Gaurav Bahl

Primary Diffuse Large B-Cell Lymphoma of the Tonsil Is a Higher Radiotherapy Dose Required?

The purpose was to evaluate the prognostic factors and treatment outcome of Indian patients with primary diffuse large B‐cell lymphoma (DLBCL) of the tonsil treated at a single institution.

NASOPHARYNGEAL CARCINOMA IN CHILDREN: COMPARISON OF CONVENTIONAL AND INTENSITY-MODULATED RADIOTHERAPY

PURPOSE To evaluate the efficacy of intensity-modulated radiotherapy (IMRT) in reducing the acute toxicities associated with conventional RT (CRT) in children with nasopharyngeal carcinoma. PATIENTS AND METHODS A total of 36 children with nonmetastatic nasopharyngeal carcinoma, treated at the Tata Memorial Hospital between June 2003 and December 2006, were included in this study. Of the 36 patients, 28 were boys and 8 were girls, with a median age of 14 years; 4 (11%) had Stage II and 10 (28%) Stage III disease at presentation. All patients had undifferentiated carcinoma and were treated with a combination of chemotherapy and RT. Of the 36 patients, 19 underwent IMRT and 17 underwent CRT. RESULTS After a median follow-up of 27 months, the 2-year locoregional control, disease-free, and overall survival rate was 76.5%, 60.6%, and 71.3%, respectively. A significant reduction in acute Grade 3 toxicities of the skin (p = 0.006), mucous membrane (p = 0.033), and pharynx (p = 0.035) was noted with the use of IMRT. The median time to the development of Grade 2 toxicity was delayed with IMRT (skin, 35 vs. 25 days, p = 0.016; mucous-membrane, 39 vs. 27 days, p = 0.002; and larynx, 50 vs. 28 days, p = 0.009). The duration of RT significantly influenced disease-free survival on multivariate analysis (RT duration >52 days, hazard ratio = 5.49, 95% confidence interval, 1.14-26.45, p = 0.034). The average mean dose to the first and second planning target volume was 71.8 Gy and 62.5 Gy with IMRT compared with 66.3 Gy (p = 0.001) and 64.4 Gy (p = 0.046) with CRT, respectively. CONCLUSION The results of our study have shown that IMRT significantly reduces and delays the onset of acute toxicity, resulting in improved tolerance and treatment compliance for children with nasopharyngeal carcinoma. Also, IMRT provided superior target coverage and normal tissue sparing compared with CRT.

Perioperative Interstitial Brachytherapy for Soft Tissue Sarcomas: Prognostic Factors and Long-Term Results of 155 Patients

BackgroundThe goal of this study was to evaluate the efficacy of temporary interstitial brachytherapy (BRT) for patients undergoing combined modality management of soft tissue sarcomas (STS).MethodsFrom January 1990 to December 2003, 155 adults 18–88 years of age (median = 42 years) with STS who had received BRT as part of locoregional treatment were included in this review. Sixty-four percent were males. Sixty-nine percent had primary lesions. Sixty percent had lesions involving the lower extremities. Spindle cell sarcoma (28%) and synovial sarcoma (16%) were the most common histologic types and 51% had grade III lesions. Treatment included wide local excision of primary tumor with BRT with or without external beam radiotherapy (EBRT).ResultsAfter a median followup of 45 months, the local control (LC), disease-free survival (DFS), and overall survival (OS) for the entire cohort was 71%, 57%, and 73%, respectively. DFS was superior for superficial tumors compared with that for deep tumors (96% vs. 54%, P =.02). Patients with a tumor less than 5 cm had superior OS (88% vs. 63%, P =.05). Cumulative radiotherapy dose greater than 60 Gy had a significant positive impact on LC (P = .003), DFS (P =.003), and OS (P =.048). Subcutaneous fibrosis (21%) was the major complication.ConclusionsTemporary perioperative iridium-192 interstitial BRT with or without EBRT after function-preserving surgery results in satisfactory outcome in patients with STS. Both low dose rate and high dose rate BRT are equivalent in terms of disease control and complications when used alone or in combination with EBRT. BRT results in fewer complications compared with the combination of BRT and EBRT.

