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Year : 2019  |  Volume : 15  |  Issue : 9  |  Page : 314-318

GC Pant Young Doctor Award

Date of Web Publication28-Nov-2019

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How to cite this article:
. GC Pant Young Doctor Award. J Can Res Ther 2019;15, Suppl S2:314-8

How to cite this URL:
. GC Pant Young Doctor Award. J Can Res Ther [serial online] 2019 [cited 2021 Feb 25];15:314-8. Available from: https://www.cancerjournal.net/text.asp?2019/15/9/314/271707

 > Abstract: If chemoresistance is a harbinger of radioresistance: Can it be circumvented by a hybrid fractionation schedule? Top

Subeera Khan, K. M. Kamble, A. K. Diwan

Department of Radiation Therapy and Oncology, GMCH, Nagpur, Maharashtra, India, E-mail: [email protected]

Background: Concurrent chemo-radiation has withstood the test of time in Locally Advanced Head & Neck Cancer (LAHNC), but factoring in the harsh reality of paucity of Radio-therapy (RT) centers in India, the grassroots situation is far from ideal. The existing RT centers are already overloaded & waiting lists for RT appointments further compound the problem. Sheer disease volume makes Indian T4b quite different from western T4b. Oftentimes, patients with Locally very advanced cancer are started on Induction Chemo-Therapy (ICT) with intent to downsize tumor volume & prevent disease progression until these patients reach an RT centre & get an RT appointment. Although clear guidelines exist for patients who respond to ICT, prognosis of non responders is poor & none of the National & International guidelines actually shed light on managing this subset of patients who fail to respond to ICT. Non-response to ICT is often an indicator of subsequent radio resistance. Objectives: Comparing 2 palliative fractionation schemes- 'Standard' (30 Gy in 10 fractions) versus 'Hybrid' (18Gy in 3 fractions on alternate days in week 1, followed by 10Gy in 5 daily fractions in week 2). Materials and Methods: Prospective randomized controlled unblinded trial. LAHNC patients treated with minimum 2 cycles of TPF were eligible if the disease progressed on ICT. Kaplan-Meier curves for OS& PFS compared by log-rank test. Response rates (RECIST criteria) & Toxicities compared using chi square test. Results: Total 60 patients, 30 in each arm. 15 (50%) in standard arm vs. 28 (93.3%) in hybrid arm achieved a PR (P value=0.0001). More than 70% regression was seen in 7 (23.3%) in hybrid arm vs. 0 (0%) in standard arm (p value<0.0001). Median PFS 2 months in standard arm vs. 4 months in hybrid arm. PFS in hybrid arm was better compared to standard arm (Log Rank test, P value<0.0001). HR for progression 0.3799 (95% CI 0.0797 to 0.3102). Median overall survival was 4.5 months in standard vs. 6 months in hybrid arm (Log Rank test, P value=0.0003). HR for death 0.3799 (95% CI 0.1364 to 0.5002). Conclusion: In comparison to the routinely used fractionation scheme of 30GY/10 fractions, hybrid fractionation offers better response rates, better Quality of life, and potential survival benefits even in the poor prognostic subset of patients failing on ICT. If chemoresistance is predictor of radioresistance, hybrid fractionation overcomes chemoresistance.

 > Abstract: Subjective and objective assessment of quality of life in patients undergoing postoperative radiotherapy for oral cancer Top

Grishma Singh, S. Nangia1, R. Khosa, G. K. Jadhav, S. Manocha, M. Bhadauria, S. Oomen

Department of Radiation Oncology, Indraprastha Apollo Hospital, New Delhi, 1Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India, E-mail: [email protected]

