in intensity modulated radiotherapy versus 3DCRT for the treatment of mid and lower third oesophageal carcinoma: A randomised propective single institutional study Top

Luri Borah, A. K. Kalita, M. Bhattacharyya, P. P. Medhi, Shashank Bansal, Ghritashee Bora, Shasi B. Sharma, M. N. Moirangtham, G. S. Sarma, Jyotiman Nath, Moumita Paul

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

Background: Esophageal malignancy is endemic in northeastern region of India. About 30-40% of patients are not suitable for surgery due to technical, functional, or medical reasons and for these patients definitive chemoradiation is the standard of care but since esophagus is surrounded by several critical organs, higher dose cannot be delivered with conventional techniques. With the advent of newer radiation delivery techniques it is now possible to deliver higher doses to primary tumour. This study is an attempt to distinguish between dosimetric parameters and associated toxicities in patients treated with two different conformal radiation techniques (3DCRT and IMRT). Materials and Methods: 30 patients with biopsy proven esophageal cancer stage cT2-3cN0-2M0, planned for concurrent chemoradiation in multidisciplinary tumor board were enrolled. All the patients received a total dose of 63Gy in 35 fractions in two phases. Two beams were used in 1st phase and 3 beams in the 2nd phase of 3DCRT plans whereas total of 7 beams were used in both the phases of IMRT plans and treatment was delivered to PTV with 6MV photons. The GTV, CTV, PTV and OARs were delineated and the homogeneity index (HI) and conformity index (CI) were calculated. Results: Significantly lower heart doses (V30, p <0.0001 and V45, p <0.0001) reported in the IMRT arm and similarly maximum spinal doses (p <0.0001) was lower in the IMRT arm. But the mean lung doses, V20 and V5 were found signifinicantly higher in IMRT arm than 3DCRT arm. No significant grade 3/4 toxicites were reported in both the arm. Three patients in the IMRT developed trachea-esophageal fistula during the treatment and were not available for assessment. Conclusion: Locally advanced unresectable esophageal cancers treated with concurrent chemoradiation, IMRT has shown better dosimetric profile. Toxicities were similar in both the arms, but higher number of patients has to be evaluated to arrive at a final conclusion.

 > Abstract: Biodosimetric evaluation of head and neck cancer patients undergoing radiotherapy or concurrent chemoradiotherapy by dicentric chromosomal aberration assay Top

Kumar Prabhat, Arun Kumar Rathi, Kishore Singh, Seema Kapoor, Savita Arora, Sunil Kumar Polipali, Ankur Jindal

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

Background: Although research has been done and results published time to time on biodosimetry, there is still paucity of Indian data regarding cytogenetic changes induced by radiation in head and neck cancer patients receiving radiotherapy or concurrent chemoradiotherapy. Purpose: To evaluate in vivo dose–response relation of dicentric chromosome aberration formation in peripheral blood lymphocyte of head and neck cancer patients undergoing radiotherapy or concurrent chemoradiotherapy. Methodology: A total 40 patients of head and neck cancer (20 patients in each group - CTRT versus RT alone) were enrolled in this study with prior informed consent. Inclusion criteria were

  • Squamous cell carcinoma or adenocarcinoma of head and neck
  • Age group-18 to 60 years
  • ECOG≤2
  • Complete blood counts, kidney function test, liver function test and 2D-ECHO (within normal limit).

