Anshuma Bansal

Human papillomavirus-associated cancers: A growing global problem

Human papillomavirus (HPV) infection is linked with several cancers such as cancer cervix, vagina, vulva, head and neck, anal, and penile carcinomas. Although there is a proven association of HPV with these cancers, questions regarding HPV testing, vaccination, and treatment of HPV-related cancers continue to remain unanswered. The present article provides an overview of the HPV-associated cancers.

Sarcomatoid variant of urothelial carcinoma of the urinary bladder

Sarcomatoid carcinoma of the urinary bladder is a rare presentation. Less than 100 case reports have been published in the literature. It has been considered as an aggressive variant of bladder carcinoma. Though different treatment modalities have been tried in the literature, yet radical cystectomy followed by adjuvant chemotherapy and radiation should be preferred in all patients, in view of high incidence of local and distant metastasis.

Radiotherapy for ovarian cancers - redefining the role.

Radiation therapy in ovarian cancers has been considered an outdated concept for many years, mainly due to toxicity and failure to show benefit in terms of survival. Chemotherapy has been extensively used after surgery for these cancers and it has almost replaced radiation therapy as an adjuvant treatment. Nevertheless, failures in ovarian cancers continue to occur even with the use of newer and effective chemotherapy regimens. About 70% patients demonstrate recurrence in the abdomen or pelvis after first line chemotherapy in ovarian cancers. With advances in technology and sophistication of radiation techniques, along with the molecular and biological knowledge of distinct histological subtypes, there is a need to redefine the role of radiation therapy. This review article focuses on the literature on use of radiation in ovarian cancers and its rationale and indications in the present day. For this, a literature pub med/medline search was performed from January 1975 to March 2014 to redefine the role of radiotherapy in ovarian cancers.

Literature review with PGI guidelines for delineation of clinical target volume for intact carcinoma cervix

For definitive treatment of carcinoma cervix with conformal radiation techniques, accurate target delineation is vitally important, yet a consensus definition of clinical target volume (CTV) remains variable within the literature. The aim of the present article is to review the guidelines for CTV delineation published in the literature and to present the guidelines practiced at our institute. For this a literature pub med/medline search was performed from January 2000 to December 2012 and reviewed to identify published articles on guidelines for CTV primary and pelvic lymph node (LN) delineation for carcinoma cervix. Taking into consideration the traditional bony landmark based fields for treating cancer cervix, the knowledge of the patterns of disease spread and recurrence and the findings from imaging studies identifying typical anatomic distributions of areas at risk of harbouring subclinical disease, the differences in various guidelines have been analyzed and discussed. The CTV in cervical cancer consists of the CTV nodal and CTV primary. In all the published guidelines, CTV nodal consists of common iliac, external iliac, internal iliac, pre-sacral and obturator group of lymph nodes, and CTV primary consists of the gross tumor volume, uterine cervix, uterine corpus, parametrium, upper third of vagina and uterosacral ligaments. The various guidelines differ however, in the definition for these individual component structures. This is the first report to provide the complete set of guidelines for delineating both the CTV primary and CTV nodal in combination.

Conventional four field radiotherapy versus computed tomography-based treatment planning in cancer cervix: A dosimetric study.

Background: With advancements in imaging, wide variations in pelvic anatomy have been observed, thus raising doubts about adequate target volume coverage by conventional external radiotherapy fields based on bony landmarks. The present study evaluates the need for integrating computed tomography (CT)-based planning in the treatment of carcinoma cervix. Aims: To estimate inadequacies in target volume coverage when using conventional planning based on bony landmarks. Materials and Methods: The study consisted of 50 patients. Target volume delineation was done on planning CT scans, according to the guidelines given in literature. The volume of target receiving 95% of prescribed dose (V95) was calculated after superimposing a conventional four field box on digitally reconstructed radiograph. The geographic miss with conventional four field box technique was compared with the CT-based target volume delineation. Results: In 48 out of 50 patients, the conventional four field box failed to encompass the target volume. The areas of miss were at the superior and lateral borders of the anterior-posterior fields, and the anterior border of the lateral fields. The median V95 for conventional fields marked with bony landmarks was only 89.4% as compared to 93% for target delineation based on CT contouring. Conclusions: Our study shows inadequate target volume coverage with conventional four field box technique. We recommend routine use of CT-based planning for treatment with radiotherapy in carcinoma cervix.

High-dose-rate interstitial brachytherapy in early stage oral tongue cancer – 15 year experience from a tertiary care institute