Background: Quality of life (QOL) takes into account the effect of cancer and its treatment on physical, social and psychological aspects of life of the patient. Studies have shown that quality of life has an impact on survival in oral cancer patients. Findings from QOL studies have shown that routine use of QOL instruments in clinical practice has the potential to improve the health status of the patients as well as the quality of care they receive. Two approaches are mainly used for assessment of QOL outcomes, psychometric-based and utility/preference-based. Purpose: To evaluate the impact of multimodality treatment on quality of life and nutritional status of oral cancer patients. Methodology: Thirty consecutive patients who underwent primary surgery for oral cavity cancer and were candidates for adjuvant radiation or chemoradiation were enrolled in the study. University of Washington quality of life questionnaire version 4 (UW-QOLv4) was used for assessment of QOL. Scored Patient-Generated Subjective Global Assessment (PG-SGA) and Body Mass Index (BMI) were used for nutritional assessment. Data collection was done prior to beginning of radiotherapy (baseline), after completion of radiotherapy and 3 months, 6 months and 12 months post radiotherapy. Scoring was done as per the scoring system provided with each questionnaire. Wilcoxon signed rank test was used to test the significance of response of different parameters at different follow ups. Results: Out of 30 oral cancer patients, maximum cases were of buccal mucosa- 47% (N=14), followed by tongue- 37% (N=11), RMT- 10% (N=3), hard palate-3% (N=1) and FOM-3% (N=1). Twenty-nine, eighteen, fourteen and twelve patients were included in statistical analysis after radiotherapy and at 3, 6 and 12 months post radiotherapy respectively, due to patients being lost to follow up and death. More than 60 percent of patients had good score (≥ 70 out of 100) at baseline in all the domains of UW-QOL except activity, recreation, mood and anxiety. Domains of Pain, Appearance, Activity, Recreation, Swallowing, Speech, Taste, Saliva and Mood significantly worsened immediately after radiotherapy (p≤ 0.05). All domains improved at 3, 6 and 12 months post radiotherapy, Activity, Recreation, Mood and Anxiety were significantly better at each follow up compared to pre-radiotherapy levels (p≤ 0.05), while other domains showed non-significant difference with baseline (p>0.05) at subsequent follow ups. PG-SGA showed significant deterioration from baseline after radiotherapy (p< 0.001), with improvement afterwards to reach baseline level at 3 months (p= 0.16). Significant improvement compared to baseline was seen at 6 months (p=0.002) and 12 months (p=0.005) after radiotherapy. No statistically significant difference was seen in BMI at any point of time. Conclusion: QOL as assessed by UW-QOLv4 deteriorated after radiotherapy but gradually improved over time and was better than pre-radiotherapy level after 1 year. Nutritional status as measured by PG-SGA was acceptable post-surgery but deteriorated significantly after radiotherapy, with gradual improvement over 1 year. BMI did not show any significant change, which is attributed to regular dietary counselling done in all our head and neck cancer patients.

 > Abstract: Dosimetric comparision of heart and left anterior descending artery in left breast cancer patients treated by 3-dimensional conformal radiotherapy and intensity modulated radiotherapy Top

Ayush Garg, 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: Radiotherapy for left breast cancer may increase risk of cardiovascular diseases. Radiotherapy guidelines suggest dose-volume constrains for the whole heart but newer trends suggest that excessive dose to the Left Anterior Descending artery (LAD) endothelium may cause cardiac toxicity and henceforth dose constraints to LAD should be evaluated. Purpose: The present study is to assess the dosimetric parameters of heart and LAD in left breast cancer patients treated with 3D conformal radiotherapy and Intensity Modulated Radiotherapy. Methodology: Twenty patients (ten in each) of left-sided breast cancer were treated from Jan to July 2019. Radiotherapy was given to chest wall and regional lymph node areas. Dose given to planning target volume was 50 Gy in 25 daily fractions over 5 weeks. Delineation of target volumes was done according to RTOG protocol. Dosimetric parameters of PTV (D95, D90, Dmean, Conformity Index and Homogeneity Index) along with V20 and mean doses of heart and LAD were evaluated. DVHs were calculated and compared. Results: Dosimetric parameters of PTV were similar for 3DCRT and IMRT, D95 (38.53Gy vs 41.61Gy), D90 (43.67Gy vs 44.77Gy), Dmean (48.3Gy vs 48.72Gy), Conformity index (1.10 vs 1.06) & Homogeneity index (0.50 and 0.28). The Dmean for LAD was significantly higher than heart in both 3DCRT (23.66Gy vs 8.46Gy; p<0.0000) and IMRT (31.53Gy vs 17.7Gy; p<0.0000). The Dmean for LAD was significantly higher than heart in both 3DCRT (23.66Gy vs 8.46Gy; p<0.0000) and IMRT (31.53Gy vs 17.7Gy; p<0.0000). The V25 for LAD was significantly higher than heart in both 3DCRT (40.27Gy vs 14.13Gy; p<0.0024) and IMRT (66.21Gy vs 27.74Gy; p<0.0002). Conclusion: Doses to LAD, rather than heart, should be evaluated to prevent late cardiac toxicities.