Radiotherapy planning was done as per standard protocol by two parallel opposed fields. Radiotherapy was delivered by TELECOBALT Co-60 (THERATRON 780E). Daily dose of 200 cGy for 5 days a week was given. Total dose varied between 50 Gy to 70 Gy. Patients planned for concurrent chemoradiotherapy were also given weekly chemotherapy with Cisplatin 40 mg/m2 on every week before radiotherapy. After required culture and incubation of heparinized blood samples, the lymphocytes were isolated and stained to identify chromosomal aberrations such as dicentric per one hundred metaphases for each individual. The yield of dicentric chromosome was measured in blood samples taken before starting treatment (day 0), during the course of radiotherapy (6, 11 and 16th fraction), each time one hour after radiotherapy. Results: In our study, comparison of the two groups at individual point of time was done and we found that there was a significant difference in terms of mean dicentric chromosome yield/cm2 at day 6 (p = 0.001), day 11 (p < 0.001), and day 16 of RT (p < 0.001). The mean dicentric chromosome yield/cm2 in the chemoradiotherapy group was greater than that of the radiotherapy alone group by 16.33%, 28.57%, and 18.68 % on day 6, 11, and 16 of RT, respectively. Conclusion: There is a strong effect on the yield of dicentric chromosome/cm2 after adding chemotherapy. The study found that dicentric chromosome yield/cm2 in the CTRT group was greater than that of the RT alone group. The dicentric chromosomal aberration assay is an established biomarker for chromosomal damage used for cytogenetic biodosimetry and the benefit of adding chemotherapy can be radiobiologically proven by dicentric chromosomal analysis.

 > Abstract: A prospective study to evaluate the role of valproic acid as radiosensitizer in patients of high-grade gliomas Top

Treshita Dey, Budhi Singh Yadav, Narendra Kumar, Pravin Salunke, Renu Madan

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

Background: High grade gliomas represent the most aggressive type of primary brain malignancy. Presently, the standard therapy is maximal safe surgical resection, followed by adjuvant radiation and chemotherapy with temozolomide (concurrent + adjuvant). Despite recent advances, their prognosis remains poor. Mostly they present with seizures for which valproic acid, a histone deacetylase inhibitor, is often used as an anti-epileptic drug due to its effectiveness and low toxicity profile. Valproate also has shown to sensitize malignant cells in both in-vivo and in-vitro studies. Purpose: In this study, we evaluated the role of valproate as radiosensitizer to determine its effect on OS (overall survival), PFS (progression free survival) and QoL (quality of life) in high grade glioma patients. Methods: Assuming 50% difference in median OS between two arms, having equal proportion of cases, sample size was estimated at 5% level of significance and 80% power of test. The estimated sample size based on Cox model is 66. Patients with glioblastoma multiforme and anaplastic astrocytoma were randomized on 1:1 basis between both the arms. All patients received adjuvant 3DCRT (45Gy in 25 fractions over 5 weeks followed by boost 14.4Gy in 8fractions over 1.5 weeks) with temozolomide, concurrent (75 mg/m2) and adjuvant (175-200 mg/m2 over 6-12 months). Patients in experimental arm received valproate, starting from 10 mg/kg a week before start of radiation with subsequent escalation till 25 mg/kg within one week and this dose was continued concurrently with radiotherapy. Adherence to valproate therapy was measured by serum valproate levels, done at the baseline and 4 weeks after initiation of radiation. Response was evaluated both clinically and radiologically (3 monthly MRI) as per RANO criteria. OS and PFS were analysed using Kaplan Meier curves (primary objective). p-value<0.05 was considered significant. QoL was assessed at baseline and 3 months post radiation, using EORTC QLQ-C30, QLQ-BN20 questionnaires and MMSE. Change in QoL (secondary objective) for each parameter was determined by calculating differences between baseline and follow-up data. QOL score change was also analysed based on age, performance status, RPA class, tumor characteristics, surgery and baseline score, both within and between the treatment groups by univariate and multivariate analyses. Results: Total 33 patients in each arm were analyzed as per intention to treat analysis. Both the study arms were balanced in terms of baseline characteristics. At median follow-up of 8 months, OS was 87.6% in experimental arm vs 83.7% in control arm (p=0.111) whereas PFS was 78.6% vs 64.9% (p=0.027). Three patients (9.1%) in experimental arm discontinued valproate owing to grade 3 and 4 thrombocytopenia and grade 4 dermatitis. Only 22 patients in each arm completed QoL at baseline and at 3 months. On univariate analysis, there was significant improvement in the baseline QoL scores post treatment with addition of valproate (p=0.02) and also with tumor histology (p=0.049), performance status (p=0.037), but not with age, RPA class, tumor volume and type of surgery. This significance was evident even on multivariate analysis with valproate (p=0.003) and tumor histology (p=0.047). Conclusion: Addition of valproate concurrently with radiation and temozolomide has significant benefit on PFS and QoL. However, this is an interim analysis, both recruitment and patient follow-up will continue.

