Asim Hafiz

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.

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.

Postgraduate Training in a Low- and Middle-income Country: Sharing Experience from a Joint Commission International Accreditation-accredited University Hospital

Madam d Our team of residents and faculty of radiation oncology, Aga Khan University, read the article published in your journal with interest [1]. Pakistan, like other lowand middle-income (LMI) countries, needs modern equipment and trained professionals [2]. We are working in a tertiary referral university hospital and our programme is regularly reviewed by internal and external audit systems, including the Joint Commission International Accreditation (JCIA). We are continuously taking steps through audits for training evaluation [3]. Radiation oncology is a quality conscious discipline. Doctors, physicists and radiation therapy technologists (RTT) are integral and crucial components of this service. However, like many countries, in Pakistan they are not getting the deserved recognition as health care providers. In the absence of robust regulatory systems pertaining to continuing medical education and practice privilege documentation, we strongly recommend peer-reviewed, sitespecialised practice [4]. We involve our postgraduates in quality initiatives, like clinical quality indicators, and they are active participants of site-specific tumour boards [5]. We believe and work on pre-defined learning objectives, which are helping us to achieve international postgraduate training standards. We have developed our syllabus as recommended by the International Atomic Energy Agency for LMI countries [6]. We are carrying out end of term briefing sessions to review the progress of structured training. In order to overcome a shortage of qualified teachers in our country, monthly activities are organised for all trainees in the city, in which learning objective-based interactive learning sessions are conducted by qualified faculty of radiation (oncologist/physicist) on a voluntary basis. This strategy is also helping us to develop collegiality among colleagues of other cancer units. Regular web-based sessions from qualified foreign consultants are also part of this

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.