 > Abstract: Patient reported health related quality of life and neurocognitive function assessment in patients with high grade glioma Top

Sobin V. Jacob, B. Selvamani, Sunitha Susan Varghese, B. Rajesh, S. Patricia, Anirudha George

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

Objective: To assess the patient reported health related quality of life (HRQOL) and Neurocognitive functioning (NCF) in high grade glioma patients who are willing to have adjuvant treatment after surgery. Methodology: This hospital based observational prospective study was conducted on patients diagnosed with high grade glioma receiving adjuvant chemo-irradiation. Patient reported HRQOL and NCF assessment studies were done at three time points, namely before and after radiotherapy and after adjuvant chemotherapy. Twenty patients were recruited for the study. HRQOL and NCF were assessed using standard questionnaires such as FACT-Br, MMSE scale and MOCA scale. Variation in the scores over the time period of study was documented and compared to assess improvement or decline in the quality of life and neurocognitive status of the patients and to evaluate correlation between HRQOL and NCF. Results and Conclusion: Of the 20 patients 10 (50%) underwent sub-total resection, 9 patients (45%) underwent gross tumour resection and one patient (5%) underwent lobectomy. There was statistically significant improvement in all the aspects of HRQOL (p value <0.0001). The overall results showed that in patients with high grade glioma, post-operative radiotherapy and chemotherapy improves the HRQOL and NCF. The decline in HRQOL and NCF in a post treatment period is directly related to disease recurrence and there is a direct correlation between neurocognition and quality of life.

 > Abstract: Dosimetric comparison of volumetric modulated arc therapy with 3-dimensional conformal radiotherapy in craniospinal irradiation Top

Ajay S. Krishnan, S. Shyama Prem1, K. Saravanan1, V. Parthasarathy1

Department of Radiation Oncology, AIIMS, Rishikesh, Uttarakhand, 1Department of Radiation Oncology, JIPMER, Puducherry, India, E-mail: [email protected]

Background: The complexity of the Craniospinal irradiation, the significant volume of irradiation and the young age requiring high dose of ionising radiation warrants the continuous search and use of better, highly conformal radiation therapy techniques. Despite its theoretical merits, Volumetric Modulated Arc Therapy (VMAT), being a relatively new technique, lacks sufficient data in this niche to be chosen indisputably for the treatment of these cases. Methods: This is an analytical study of two plans: 3D CRT (3 Dimensional Conformal Radiotherapy) and VMAT (Volumetric Modulated Arc Therapy). CT scans of 15 children requiring Craniospinal irradiation were collected both retrospectively and prospectively from our institute. 3D CRT and VMAT plans were made by the same medical physicist well versed in both planning techniques, attempting to achieve the prescribed constraints. The plans made were evaluated for target coverage using Conformity index, Homogeneity index. The doses to Organs at Risk (OARs) were evaluated. Volumetric dose distribution data were collected for the heart, lungs, and kidneys. In addition, the plans were also evaluated for logistical feasibility. Results: VMAT is found to conform to the target significantly better with a huge absolute mean difference. But, 3D CRT is found to give a marginally, but significantly better homogeneous distribution within the PTV. VMAT is found to be able to spare eyes (19% lesser dose), cochlea (31% lesser dose), parotid (33% lesser dose), thyroid (36% lesser dose) and heart (45% lesser dose) significantly compared to 3D CRT. However, lungs (69% lesser dose), and kidneys (71% lesser dose) benefited significantly with 3D CRT. The treatment time (beam on time) and planning time for VMAT are found to be equivalent for the techniques. Another finding that is of utmost importance is the way in which the field junctions were managed by the VMAT technique. Instead of a line junction with 3D CRT which potentially leads to disastrous hotspots, the VMAT technique has a volume overlap in the junction. This volume overlap spreads out the excess dose that may arise due to random errors at the field junction; at the same time preventing any coldspots at the site. The magnitude of the effect depends on the extent of overlap between the fields. Conclusion: We find that VMAT has a significant improvement in conformity and improved sparing in most organs at risk, especially cochlea (which reaches its tolerance dose). Even with all its complexities, we find that VMAT does not tax the workflow of a busy radiotherapy setup significantly, both in terms of machine time as well as planning time. Although not a planned analysis, an additional merit and by far, the strongest case for preferring VMAT in CSI is its use of overlapping junctions for management of the junctions between fields. However, the optimal length of overlap and techniques to improve the linear dose gradient in the overlap region requires further study.