 > Abstract: Evaluation of response and toxicities with magnetic resonance imaging based adaptive brachytherapy for locally advanced carcinoma cervix using Cobalt-60 source: A prospective single institutional study Top

Hambir Chowdhury, Abhishek Basu, Krishnangshu Bhanja Chowdhury, Yansaromo Yanthan, Debdeep Samaddar, Pritha Roy, Kousik Ghosh, Santu Chandra, Chandan Dasgupta

Department of Radiation Oncology, R. G. Kar Medical College and Hospitals, Kolkata, West Bengal, India, E-mail: [email protected]

Background: Image guided adaptive brachytherapy (IGABT, using MRI) has become the standard of care for the treatment of locally advanced carcinoma cervix (LACaCx). However there is paucity of data regarding clinical outcomes of MRI based IGABT in India and there is no known data using Cobalt 60 based HDR brachytherapy in this setting, to the best of our knowledge. Purpose: To study the clinical impact of MRI-based IGABT treatment planning in LACaCx with the aim to assess the feasibility, efficacy and late morbidity with this approach. Methodology: A prospective single institutional study was initiated to treat LACaCx FIGO (2015) stages IB2 – IIIB, ECOG PS 0-2 with adequate blood parameters with External Beam Radiotherapy (3D CRT; 45Gy/25#/5 wks) with concomitant Inj. Cisplatin 40 mg/m2 weekly (CTRT) followed by HDR BT (Planning aim) 7 Gy x 4# using Multisource Co 60 remote afterloading system (Eckert and Ziegler Bebig GmBH, Germany) with MRI imaging with GYN GEC ESTRO IV guidelines. Dosimetry was recorded per GYN GEC ESTRO and ICRU 89 recommendations. Response was assessed by RECIST v1.1 and toxicities graded by CTCAE v4.0. The primary endpoint was ORR and the secondary endpoints were LRC, PFS, toxicities. Results: Between April 2016 – January 2019, thirty four patients of LACaCx (median age 55 yrs, majority stage IIB) were treated with CTRT followed by HDR BT (Planning aim) 7 Gy x 4# (FSD application - tandem and ovoid) with MRI imaging (GYN GEC ESTRO; ICRU 89). All doses were computed with the EQD2 concept using α/β = 10 Gy for tumour and 3 Gy for OARs using the GEC ESTRO spreadsheet. The median overall treatment time was 50 days (range 42 – 58 days). The mean ± standard deviations of the dosimetric parameters are mentioned. The D90 HRCTV was 91.47 Gy ± 7.01 Gy EQD2 and D90 IRCTV was 61.44 Gy ± 4.13 Gy EQD2. The D2cc for bladder, rectum and sigmoid were 82.96 Gy ± 8.47 Gy EQD2, 65.92 Gy ± 4.9 Gy EQD2 and 63.66 Gy ± 7.97 Gy EQD2 respectively. At a median follow up of 32 months (range 8 – 53 months), there were 28 evaluable patients. Among them, there were three failures (all distant – lung two, liver one) and two deaths (LRC – 89.23%). There were three G2 bladder toxicities (10.71%) and four rectal toxicities (one G3 3.57%, three G2 10.71%). The median PFS for the cohort was 48.23 months (95% CI 43.41 – 53.04 months). The median PFS for Stage IIB and Stage IIIB were 50.5 months and 35.61 months respectively. Conclusion: IGABT using MR-imaging is feasible using Co 60 HDR source. The initial results are comparable with published literature using Ir 192 source and appear promising.