Prognostic Factors and Outcome in Askin-Rosai Tumor: A Review of 104 Patients

PURPOSE To evaluate the prognostic factors and treatment outcome of patients with Askin-Rosai tumor of the chest wall treated at a single institution. METHODS AND MATERIALS Treatment comprised multiagent chemotherapy and local therapy, which was either in the form of surgery alone, radical external-beam radiotherapy (EBRT) alone, or a combination of surgery and EBRT. Thirty-two patients (40%) were treated with all three modalities, 21 (27%) received chemotherapy and radical EBRT, and 19 (24%) underwent chemotherapy followed by surgery only. RESULTS One hundred four consecutive patients aged 3-60 years were treated at the Tata Memorial Hospital from January 1995 to October 2003. Most (70%) were male (male/female ratio, 2.3:1). Asymptomatic swelling (43%) was the most common presenting symptom, and 25% of patients presented with distant metastasis. After a median follow-up of 28 months, local control, disease-free survival, and overall survival rates were 67%, 36%, and 45%, respectively. Median time to relapse was 25 months, and the median survival was 76 months. Multivariate analysis revealed age ≥18 years, poor response to induction chemotherapy, and presence of pleural effusion as indicators of inferior survival. Fifty-six percent of patients with metastatic disease at presentation died within 1 month of diagnosis, with 6-month and 5-year actuarial survival of 14% and 4%, respectively. CONCLUSION Primary tumor size, pleural effusion, response to chemotherapy, and optimal radiotherapy were important prognostic factors influencing outcome. The combination of neoadjuvant chemotherapy, surgery, and radiotherapy resulted in optimal outcome.

Interstitial brachytherapy for childhood soft tissue sarcoma.

To evaluate the efficacy of interstitial brachytherapy (BRT) in children undergoing combined modality treatment for soft tissue sarcomas (STS).

Primary non-Hodgkin's lymphoma of the nasopharynx: prognostic factors and outcome of 113 Indian patients.

This single institutional study evaluated the prognostic factors and treatment outcome of 113 Indian patients with primary nasopharyngeal non-Hodgkins lymphoma. At presentation, 28% had stage I and 62% had stage II disease. Treatment comprised of a combination of chemotherapy (CTh) and radiotherapy (RT) in the majority of the patients (76%). After a median follow-up of 56 months, the 5-year disease-free survival (DFS) and overall survival (OS) for the whole group were 55.8% and 57.9%, respectively. Multivariate analysis showed that; age > 30 years [hazard ratio (HR) = 6.59, 95% confidence interval (CI) = 2.59 – 16.7, P < 0.0001], WHO performance score ≥ 2 (HR = 2.34, 95% CI = 1.01 – 5.46, P = 0.050), T-cell lymphomas (HR = 2.81, 95% CI = 1.14 – 6.96, P < 0.001) and the presence of B symptoms (HR = 3.65, 95% CI = 1.77 – 7.53, P = 0.025), had a negative influence on survival. Patients treated with a combination of CTh and RT had a significantly better outcome than those treated with CTh alone (OS: 69%vs. 31%, P < 0.00001). HR for death in the CTh alone group was 3.73 (95% CI = 1.95 – 7.13). The CR (P = 0.01), DFS (P = 0.01) and OS (P = 0.03) rates were significantly better for patients receiving a RT dose of ≥4500 cGy. HR in the subgroup that received a RT dose of <4500 cGy was 2.51 (95% CI = 1.04 – 6.06). These results suggest that combined modality treatment, comprising of CTh and RT (with an RT dose of ≥4500 cGy), results in satisfactory outcome in patients with this rare neoplasm.

Non-Hodgkin's Lymphoma of Waldeyer's Ring in Children: Outcome using Chemotherapy and Involved Field Radiotherapy

AIM To evaluate the prognostic factors and treatment outcome of children with non-Hodgkins lymphoma (NHL) of Waldeyers ring treated at a single institution. MATERIALS AND METHODS Thirty-two children with NHL of Waldeyers ring treated at our institute between January 1990 and December 2001 were included in this analysis. The median age at presentation was 14 years, and most of the patients (87%) were boys. The most common histological subtype was diffuse large B-cell lymphoma (75%), 25% patients had stage I and 75% had stage II disease. Treatment comprised a combination of chemotherapy and radiotherapy in most of the patients (75%). Among these patients, 71% received a radiotherapy dose of > or = 45 Gy. RESULTS After a median follow-up of 45 months, the 5-year disease-free and overall survival rates were 76.5 and 83.2%, respectively. Age > 10 years (P = 0.032), bulky tumours (P = 0.001) and the presence of B-symptoms (P = 0.004) had a negative influence on disease-free survival. Patients treated with a combination of chemotherapy and radiotherapy had a better outcome than patients treated with chemotherapy alone (disease-free survival: 87.1% vs 56.2%, P = 0.056). The complete response (P = 0.003), disease-free survival (P = 0.001) and overall survival (P = 0.001) rates were significantly better for patients receiving a radiotherapy dose > or = 45 Gy. CONCLUSION The age at diagnosis, the size of the tumour, and the presence of B-symptoms significantly influenced the outcome of children with NHL of Waldeyers ring in this study. A combined modality treatment, comprising chemotherapy and radiotherapy, resulted in a satisfactory outcome in patients with this rare neoplasm.