 > Abstract: Single institution retrospective analysis of outcomes for locally advanced rectal cancer treated with neoadjuvant chemo-radiotherapy Top

Rohit Kabre

P.D.Hinduja Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]

Background: Neo-adjuvant chemo-radiotherapy (NACTRT) is universally adopted standard of care in locally advanced rectal cancer- LARC (T3-T4 or node positive disease) management. Purpose: Our aim was to audit the results of treatment, toxicities and predictors of overall survival in the patients treated at our centre. Materials and Methods: Retrospective analysis was performed of patients receiving NACTRT from 2013- 2019. Patients with distant metastatic disease & oligo-metastatic disease who received surgical management or Chemotherapy were excluded. Association between tumor characteristics (histological grade, stage, cranio-caudal length of disease), treatment parameters & pathological response was evaluated. Survival analysis based on pathological response & tumor down staging was conducted. Use of neo-adjuvant or adjuvant chemotherapy, type of surgery performed, overall treatment toxicities and colostomy rate either permanent or temporary according to disease subsite were documented. Statistical analysis was done using SPSS (Version 21) software (IBM, Chicago, IL). Results: Out of total 87 patients who received NACTRT, 79 patients were included in this analysis owing to non-distant metastases status. Majority of the patients were from age group of 41-60 years. Male preponderance 61 (72%), long duration of symptoms history (74.6 % showing more than 12 weeks of symptoms), 23 (27.8 %) patients having family history of malignancy was seen in study cohort. Stage III disease was seen in 55 (69.6%) patients while node positive disease was seen in 62 (70.8%) patients. Six patients received neo-adjuvant chemotherapy before NACTRT while two patients underwent Total Neo-adjuvant therapy before surgical intervention. Majority of patients received long course conventional fractions RT by IMRT-VMAT technique after CT+MRI fusion based simulation. Radical surgery was either low or ultra-low anterior resection in 41 (51.8%) patients while seven patients were inoperable post NACTRT. Complete pathological response (pCR) was observed in 20 (25.3%) while 45 (65.2%) showed tumor downstaging post NACTRT. Time interval to surgery group of ≤ 8 weeks was significantly associated with pCR & tumor downstaging with p=0.033 & p=0.026 respectively. Stage I-II showed better pathological response as opposed to stage III disease (p= 0.032). Kaplan- Meier survival analysis showed at 5 years, Overall survival (OS) rate of 64.4% and local recurrence free survival (LRFS) rate of 72.2%. Both OS & LRFC were significantly higher in patients who showed pCR & tumor downstaging after NACTRT. Adjuvant chemotherapy was indicated in 48 patients (60.7%). One patient died due to grade V gastro-intestinal (GI) toxicity while 10 (12%) experienced grade III-IV diarrhoea & 24 patients (30%) had grade II-III proctitis during treatment. Long term GI complications like bowel urgency, fistula, bowel stricture, stoma complications were seen in 11 (15 %) patients. Genito-urinary complications like renal dysfunction, hydronephrosis, stricture & erectile dysfunction was noticed in 15 (21.5%) patients. Conclusions: Our study reaffirmed efficacy of pre-op NACTRT as upfront standard of care in LARC in Indian population. Time interval to surgery to the tune of ≤ 8 weeks yielded optimal pCR & tumor downstaging which translated into significantly better survival in subgroup.

 > Abstract: Hematological and biochemical changes (liver functions and tumor markers) during and poststereotactic body radiotherapy for hepatocellular carcinoma: An institutional study Top