 > Abstract: Prospective randomized study comparing three dimensional conformal radiation therapy and intensity modulated radiation therapy in locally advanced carcinoma cervix Top

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

Department of Radiation Oncology, AIIMS, Rishikesh, Uttarakhand, India, E-mail: [email protected]

Background: Carcinoma Cervix continues to be a major problem in developing countries. Newer techniques like IMRT and VMAT have transformed Radiation Oncology practices by increasing dose conformity in majority of the diseases sites. These techniques have not been widely adopted in treatment of carcinoma cervix. Purpose: To compare acute toxicity along with a dosimetric correlation in patients with Locally Advanced Carcinoma Cervix treated with 3 Dimensional Conformal Radiation Therapy and Intensity Modulated Radiation Therapy. Methodology: Between January 2018 and May 2019, 35 patients with International Federation of Gynecology and Obstetrics (FIGO) Stage IB2-IVA Carcinoma Cervix were randomised to receive 50Gy in 25# via either 3D-CRT or IMRT with concurrent weekly Cisplatin. CTCAE version 4.0 was used for grading acute toxicity. Results: Total 35 patients were included in the study with 19 in IMRT and 16 in 3D-CRT arm. There were 37% in Stage IIB, 31% in IIIB; 11% in IIIA. PTV coverage evaluated using D95 were 48.2 ± 1.3 Gy in 3D CRT arm as opposed to 47.8 + 1.1 Gy in IMRT arm. No significant difference was seen in maximum dose. Bladder and rectum dose (D15, D35, D50) did not show any significant difference. Bowel bag dose was significantly controlled using IMRT (210 + 16 cc) as compared to 3D CRT (456 + 24 cc). Acute toxicities as evaluated weekly during the treatment course showed no significant difference between the two groups. Significant difference of 2.7Gy was seen in the Right Femur Dmax. Similar difference seen in left femur was not statistically significant. Conclusion: This prospective randomised data did not show any significant advantage in use of IMRT over 3D CRT in controlling acute toxicity in radical chemoradiation of locally advanced Ca Cervix. A significant dosimetric advantage was observed in bowel bag and femoral head dose although this has not translated into any immediate clinical benefit. Long term follow up is required to assess the local control and late toxicities.

 > Abstract: Pattern of failure in locally advanced head and neck squamous cell cancer treated with intensity modulated radiotherapy: Initial experience from AIIMS Rishikesh Top

Debanjan Sikdar, A. S. Krishnan, R. Ahuja, T. S. Athira, N. Sharma, S. Raut, L. Pandey, M. Sharma, R. Mahajan, S. Gupta, D. M. Joseph, R. Pasricha, M. Gupta

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

Background and Introduction: Radiotherapy plays an integral part in the radical treatment of non-metastatic Head and Neck cancer (HNC) treatment. For early stage head & neck cancers, it is used as single modality. Concurrent Chemo-Radiation is the treatment of choice for inoperable locally advance HNC. Modern radiotherapy is delivered using highly advance techniques like IMRT & VMAT. Although we can spare lot of normal tissues and decrease morbidity using these techniques, they are highly sensitive to intra & inter fraction errors leading to geographical miss and ultimately treatment failure. Analysis of patterns of failure provides an opportunity to improve our treatment techniques and minimise failures. We here present our data regarding patterns of failure of HNC treated by IMRT &VMAT and exploration of possible reasons for treatment failures. Methods: This is a retrospective evaluation of of patients of non-metastatic Head and Neck carcinoma treated with radiotherapy or concurrent chemo-radiotherapy using IMRT & VMAT techniques at department of Radiation oncology, AIIMS Rishikesh between 1st June 2018 and 31st Dec 2018. Case files were checked to record disease status at last follow up visit. Associated factors also evaluated for recurrence. Results: Files of 62 patients meeting the requirements were secured from the records section. Mean age of patients was 57.4 yrs. Most common histopathology among inoperable HNC was Squamous Cell Carcinoma of the Oropharynx (51%). 17 (24.1%) of the evaluated patients have residual or recurrent disease present after a median follow up of 7 months, 14 (22%) patients have loco-regional residual or recurrent disease among them 15 patients are locally advanced head and neck cancer 1 patient is post op and 2 patients have distant mets (all in lungs). 3 patients had a disease free period before recurrence was diagnosed. Conclusions: Recurrence after radical treatment of Head and Neck Squamous cell carcinoma is not infrequent. Globally, failure rate post radical treatment of Head and Neck cancer is between 18-26% after a median follow up of 3 to 5 years. In our study total failure rate is 20.7% post median follow up of 7 months. Two thirds of these patients never had complete response to treatment suggesting resistance to the treatment offered. Longer follow up is needed for more meaningful data about local control, pattern of failure of radiotherapy in both radical setting.

