Ahmed Nadeem Abbasi

Plan Dose Evaluation of Three Dimensional Conformal Radiotherapy Planning (3D-CRT) of Nasopharyngeal Carcinoma (NPC): Experience of a Tertiary Care University Hospital in Pakistan

BACKGROUND Radiation therapy is the mainstay of treatment for nasopharyngeal carcinoma. Importance of tumor coverage and challenges posed by its unique and critical location are well evident. Therefore we aimed to evaluate our radiation treatment plan through dose volume histograms (DVHs) to find planning target volume (PTV) dose coverage and factors affecting it. MATERIALS AND METHODS This retrospective study covered 45 histologically proven nasopharyngeal cancer patients who were treated with definitive 3D-CRT and chemotherapy between Feb 2006 to March 2013 at the Department of Oncology, Section Radiation Oncology ,Aga Khan University Hospital, Karachi, Pakistan. DVH was evaluated to find numbers of shrinking field (phases), PTV volume in different phases and its coverage by the 95% isodose lines, along with influencing factors. RESULTS There were 36 males (80%) and 9 females (20%) in the age range of 12-84 years. Stage IVA (46.7%) was the most common stage followed by stage III (31.1). Eighty six point six-percent received induction, 95.5% received concurrent and 22.2% received adjuvant chemotherapy. The prescribed median radiation dose was 70Gy to primary, 60Gy to clinically positive neck nodes and 50Gy to clinically negative neck regions. Mean dose to spinal cord was 44.2Gy and to optic chiasma was 52Gy. Thirty seven point eight-percent patients completed their treatment in three phases while 62.2% required four to five phases. Mean volume for PTV3 was 247.8 cm3 (50-644.3), PTV4 173.8 cm3 (26.5-345.1) and PTV5 119.6 cm3 (18.9-246.1) and PTV volume coverage by 95% isodose lines were 74.4%, 85.7% and 100% respectively. Advanced T stage, intracranial extension and tumor volume >200 cm3 were found to be important factors associated with decreased PTV coverage by 95% isodose line. CONCLUSIONS 3D CRT results in adequate PTV dose coverage by 95% isodose line. However advanced T stage, intracranial extension and large target volume require more advanced techniques like IMRT for appropriate PTV coverage.

Comment on: Are we training the next generation of proficient Radiation Oncologists, or just better examination candidates?

Dear Editor, Our team of residents and faculty of Radiation Oncology, Aga Khan University, have read with interest, your editorial in June 2016 issue. We wish to vouch and acknowledge the comments made by Turner et al. with reference to the Kleiven et al.’s survey. Our team agrees with points made by the authors, but in the context of post graduate training programmes in developing countries, the issue of nurturing a patient centred carer, proficient Radiation Oncologist rather than just an examination candidate becomes more pertinent and detrimental. In the absence of robust regulatory systems pertaining to continuing medical education (CME) and practice privilege documentation after passing the post graduate exit exam, we strongly recommend peer-reviewed, site-specialized Radiation Oncology practice. It may not be as vitally important and detrimental in developed countries with established healthcare systems. We wish to further add to Turner et al.’s comments that more emphasis should be given to the establishment of regular end of term assessments. In our residency programme, we are conducting theory, viva voce and Objectively Structured Assessment of Technical Skills (OSATS) on three-monthly basis and we offer reassessment to all those residents who are not able to secure 60% score in any of the components. The promotion of a resident in the subsequent training year is dependent on his/her success in the annual assessment. We strongly agree with Turner et al. that passing exam should not be considered as the final goal. Radiation Oncology is a very quality conscious discipline of medicine. After passing the exit exam, peerreviewed, site-specialized practice can ensure safety and quality of radiation treatment planning and delivery. We involve our residents in the tasks and assignments of clinical quality indicators and they are active participants of our quality improvement and site-specific multidisciplinary tumour board meetings. We believe and work on pre-defined learning objectives which are helping us in achieving international post graduate training standards. Our programme is regularly reviewed by internal and external audit systems including the JCIA (Joint Commission International Accreditation). In a recent published report, resident’s involvement in quality improvement projects has proven to be beneficial for Radiation Oncology training and service. After passing the examination, robust continued professional development programmes comprising of learning objective-based formal structured processes is the answer to this issue. The Exit examination can be regarded as an important milestone in postgraduate specialist training. However, it cannot be considered as the final destination of a carer who considers himself or herself as a part of multidisciplinary site-specific team. It is a matter of nurturing patient-centred care provider who considers himself or herself as a team member of a site-specialized multidisciplinary team. The inclusion of quality and ethical Radiation Oncology practice should be considered an integral part of structured curriculum and assessment of all Radiation Oncology residency programmes. All the above-mentioned points are equally valid in case of Medical Physics and Radiation Therapy Technologist (RTT) training programmes. Complete professional training before exit exams of all three disciplines is vitally important in both developed and developing countries.