Shipra Gupta, Hanuman P. Yadav, S. K. Sarin

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

Background: SBRT for unresectable non metastatic HCC is now being supported with growing evidence as a safe and effective treatment approach. High dose per fraction radiation delivered with highly conformal technique has shown to have immunomodulatory effects. Various studies have proposed combining SBRT with immunotherapy. In this study the safety and tolerability of SBRT in terms of systemic toxicity with in 3 months from start of treatment is determined. Purpose: To study the hematological and biochemical parameters over the course of SBRT treatment. And to establish its clinical and dosimetric correlations. Methodology: A total of 27 patients with unresectable and nonmetastatic HCC were treated with stereotactic body radiotherapy (SBRT). Triple phase 4DCT was done for simulation and contouring was done with the generation of internal target volume. Complete blood counts, liver functions and tumor markers, namely Alpha feto protein (AFP) & Protein induced by vitamin K absence-II (PIVKAII) were collected at baselines, during 1st and 2nd week of SBRT, at 1 month and at 3 months of treatment. The dose-volume effect of Spleen was correlated with thrombocytopenia and leukopenia. Students T test and the bivariate correlation analysis was used for the statistical analysis. Confidence interval was set to 95% and p value was set to be significant at <0.05. Results: A total of 14 and 13 patients had child pugh A and B, respectively. The mean dose per fraction delivered was 7.6Gy (3-10Gy) over an average period of 2 weeks. Majority of the patients belonged to staged IV (BCLC –C). There was significant decrease in the lymphocyte count during SBRT at 1st and 2nd week as compared to baseline (p=0.001). The thrombocytopenia and packed cell volume at 2 weeks was correlated with the volume of spleen receiving more than 10 Gy of dose (V10). The mortality rate was correlated with higher mean dose to the spleen. Significant rise of neutrophil to lymphocyte ratio was seen during both the weeks of treatment. AFP and PIVKA II were collected and compared. There was an initial rising trend of AFP during 1st week of treatment which started to fall after 1 month. Levels of PIVKA II were found to fall rapidly from baseline till 2nd week of radiation. No significant changes were observed in liver functions during the radiation course. None of the patients developed radiation induced liver disease. Conclusion: Liver SBRT is safe and is related with only moderate morbidity to the patients. Leukopenia and thrombocytopenia is observed mainly during the course of radiation, which normalizes till 1 month of treatment. AFP levels shows a rise initially and start to decrease till 1 month after radiation unlike PIVKA II which tends to fall at the commencement of radiation.

 > Abstract: Feasibility of intensifying peri-operative chemotherapy with radiotherapy in resectable gastro-esophageal junction and stomach cancer patients at a tertiary cancer care centre and comparison with historic control Top

Siddharth Pant, Shalini Singh, Shagun Misra, Rajneesh Kumar Singh1, K. J. Maria Das, Shaleen Kumar

Departments of Radiotherapy and 1Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Purpose: To ascertain compliance and toxicity of neo-adjuvant chemo-radiotherapy (NACTRT) in potentially resectable carcinoma GEJ and stomach patients and compared with the current standard of treatment at our institute that is, peri-operative chemotherapy in the context of compliance, toxicity and pathological complete response (pCR) rate. Methods: Between 2017-2018 28 patients with resectable stomach and GEJ adenocarcinoma after discussion in multidisciplinary tumor board were enrolled for NACTRT protocol. Treatment comprised of two cycles neo-adjuvant chemotherapy with inj. Cisplatin (@60 mg/m2 day 1) and oral capecitabine (@ 625 mg/m2 bid day 1-21) followed by external beam radiotherapy (EBRT) 45Gy/25# along with concurrent oral capecitabine (@ 850 mg/m2 bid day 1-5 on RT days only). Post EBRT a diagnostic CECT (abdomen and pelvis) was done to assess response and to rule out any asymptomatic progression. Those deemed fit were taken up for surgery following which patient received adjuvant chemotherapy for another 3 cycles. Peri-operative chemotherapy patients treated between 2015-2018 (n =65) were taken up for comparative analysis. Chemotherapy protocol was similar to pre-op strategy with only minor addition of a third drug. ECX (Epirubicin @ 50 mg/m2, Cislplatin @60 mg/m2, Capecitabine @ 625 mg/m2). Statistical methods for comparative analysis comprised of demographics with special focus on compliance and treatment toxicity for each treatment strategy. The cut-off date for all time-to event analyses was 1st September 2019. Results: The median age of patient receiving NACTRT was 56 years (20-73) with male predominance 85%. 1/3rd of the patient had >10%weight loss of the usual body weight. 54% (n=15) patients had Siewert type II/III disease. 90% (n =25) of the patients completed the planned NACT without dose reduction. 2/3rd (n=18) patients received NACTRT while <50% (n=12) patients eventually went for surgery. The major reason for drop outs between subsequent treatments was tumor progression (35%, n =10) both before and after NACTRT. Among those who underwent radical surgery, primary tumor and nodal disease down staging was observed in nearly all patients with 1/4th achieving pCR. Chemotherapy was well tolerated with <10% patients had grade 3 or 4 hematologic toxicity while <5% patients had diarrhea or vomiting requiring intravenous fluids. At a median follow-up of 12 months, 60% of the patients were still alive with an estimated median OS of 22 months. In comparison with the peri-operative chemotherapy patients, the demographics and clinical parameters were similar except these patients had predominantly stomach cancer (80%, n= 52). 90% (N= 55%) patients completed the planned 3 cycles of NACT with more patients (1/5th) requiring dose reduction between subsequent cycle however, grade 3 or 4 hematological or gastrointestinal toxicity were similar in both the groups. Number of patients undergoing radical surgery was similar (Peri-op chemotherapy 38% (25/65); NACTRT 39% (11/28)) however, pCR rate was lower in the peri-op setting 16% (n=4) with a relatively inferior median OS 16 months at a median follow-up of 29 months. Conclusion: We observed encouraging pCR rates with NACTRT while compliance and toxicity were similar in both the groups. NACTRT is feasible with a multidisciplinary team approach and cautious patient selection.