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

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

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

Purpose and Objectives: Radiation therapy to primary and metastatic brain tumours is delivered by different modalities of External beam Radiation Therapy (EBRT). Compared with conventional fixed-field IMRT, VMAT can generate precise conformal dose distribution through rotational delivery accompanied by variability of the multi-leaf collimator (MLC) position, dose rate, and gantry rotation velocity, thereby improving the dose distribution, reducing the dose to normal tissues, and shortening the delivery time. Noncoplanar arcs are generally used to improve PTV conformity and homogeneity and an additional degree of freedom for potential additional gain in quality of treatment. This arrangement can be readily achieved by rotating table and gantry. Very few studies have compared dosimetric difference between non-coplanar and coplanar VMAT techniques. This study was planned for comparing the dose distribution to the planning target volume (PTV) and organs at risk (OAR) of c-VMAT and nc-VMAT techniques and to find which of these can maximally reduce doses to OAR in patients without compromising prescribed tumor dose. Materials and Methods: This single institute study included 25 consecutive brain tumor patients. After immobilisation, patients underwent a planning contrast CT (Computerised Tomography) & MRI (Magnetic Resonance Imaging) scans which were co-registered and fused using image registration software of treatment planning system (TPS)(Monaco V5.11, Elekta Medical system). Gross tumor volume (GTV), clinical target volume (CTV), PTV & OARs were contoured using RTOG guidelines. Two different treatment plans coplanar (PLAN-A) and non-coplanar arcs (PLAN-B) using VMAT technique for the prescribed doses [60Gy, 54Gy, others (SRS/SRT)] were created using inverse-planning methods incorporating dynamic multileaf collimator (MLC). Dose-volume histograms (DVHs) for planning target volumes (PTVs) and organs at risk (OARs) were generated. Results: A total of 52 plans of 25 patients (26 plan A & 26 plan B) were evaluated (One patient had 2 lesions which were planned & analysed separately). There were 13 female and 12 male patients with good KPS (Around 70 % between 80-90). Most patients were of gliomas 19 (76%) followed by brain metastasis (16%) and meningioma (8%). Plan evaluation indices were compared between c-VMAT with nc-VMAT for all dose categories, 60Gy, 54Gy and others. Plan A significantly reduced dose to optic chiasm (2464.80 cGy & 2692.71 cGy, p-0. 0.001) compared to plan B. Doses to other OARs in plan A&B including Point dose to right optic nerve (1408.07 & 1571.30 cGy, p-0.143), left optic nerve (1567.09 & 1565.84 cGy, p- 0.328), brain stem (3222.89 & 3393.82 cGy, p- 0.089) were similar. Mean dose left cochlea was significantly lower in plan A than plan B, while Brain-PTV Dmean was significantly lower in Plan B than Plan A. Mean doses to right and left eyes, lens, right cochlea and remaining brain (brain-PTV) were also not significantly different in both the plans. When assessed according what actual dose prescribed, in 60Gy group right eye Dmean and optic chiasma Dmax were significantly lower in plan A, while other parameters were similar. For 54Gy Group, Brain-PTV Dmax was significantly less in plan A compared to plan B, rest parameters were equal in both plans. Conclusions: Both the techniques are comparable in term of doses to PTV & homogeneity and conformity index. Non-coplanar plan had better Brain-PTV Dmean, but Optic chiasma Dmax and Dmean left cochlea were better in coplanar plan. For an individual patient, factors like minimum set-up time, ease of reproducibility on daily basis and other logistic issues may help in selecting the optimum technique.
Table 1:

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 > Abstract: 4D computed tomography simulation with synchronized intravenous contrast injection in hepatocellular carcinoma for target delineation Top

Anil Gupta, Rishabh Kumar, Hanuman Prasad Yadav, Manik Sharma, Rose Kamal, Deepak Thaper, Prabir Banik, Kartik Saroha

Department of Radiation Oncology, Institute of Liver and Biliary Sciences, New Delhi, India, E-mail: [email protected]