Synchronous mucosa-associated lymphoid tissue (MALT) lymphomas involving bilateral orbits and breasts: a rare clinical entity

Primary orbital and primary breast lymphomas comprise very small subgroups of extranodal lymphomas. Clinical presentation at both these sites together is extremely rare. We describe a case of bilateral orbital and bilateral breast mucosa-associated lymphoid tissue (MALT) lymphomas with bilateral pre-auricular lymph nodal metastasis. The case history, staging and management for this unusual entity are discussed.

Long-term Outcomes and Late Effects of Definitive Chemoradiotherapy in Patients with Cervical Cancer in Nova Scotia

Purpose: To determine the long-term oncologic outcomes and toxicity of patients treated with definitive chemo-radiotherapy for cervical cancer. Methods and Materials: The study period was January 1, 2000 to December 31, 2009. All patients diagnosed with cervical cancer who received curative-intent chemoradiotherapy were included. Patients were excluded if they resided out of the province, received surgery as an initial treatment, or were treated with palliative intent. A retrospective chart review was performed. Results: Four hundred and eighty-six patients were diagnosed with cervical cancer; 190 met eligibility criteria. Median follow-up for all patients was 3.2 years (interquartile range 1.1—5.6 years). Clinical stage was FIGO IIB or higher in 139 of 190 patients (73.2%). One hundred and fifty-eight (82.7%) received concurrent cisplatin chemotherapy (mean # cycles = 4.8). The most common external beam radiotherapy (EBRT) dose/fractionation schedule was 45 Gray (Gy) in 25 fractions (149 pts, 78.0%). One hundred and thirty-six (71.2%) received low-dose-rate (LDR) brachytherapy (BT: most common dose = 35 Gy). High-dose-rate (HDR) BT was implemented in 2008; the most common HDR dose was 24 Gy in 8 fractions over five days. Five-year overall survival (OS) and progression-free survival (PFS) were 69.4% and 61.4%, respectively. OS and PFS were significantly higher in patients who received chemotherapy vs. radiotherapy alone. For those receiving HDR-BT, there was a significantly higher OS, but not PFS. The rate of late RTOG Grade 3/4 toxicity at five years was 23.3% (gastrointestinal - 26 events, 13% of patients; genitourinary - 13 events, 8% of patients). Fourteen patients had Grade 3 radiation proctitis as the only late toxicity. EBRT dose above 45 Gy was the only factor associated with late toxicity on multivariate analysis. Conclusion: Outcomes of patients treated with chemoradiotherapy for cervical cancer are in keeping with those reported in other series. Chemotherapy improved OS and PFS. External beam radiotherapy dose above 45 Gy was the only predictor of late toxicity.

High-dose-rate brachytherapy boost for carcinoma of external auditory canal

PURPOSE To report dosimetry and outcome in a case of early stage carcinoma of external ear (T1N0M0) treated with radical radiotherapy alone using a combination of external beam radiotherapy (EBRT) and intracavitary irradiation with a high-dose-rate (HDR) (192)Ir remote afterloading system. METHODS AND METHODS A 64-year-old gentleman who was diagnosed as T1N0M0 carcinoma of external ear was treated with combination of external beam radiation therapy followed by brachytherapy (BRT). A total dose of 40Gy was delivered by EBRT, following which a 6-Fr catheter for the HDR (192)Ir remote afterloader, fixed by a customized acrylic mold, was inserted into the external auditory canal (EAC) and a total intracavitary radiation dose of 22.5Gy (4.5Gy/F) was given. RESULTS Evaluation at the completion of treatment and at the end of 4-year followup revealed no evidence of the disease. CONCLUSIONS In the radical treatment of early stage EAC carcinoma, combination of external beam radiation therapy and BRT may be a modality of choice for its efficacy, less severe side effects, and better cosmetic results.