 > Abstract: Efficacy and toxicity of stereotactic radiotherapy for advanced hepatocellular carcinoma: Results from a clinical audit Top

Rishabh Kumar, Hanuman Prasad Yadav, S. K. Sarin, Deepak Thaper, Rose Kamal

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

Introduction: HCC is the 4th most common cause of cancer related death and is often complicated with portal vein tumor thrombosis (PVTT). There is no consensus in the management of HCC with PVTT, the west offer systemic therapy only while in Asia locoregional treatment is also given along with systemic treatment. In this study we evaluated the outcomes of stereotactic radiotherapy (SBRT) in the treatment of unresectable HCC that are unsuitable for, or refractory to other liver-directed therapies. Methods: Between May 2018 and September 2019, patients with primary unresectable HCCs refractory to or unsuitable for treatment with other liver-directed therapies were treated with SBRT. Patients of Child status A5-B7 and with normal liver reserve ≥ 700cc were preferred. Local control (LC), overall survival (OS), progression free survival (PFS), time to tumor progression and effect of prognostic factors were analysed. Results: 25 patients with inoperable HCCs were treated. 88% of them had PVTT, The median tumour diameter was 8.6cm (5-14) and median tumour volume was 275 cc (75-930). The median SBRT dose prescription was 48Gy (35-50Gy in 5 to 6 fractions). The 1 year LC, PFS and OS rate was 95%, 53.4% and 60% respectively. There were a total of 8 progression events and the most common form of failure was out of field liver progression. The median time to progression was 2 months (1-4) and the median progression free survival was 14 months. The most common form of toxicity was grade 3 lymphocytopenia and the incidence of Radiation induced liver disease was 8%. Also, tumours with GTV < 350cc volumes had a better OS and PFS when compared to GTV of greater than 350 cc. Conclusion: SBRT for advanced HCC is safe and results in excellent local control. Early and high rate of out of field progression highlights the need of adjuvant systemic treatment following SBRT in this cohort. Further trials of combined modality management in advanced HCC complicated with PVTT are warranted.

 > Abstract: Swallowing outcomes in re radiation for second primary and recurrent head neck cancers Top

Carlton Johnny, Sarbani Ghosh Laskar, Ashwini Budrukkar, Naveen Mummudi, Monali Swain

Tata Memorial Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]