Background: Delivering Stereotactic Body Radiotherapy (SBRT) for Hepatocellular Carcinoma (HCC) is challenging mainly due to two reasons. First, due to motion of the liver in six degrees of freedom and second, due to HCC's density similar to surrounding normal liver tissue in non-contrast CT scan, making delineation of tumor difficult. It has a characteristic appearance on contrast imaging with arterial phase enhancement and washout in porto-venous and delayed phases. To tackle both challenges simultaneously, we need a synchronized intravenous contrast enhancing 4D CT in both arterial and delayed phase. Previous work generated only delayed phase which gives inadequate information. In our study, we aim to solve these challenges. Materials and Methods: We took 25 patients of HCC planned for SBRT on whom breath hold technique was not feasible. 4D CT simulation planned with synchronized intravenous contrast based on formula TSCAN DELAY = Tpeak – T0, where TSCAN DELAY is the time duration by which scan start is delayed with respect to the start of intravenous contrast to make it synchronized, Tpeak is the time elapsed from start of the contrast injection to the peak enhancement of the aorta and T0 is time taken by the CT scanner to come at the level of interest. It was followed by a delayed 4D CT scan. Results: We found that by following scan delay protocol, the peak HU of contrast 4D and diagnostic CT were similar (mean peak HU 144 vs 157.6, p value N.S). When compared with non-contrast CT there was significant rise in mean peak HU (Mean peak 144 vs 60 p value = .01). Conclusion: A synchronized contrast 4D CT simulation for HCC is safe, feasible and results in good contrast enhancement and image quality which is quite similar to a diagnostic 3D contrast CT scan. Complementing it with a delayed phase allows a radiation oncologist to differentiate it from other lesions in the liver and also helps to identify HCC more accurately. With our protocol other sites that require a contrast 4DCT can also be targeted.

 > Abstract: Blood parameters as surrogate markers to predict treatment response after radiation therapy in head and neck malignancies Top

T. S. Aathira, Ajay Krishnan, Rachit Ahuja, Sagar Raut, Nidhi Sharma, Gaurav Sharma, Debanjan Sikdar, Rohit Mahajan, Sweety Gupta, Deepa Joseph, Rajesh Pasricha, Manoj Gupta

Department of Radiation Oncology, AIIMS, Rishikesh, Uttarakhand, India, E-mail: [email protected]

Background: Head and neck cancers (HNC) are the most common malignancies in India with an incidence of 11.42% and mortality of 10.09%. Several prognostic factors have been defined for Head and neck cancers that can influence response to therapy and eventual outcome eg stage, performance status. Blood and tumor tissue are common sources for specimens for prognostic biomarker measurements. Recent studies show that Neutrophil to Lymphocyte ratio (NLR) and Platelet to Lymphocyte ratio (PLR) are hematologic makers that have started to show prognostic significance across many types of cancers. Also, Red blood cell distribution width (RDW) has been reported to reflect inflammation and nutritional status and to predict prognosis in several different types of cancer. Purpose: Evaluate role of NLR, PLR and RDW as surrogate markers to predict treatment response in head and neck malignancies. Methodology: We retrospectively analysed patients with HNC, stage II to IVB treated with radical intent from Jan 2018 to Dec 2018 in the department of Radiation oncology, AIIMS Rishikesh and with a minimum follow up of 6 months post radiation therapy. Inclusion criteria were new histologically confirmed head and neck squamous cell cancer. Exclusion criteria were history of previous HNC, patient having inflammatory disease such as inflammatory bowel disease, rheumatic disease, and chronic infection or acute infection within 1 month of blood sample collection and patient received systemic corticosteroids. Measurement of Variables: Pre-treatment Blood parameters collected from CBC included white blood cells (WBCs), platelets (PLTs), and RDW (percentage). Peripheral blood smear reports were also collected. Normal range of RDW obtained from the CBC in our institute laboratory was 11.5–14.5. NLR was calculated by dividing neutrophil count with the lymphocyte count and PLR was calculated by dividing platelet count with lymphocyte count. Results: Total 51 patients were included for analysis in the study. Age ranged from 30-78 years (mean -54). 31 patients had complete response and 19 had residual/recurrence at the time of analysis. RDW ranged from 10.2-20.1. Baseline NLR and PLR ranged from 1.02-18.6 and 22.7-608.9 respectively. In complete response patients mean NLR was 2.0 (CI-1.78-2.21) which was significantly lower than mean NLR in disease that which was 5.18 (CI-3.46-6.90). Mean PLR in complete response patients was 93.99 (CI-79.11-108.87) that was significantly lower than mean PLR in disease which was 218.47 (CI-158.59-278.35). There was a significantly higher RDW in disease patients with mean 16.0 (CI-15.13-16.87) than mean RDW in complete response patients which was 13.52 (CI-12.93-14.88). Conclusion: Elevated pre-treatment NLR or PLR or RDW may predict poor response to treatment. Blood parameters may be a potential surrogate marker for pre-treatment prognostication in adjunct to other modalities. More prospective studies with larger sample size is warranted for the same.