Correspondence on the article: “Patients treated with neoadjuvant chemotherapy + radical surgery + adjuvant chemotherapy in locally advanced cervical cancer: long-term outcomes, survival and prognostic factors in a single-center 10-year follow-up”

Our team has gone through this article authored by Luvero et al. [1]. Certainly, 10-year follow-up of 90 cervical cancer patients is an impressive long-term follow-up. In this study, authors reported a negative correlation for involved nodes and outcome and also mentioned that site of involved nodes is not related to survival. Our team is inclined to disagree with this statement. In one study by Kidd et al. [2], it was reported that on PET/CT imaging the more distant level of nodal involvement was associated with poor survival. In another study by Paumier et al. [3], three-year survival was 58 and 24 % in patients without and with paraaortic lymph node involvement, respectively. These patients were staged by PET/CT. It is reported in this series that patients with parametrial invasion had poor survival as compared to those without parametrial invasion. It is understandable that in these patients local failure remains a major problem if not offered adjuvant chemoradiotherapy. We do agree with authors that systemic relapse remains a major challenge, and to cope with this issue various ongoing clinical trials are investigating the role of adjuvant chemotherapy. Internationally accepted standard of care for the management of locally advanced cervical cancer is concurrent chemoradiotherapy, but authors have not mentioned the selection criteria of offering chemotherapy and surgery followed by chemotherapy. There are evidences in the literature published on this issue in favor of chemoradiation therapy followed by adjuvant chemotherapy [4]. Overall survival reported in this study is almost the same as reported in contemporary chemoradiation therapy series. Seventy percentage of patients in this series were having tumor size less than 4 cm and probably could be assigned as having low risk of distant metastases and were in any case candidates for surgery [1]. We would request the authors to consider sharing their exclusion and inclusion criteria which they have adopted in this study. This information would help us and other readers in drawing meaningful inferences from this commendable effort.

Implementation of quality medical physics training in a low‐middle income country — sharing experience from a tertiary care JCIA‐accredited university hospital

To the Editor: Our team wishes to share with the readers of a medical physics journal our experience of establishment of a two-year radiation oncology physics postgraduate training program. Our purpose of sharing this experience is to encourage medical physics colleagues to come up with innovative ideas and to take up this challenge of improving the quality of medical physics training in order to improve the overall health-care quality of professionals involved in the radiation oncology services of cancer patients in countries like Pakistan. The Aga Khan University (AKUH), Pakistan’s first private international university, is committed to the provision of education, research, and health care of international standard relevant to Pakistan and the region. In line with this vision, the University Hospital has established a state-of-the-art Radiation Oncology facility. AKUH is the only hospital in Pakistan, and one of the few teaching hospitals in the world, to be awarded Joint Commission International (JCI) accreditation for achieving and maintaining highest international quality standards in health care. AKUH has also received the ISO 9001:2008 certification. In the specialty of radiation oncology, medical physicists play an imperative role. They are skilled professionals with multidisciplinary responsibilities including, but not limited to, radiation safety, treatment planning, treatment delivery, and quality assurance in radiation therapy. A number of new modern radiotherapy units, such as Gamma Knife, Cyber Knife, Varian Trilogy, Elekta Synergy, have recently been installed in Pakistan and especially in Karachi. This makes the deficiency of skilled medical physicists even more critical in private sector. The AKUH has taken the initiative of ‘capacity building’ locally, with the help of international expertise, by establishing a two-year Certificate Program in Medical Physics specializing in radiation therapy to meet the emerging needs of quality radiation therapy.

Chemoradiation and the Role of Adjuvant Chemotherapy in Lymph Nodal–Metastatic Cervical Cancer

Purpose To report the long-term outcome in lymph nodal–metastatic cervical squamous cell cancer after chemoradiation followed by adjuvant chemotherapy. Patients and Methods Between 2010 and 2013, five patients were diagnosed with advanced cervical cancer with clinically involved para-aortic lymph nodes (ie, International Federation of Gynecology and Obstetrics stage IVB). These patients were treated with concurrent chemoradiation therapy followed by adjuvant chemotherapy. Concurrent chemoradiation consisted of cisplatin given once per week concomitantly with extended-field radiation therapy followed by high-dose-rate brachytherapy. Adjuvant chemotherapy comprised four courses of carboplatin and paclitaxel given every three weeks. The primary outcomes were local and distant failures. Results None of the patients had local recurrence or distal failure after a minimum follow-up time of 3 years. Conclusion Adjuvant chemotherapy after chemoradiation has a probable role in the management of lymph nodal–metastatic cervical cancer.

Glioblastoma Multiforme Involving Conus Medullaris in a Child

Primary spinal cord glioblastoma multiforme involving the conus medullaris is an uncommon entity with poor outcomes. An aggressive multimodality treatment approach has been used, but prognosis remains same. There are no guidelines for the treatment of patients with spinal glioblastoma multiforme (GBM). We highlight the case of a child diagnosed with conal GBM. He was treated with definitive surgery followed by adjuvant concurrent chemoradiation. After completion of treatment, he showed a temporary symptomatic improvement, but later on his condition deteriorated. We elaborate the stepwise treatment approach employed in this patient.