Background: Re irradiation (Re RT) in recurrent/second primary head neck cancers has been used judiciously and have varied success. Complication rates after re irradiation vary from 7% to 50% with increased complications when the target is in close proximity to critical organs. In patients receiving re irradiation for head neck cancer, aggressive treatment can significantly affect breathing, swallowing, speech or physical appearance. In patients receiving Re RT, Quality of life (QOL) related to swallowing is already impaired due to prior therapies and there is paucity of data regarding swallowing outcomes, dose constraints and prognostic factors for morbidity. The aim of the present study is to fill this missing gap in the available literature. Methods: All patients of recurrent or second primary head neck cancers planned for radical radiotherapy were eligible for the study. At baseline a detailed history of previous cancer related treatment was obtained. Swallowing function was assessed subjectively using the EORTC QLQ C30, HN35 questionnaire and objective assessment was done using Functional oral intake scale (FOIS), Leipzig Pearson (LP) scale at baseline, radiotherapy conclusion, subsequent follow-ups. The Dysphagia aspiration related structures (DARS) were delineated on the planning CT images and dosimetry was obtained. NTCP was calculated using biological modeling with Equivalent Uniform Dose (EUD). Results: Totally 52 patients were included in the study. Oral cavity was the most common site with 45 patients (85%) and 77% of the patients had surgical intervention prior to Re radiation. The median Re Radiation dose was 60Gy (IQR 60-64Gy) and median Re Radiation No of fractions were 30 (IQR 30-32). Median Re Radiation overall treatment time was 44 days (42-48 days). Median PTV volume was 480 (304-608.7) cc. 54.9% had a feeding tube at baseline, but on the first follow-up feeding tube rates were only 25.8%. The QOL domain score and swallowing scores are given in the [Table 1] below. The NTCP for TD 47, TD 50 are 25.1% and 3.7%. the EUD for TD 47, TD 50 are 42Gy, 40.8Gy. Logistic regression analysis showed a significant correlation of DARS V30, V40, V50 with the presence of feeding tube at first follow-up. There was also a significant correlation between the DARS V30, V40, V50, Mean dose and PTV volume with the 1st follow-up HNSW QOL score. Conclusion: There is a definite impact of Re Irradiation on the Quality of Life. There is an initial decline in the Quality of Life scores post Re Radiation due to the acute symptoms but there is a return to baseline score for the Global QOL score and the Head Neck Coughing (HNCO) on follow-up. There is a correlation between the DARS V30, V40, V50, Mean dose and PTV volume with worst Head Neck Swallowing Quality of Life score. There is also a significant correlation between the DARS V30, V40, V50 and presence of feeding tube at first follow-up.
Table 1: Quality of life and swallowing assessment scores

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 > Abstract: Great vessel motion mapping from four dimensional magnetic resonance imaging to three dimensional computed tomography - Implications for Oligo metastatic spinal stereotactic body radiotherapy vessel constraint Top

Bhavya Patneedi, H. Vyas, S. Vangipuram, A. Bhange, P. Bhaskar, K. Samy

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

Purpose and Objective(s): 4DMRI imaging offers good soft tissue details & a real time motion assessment. We hypothesize that the actual volume of the aorta and the dose received by it would be more than what it seems on a static planning CTimage due to the dynamic pulsatile motion of the great vessel. In this study, we made an effort to quantify the volume and dose variations of the aorta with the volumes marked on planning CT scan Vs 4DMRI scan based PRV generation in cases of oligo metastatic spine SBRT. Materials and Methods: Five patients of oligo metastatic spine SBRT (Lumbar2; Dorsal3) were chosen for this study. All patients underwent planning CT scan using deep inspiratory breath hold (DIBH) technique with RPM device. All patients underwent 4DMRI scan sequences (FIESTA 4chamber view, contrast LAVA, DEFFICO sequences) using pulse gated technique with breath holding in the treatment planning position on 1.5T MRI machine. Breathhold 4D MR Scan mitigates respiratory motion and allows us to capture true pulsatile motion. Aorta was delineated in 2 clinical contexts (1) Aorta MRI: Aorta delineated in one of the 4DMRI bins (4 chamber view) was deformably propagated onto the rest of the bins using intensity based deformable registration algorithm software and the PRV for the aorta was generated. The PRV Aorta MR volume was registered with BH CT Scan and contours were mapped. (2) Aorta CT: On static BH planning CT scan. The target volume and all other OARs were contoured on the Planning CT scan and transferred to TPS for planning The target coverage parameters and OAR constraints were achieved as per RTOG protocol. The PRV Aorta volumes on MRI and CT along with the D max and Threshold dose received by the respective PRV Aorta (Aorta MRI & Aorta CT) where assessed. These parameters were analyzed using Paired sample t test in SPSS software. Results: The median motion of aorta due to its pulsations was 2 mm (Range 12.5 mm). The PRV Aorta Volumes in MR were significantly more compared to CT (p value0.008). Similarly, the D max and threshold dose received by the PRV Aorta MR as compared to CT were more and were statistically significant (p Value 0.05 and p Value0.008 respectively). Conclusion: We noticed statistically significant change in the volumes and doses (max and threshold) of aorta contoured on 4DMRI vs Planning CT scan. As the tolerance limit of great vessel (aorta) for single fraction spine SBRT is higher than the maximum doses delivered to the target, these results may not hold any significance but this study may form a basis for future studies of SBRT in abdominal malignancies close to great vessels in terms of dose fluctuations due to their pulsations. This is the first study reported in literature and proofofconcept to map the 4D MR motion on the 3D CT datasets & analyse the dose deformations.


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