Abstract: Esophageal cancer is the 7th most common cancer in the world and accounts for approximately 6 lakh new cases every year. While in India, it is the 6th most common cancer and accounts for approximately 52 thousand new cases every year

Nelesh Aggarwal

SGPGIMS, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Introduction: Esophageal cancer is the 7th most common cancer in the world and accounts for approximately 6 lakh new cases every year. While in India, it is the 6th most common cancer and accounts for approximately 52 thousand new cases every year. External beam radiotherapy plays an important role in the management of esophageal malignancies in the preoperative setting for operable cases and as a definitive treatment for patients that are not resectable due to medical or technical considerations. Radiation fields are typically defined on Helical Computed Tomography (CT) scan done while the patient is in free breathing which produces significant artefacts and inaccuracies in CT images. The International Commission on Radiation Units and Measurements (ICRU) introduced the concepts of gross tumor volume (GTV), clinical target volume (CTV) and planning target volume (PTV). The GTV and CTV are defined based on oncological principles and should be independent of any therapeutic approach. Thus, determination of the appropriate PTV is important to minimize locoregional recurrence and limit toxicity of normal surrounding tissues. The ICRU report 62 modified the definition of PTV to include: (1) The setup margin (SM) to account for uncertainties in beam alignment and patient position, and (2) The internal target volume (ITV) to account for variations in size, shape, and position of the tumor. Minimization of margins, without sacrificing CTV coverage, is necessary to minimize treatment-related toxicities to the lungs and heart when treating esophageal malignancies. Unnecessarily large radiation therapy (RT) fields increase the risk of radiation pneumonitis and pericarditis in esophageal cancer treated with RT. Conformal RT has the potential of allowing physicians to more precisely target a tumor with RT beams, the more restricted target volume also makes such techniques predisposed to treatment uncertainties, such as inaccurate patient positioning and organ motion. An accurate assessment of esophageal motion is important when determining an appropriate PTV. Physiologic esophageal motion results from the respiratory cycle, cardiac motion, and esophageal peristalsis. Varying reports analysing esophageal motion have shown average anterior and posterior motion ranges from 0.1 to 4 mm, lateral motion from 0.3 to 4.2 mm, and superior-to-inferior motion from 3.7 to 10 mm. An analysis evaluating interfraction esophageal motion in the right–left and AP direction showed average right–left motion of 1.8 ± 5.1 mm (favouring leftward movement) and average AP motion of 0.6 ± 4.8 mm (favouring posterior movement), with an average absolute motion of 4.2 mm or less in the right–left and AP directions. The authors concluded that 12-mm left, 10-mm posterior, and 9-mm anterior margins are appropriate. The study was duly approved by the Institutional Ethics Committee and defined an appropriate margin for planning target volume (PTV) based on internal margin and setup margin so as to ensure that the PTV adequately covers the Clinical Target Volume (CTV) according to the location of tumor. Materials and Methods: Prospectively registered patients of thoracic esophageal cancer after being assessed in the multidisciplinary joint clinic and found to be eligible for radical strategies of radiation treatment either in the neo adjuvant or definitive setting were taken for this study. Patients were divided into categories based on the American Joint Committee on Cancer (AJCC) report into following regions: upper thoracic, mid thoracic, and lower thoracic for assessing the motion. Motion Assessment: 4D CT image acquisition Patients with normal KFT were positioned on thoracic wing board and underwent contrast enhanced CT simulation in free breathing. Following the free breathing CT scan, a four Dimensional CT was