Purpose To determine outcomes of interstitial high-dose-rate brachytherapy (HDR-BT) in patients with early stage oral tongue cancer. Material and methods Ninety-two patients with stage I and II oral tongue cancer were treated with HDR-BT between 1999 and 2014: brachytherapy alone = 62 (67.4%), and combination of external beam radiotherapy (EBRT) and brachytherapy = 30 (32.6%). Median follow-up was 53.5 months. Patterns of failure, overall survival (OS), disease-free survival (DFS), local control rates (LCR), and nodal control rates (NCR) were determined. Results 5-year OS, DFS, LCR, and NCR were 73.2%, 58.2%, 64.2%, and 83.8%, respectively. In total, 43 patients (46.7%) failed treatment: isolated local failures = 28 (30.4%), isolated nodal failures = 8 (8.7%), both local and regional failures = 7 (7.6%). While in T1 stage, 5 year LCR were significantly higher in brachytherapy alone group compared to combined EBRT and brachytherapy group (81.7% vs. 62.5%, p = 0.04), the isolated nodal failure rates were not significantly different among the two groups. For T2 stage, NCR were higher in combined EBRT and brachytherapy group compared to brachytherapy alone (92.9% vs. 74.3%). Acute mucositis (grade ≥ 2) was seen more in brachytherapy alone group compared to the combined modality group (87% vs. 66%), and this correlated significantly with the higher biological equivalent dose (BED) in the brachytherapy alone group. Conclusions Our study recommends treating patients with brachytherapy alone in T1 stage, and demonstrates the need for addressing nodal region either by neck dissection or nodal irradiation in T2 stage patients. Also, the study highlights the need for dose escalation (from the doses used in the study) in both T1 and T2 stage tumors when using interstitial brachytherapy either as sole modality or as a boost.

Impact of Integrating Pet-Ct in Radiotherapy Planning of Non-small CellCarcinoma Lung: Dosimetric and Radiobiological Comparison

The integration of PET and CT scans allows the simultaneous use of biologic and anatomic imaging data for better delineating tumor and sparing normal critical structures. The aim of this study is to assess the impact on target volume delineation using CT vs. PETCT based plans, and to determine radiobiological effect on tumor and normal tissue by comparing Tumor control probability (TCP) & normal tissue complication probability (NTCP) of CT & PET-CT based plans. 15 patients of inoperable NSCLC planned for radical radiotherapy, underwent a planning CT scan of the thorax. Target volumes were contoured. Later PETCT images with the auto contoured MTV (Metabolic target volume) images, were fused with the planning CT images. Margins were similarly given to PETMTV for the generation of PET CTV and PET PTV. 3 Dimensional conformal radiotherapy (3DCRT) plans were made on the planning CT images and the planning PETCT images, and were compared dosimetrically and radio biologically. The study shows that the use of PETCT resulted in significant decrease in PETCT generated MTV versus GTV delineated on CT. Also, there was statistical significant decrease in the volume of the normal lung irradiated in terms of V40 and the MLD. TCP for PETCT based plans was significantly higher than that with CT based plans. Also, PETCT based planning resulted in a statistically significant decrease in the NTCP for lung and spinal cord. Therefore, the study concludes that incorporation of PETCT into radiotherapy planning of NSCLC is technically feasible and dosimetrically appealing strategy for patient treatment.

Pelvic Nodal CTV from L4-L5 or Aortic Bifurcation?—An Audit of the Patterns of Regional Failures in Cervical Cancer Patients Treated with Pelvic Radiotherapy

OBJECTIVE To assess the patterns of recurrence in cervical cancer patients treated with pelvic nodal clinical target volume at L4-L5 junction instead of aortic bifurcation. METHODS Records of patients with locally advanced cervical cancer treated with chemo-radiation were reviewed. Patients treated with standard pelvic fields (superior border of the field at L4/L5 junction), without any radiological evidence of regional lymphadenopathy (<10 mm) were included in the study. The level of aortic bifurcation was retrospectively documented on computed tomography. Patterns of recurrences were correlated to the aortic bifurcation and the superior border of the radiation fields (L4/L5). RESULTS Aortic bifurcation was above the radiation fields (above L4/5) in 82 of 116 (70.7%) patients. Of the nine patients that recurred above the radiation field, 5 (55%) were above L4/5 failures, i.e. between aortic bifurcation and L4/5, and 4 (45%) had para-aortic failures. On retrospective analysis, 16 patients were found to have subcentimeter lymph nodes and higher nodal failures (7/16) were observed in patients with subcentimeter regional lymph nodes at diagnosis. CONCLUSIONS Superior border of nodal clinical target volume should ideally include the aortic bifurcation instead of L4-L5 inter space in patients with locally advanced cervical cancer. Radiotherapy fields need to be defined cautiously in patients with subcentimeter pelvic lymph nodes.

A 60-year-old Indian male with altered sensorium and extensive lymphoma of the scalp.

Primary cutaneous non-Hodgkin lymphoma (NHL) is an uncommon entity, representing 10% of all extranodal NHLs.1 Among all cutaneous sites, the scalp is a rare site of presentation. To date, only nine such cases have been reported in the literature2; most of them, however, were considered as NHL of the cranial vault, rather than primary NHL of the scalp. This report presents a diagnostic dilemma in such a case, and the manifestation from its origin on the choice of final management. We have posed this dilemma to an international multi-disciplinary panel as follows: (1) Did this lymphoma likely start from the scalp or skull vault? (2) How should various treatment modalities (ie, chemotherapy and/or radiation) be sequenced for this patient?

Rare presentation of urachal adenocarcinoma with skip metastasis to colon

Urachal carcinoma is a rare malignancy constituting <1% of bladder malignancies. The disease arises from a malignant transformation of rests of enteric epithelium in the urachus. Most common sites of metastasis are lung, liver, and bone. We report a postoperative case of urachal carcinoma presenting with distant metastasis to lung and skip lesions in colon. As both urachal and colon carcinoma share common histopathological features, most of the literature suggested using chemotherapy regimens similar to those recommended for colon malignancies. There are no randomized trials till date regarding the management of urachal adenocarcinomas except for the primary treatment being surgery.