Hidradenocarcinoma: Five Years of Local and Systemic Control of a Rare Sweat Gland Neoplasm with Nodal Metastasis

Hidradenocarcinoma is a rare and locally aggressive tumor rendering a poor prognosis. Furthermore, very few cases present with nodal metastasis. Diagnosing such an entity, and then differentiating it from a benign counterpart, poses a great challenge to the clinicians. There are no established treatment guidelines for the management of this disease, particularly in patients with nodal involvement. We present a case of a young male who was diagnosed with hidradenocarcinoma of the scalp, along with a neck swelling. A thorough diagnostic evaluation was done with endoscopy, pathological, and radiological investigations. He was successfully treated with resection of the scalp lesion and right-sided neck dissection followed by adjuvant concurrent chemoradiation. He remains free of any local and distant disease after five years of regular follow-up.

Extramedullary plasmacytoma: rare neoplasm of parotid gland

A 45-year-old man presented with left-sided facial swelling. Initial excisional biopsy was done somewhere else without prior imaging and it came out to be pleomorphic adenoma; local imaging after biopsy showed mass over the left parotid gland with ipsilateral lymphadenopathy. On examination, there was a well-circumscribed mass with signs of left facial nerve palsy. He underwent left radical parotidectomy with ipsilateral modified radical neck dissection, and per operatively, it came out to be neoplastic lesion. Final histopathology was plasma cell neoplasm of the parotid gland. After surgery, the patient received radiation therapy to the left parotid region on account of uncertain surgical margins. It has been 3 years down the road that there is no evidence of local recurrence or transformation into multiple myeloma. Available evidence reveals that mere surgery for extramedullary plasmacytoma is not enough for local control whenever there is doubt of residual disease consider radiation therapy.

Role of metastasectomy and chemotherapy in carcinoma of uterine cervix

Squamous cell carcinoma of uterine cervix is potentially a curable disease; however, many patients treated with definitive chemoradiotherapy develop distant metastases, with few of them having a single metastatic deposit. There are no guidelines for the treatment of patients with oligometastatic cervical cancer. We present a case of a patient with International Federation of Gynecology and Obstetrics (FIGO) Stage IIB squamous cell carcinoma of uterine cervix. She was successfully treated with concurrent chemoradiotherapy with definitive intent. One year later, she developed a solitary pulmonary nodule for which she underwent resection followed by chemotherapy. She is free of any local or distant disease at 5 years of regular follow-up.

Correspondence on review article published in Oral Oncology (Vol. 59, August 2016): “Evaluation of the benefit and use of multidisciplinary teams in the treatment of head and neck cancer.”

http://dx.doi.org/10.1016/j.oraloncology.2016.08.023 1368-8375/ 2016 Published by Elsevier Ltd. To the Editor: Our team has read with interest the article published in Oral Oncology [1]. This review has mentioned facts pertaining to Multidisciplinary Teams (MDT) functions in the treatment of head and neck cancer (H&N Ca). We are practicing in the region classified under the category of Lower and Middle Income (LMI) countries as per World Health Organization stratification based on Gross National Income [2]. H&N Ca is most prevalent malignancy in Pakistan [3]. Although we do not have hard core published data to quote, but our clinical experience and raw published data are showing that patients present to us in clinic with locally advanced stages [4]. The clinical behavior of these tumors tends to be more aggressive and much faster in pace than quoted in western literature. This published review highlights the importance of MDT culture, which is quite well established in countries where strong health care policies are being implemented by the state. The authors have covered goals, benefits, outcome and costing of MDT in H&N Ca [1]. From the perspective of LMI countries, the health care policies are not as robust and established as they are in countries mentioned in this review. Our university based hospital acts as hub for the whole country and patients from neighboring countries are also seen and treated here which gives us exposure to various clinical scenarios. We see locally advanced tumors of every site of head and neck region. Intracranial extension of nasopharyngeal carcinoma is also a prevalent feature [5]. We wish to share our experiences of treating H&N Ca at our tertiary care university hospital where we had established a weekly site specific H&N Ca MDT in February 2007. Our MDT consists of a minimum of five core members namely Surgeon, Radiation Oncologist, Medical Oncologist, Pathologist and Radiologist. Differing in opinion from Licitra et al. [1], cost constraints and resource allocation are major detrimental factors in founding site specific MDT tumor boards in LMI countries. We are of the belief that determination and commitment of the core members are essential in establishing MDT. Our H&N Ca MDT tumor board is effectively functioning without any allocation of finances. Furthermore, the same approach facilitated us to establish different site specific MDT tumor boards in our institute. In our team’s opinion, MDTs are a lifeline for our patients [6], as we cannot afford to miss the opportunity of discussion among specialties due to danger of sub optimal treatment plan. Organ preservation can only be offered to those patients who are discussed in MDT tumor boards before the commencement of first modality of treatment. We are witnessing a positive change in our country after the establishment of site specific MDTs [7]. We strongly believe that costing is not as important as the quality of treatment and in our circumstances, the discussion of every case in site specific MDT ensures the best management plan.