performed using the Varian Real-time Position Management (RPM) Respiratory Gating system (Varian Medical Systems, Palo Alto, CA). The CT data set were organized into 10-phase bins of the respiratory cycle, and phase-by-phase evaluation was performed. The 10-phase sets range from 0% to 90% in steps of 10%, with either 0% or 90% as the 0% end inspiratory phase and 50% as the end-expiratory phase. Contouring was done in free breathing scan and 10 phases of 4DCT scan for motion assessment. Motion was assessed in superio-inferior, medio-lateral and anterio-posterior directions manually using 1.00 mm grid and GTV of free breathing scan as reference. Treatment Planning/Target Volumes: CT data sets were imported into the Eclipse radiotherapy treatment planning system (Varian Medical Systems, Palo Alto, CA) using the DICOM-RT protocol for contouring and planning. ICRU-50 and ICRU-62 prescription and nomenclature were utilized for delineation. All available information was utilized to define target volumes including barium studies, upper GI endoscopy and CECT. Consensus guidelines for delineating GTV/CTV as by Wu et al were used. Setup Errors Assessment: Before each treatment, patients were immobilized in the supine position on the treatment table with the same immobilization devices. For all patients Portal image (PI) and Cone Beam CT (CBCT) were acquired on alternate days with minimum of three images in the first week and weekly thereafter for rest of the treatment course. Verification was done using carina and vertebral bodies as surrogates for PI while for CBCT, bone auto-match using clip box for vertebral bodies was used. All errors were calculated on off-line review and PTV margins were calculated using Var Herk's margin recipe (2.5 Σ + 0.7 σ). Results: 10 patients with 84 Portal images and 56 CBCT images were assessed for set-up errors. The PTV margins in Anterio-posterior (Z), Cranio-caudal (Y) and Medio-lateral (X) axis from PI's, were 5.49 mm, 11.35 mm and 13.29 mm respectively, and from CBCT's were 3.26 mm, 8.98 mm and 8.76 mm respectively. 9 patients with 90 image sets corresponding to phase of respiration were assessed for tumor motion using 4 dimensional CT data. The Mean + SD in superior-inferior, anterio-posterior and medio-lateral directions were 3.67+2.43 mm, 1.94+1.23 mm and 2.31+1.49 mm respectively. According to the location of bulk of disease in esophagus the Mean + SD in superior-inferior, anterio-posterior and medio-lateral directions, for upper 1/3rd (3 patients) were 3.00+2.68 mm , 1.61+1.00 mm and 1.78+1.28 mm respectively , for middle 1/3rd (3 patients) were 3.50+2.26 mm , 1.17+0.91 mm and 1.50+1.01 mm respectively and for lower 1/3rd (3 patients) were 4.50+2.51 mm, 3.06+0.98 mm and 3.67+1.26 mm respectively. Conclusion: The set-up errors were well with-in the PTV margins and the variation in PTV margins from PI and CBCT is possibly due to ability to correct rotational motions (Pitch and Roll) better on CBCT than PI. The motion of tumor was maximum in superior-inferior direction and for lower 1/3rd + GE junction tumors.

 > Abstract: 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 Mohanda

PG AHRCC, Cuttack, Odisha, India

Introduction: Concurrent Chemoradiation (CCRT) is the standard of care for locally advanced cervical cancer patients. Addition of chemotherapy to pelvic radiotherapy augments Haematological Toxicity (HT). Whether Bone Marrow Sparing IMRT (BMS-IMRT) will really helps in reducing dose to Bone Marrow as compared to Standard IMRT (SD-IMRT) without compromising the PTV is not clear. Aim: 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. 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: A Prospective Randomized Controlled Comparison of Hypofractionated Radiotherapy with Conventional Radiotherapy in Poor Prognosis High Grade Glioma Top

Rakesh Ranjen

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

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

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

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


  [Table 1], [Table 2]


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