Goura Kisor Rath

Early Clinical Outcomes and Toxicity of Intensity Modulated Versus Conventional Pelvic Radiation Therapy for Locally Advanced Cervix Carcinoma: A Prospective Randomized Study

PURPOSE To evaluate the toxicity and clinical outcome in patients with locally advanced cervical cancer (LACC) treated with whole pelvic conventional radiation therapy (WP-CRT) versus intensity modulated radiation therapy (WP-IMRT). METHODS AND MATERIALS Between January 2010 and January 2012, 44 patients with International Federation of Gynecology and Obstetrics (FIGO 2009) stage IIB-IIIB squamous cell carcinoma of the cervix were randomized to receive 50.4 Gy in 28 fractions delivered via either WP-CRT or WP-IMRT with concurrent weekly cisplatin 40 mg/m(2). Acute toxicity was graded according to the Common Terminology Criteria for Adverse Events, version 3.0, and late toxicity was graded according to the Radiation Therapy Oncology Group system. The primary and secondary endpoints were acute gastrointestinal toxicity and disease-free survival, respectively. RESULTS Of 44 patients, 22 patients received WP-CRT and 22 received WP-IMRT. In the WP-CRT arm, 13 patients had stage IIB disease and 9 had stage IIIB disease; in the IMRT arm, 12 patients had stage IIB disease and 10 had stage IIIB disease. The median follow-up time in the WP-CRT arm was 21.7 months (range, 10.7-37.4 months), and in the WP-IMRT arm it was 21.6 months (range, 7.7-34.4 months). At 27 months, disease-free survival was 79.4% in the WP-CRT group versus 60% in the WP-IMRT group (P=.651), and overall survival was 76% in the WP-CRT group versus 85.7% in the WP-IMRT group (P=.645). Patients in the WP-IMRT arm experienced significantly fewer grade ≥2 acute gastrointestinal toxicities (31.8% vs 63.6%, P=.034) and grade ≥3 gastrointestinal toxicities (4.5% vs 27.3%, P=.047) than did patients receiving WP-CRT and had less chronic gastrointestinal toxicity (13.6% vs 50%, P=.011). CONCLUSION WP-IMRT is associated with significantly less toxicity compared with WP-CRT and has a comparable clinical outcome. Further studies with larger sample sizes and longer follow-up times are warranted to justify its use in routine clinical practice.

Radiation induced oral mucositis: a review of current literature on prevention and management

Oral mucositis (OM) is a major limiting acute side effect of radiotherapy for head and neck cancer. The spectrum of problems associated with mucositis includes oral pain, odynophagia, reduced oral intake, and secondary infections. Incidence of mucositis is increased with addition of concurrent chemotherapy as well as altered fractionation schedules. This leads to treatment interruption and suboptimal disease control. Hence, prevention as well as timely management of OM is necessary for optimum tumor control. We reviewed the English literature with key words “Radiation induced mucositis, Mucositis, Oral Mucositis” to find relevant articles describing incidence, pathophysiology, prophylaxis, and treatment of oral mucositis. Prevention and treatment of OM is an active area of research. Maintenance of oral hygiene is an important part in prevention of OM. A battery of agents including normal saline and alkali (soda bicarbonate) mouth washes, low level laser therapy, and benzydamine (non-steroidal analgesic and anti-inflammatory) have effectiveness in the prevention and treatment of radiation induced oral mucositis. Chlorhexidine mouth gargles are recommended for prevention of chemotherapy induced oral mucositis but is not recommended for radiotherapy associated mucositis. Treatment of co-existing infection is also important and both topical (povidone iodine) and systemic anti fungals should be used judiciously. Radiation induced oral mucositis is a common problem limiting the efficacy of radiation by increasing treatment breaks. Adequate prophylaxis and treatment may limit the severity of radiation mucositis and improve compliance to radiation which may translate in better disease control and survival.

Use of transrectal ultrasound for high dose rate interstitial brachytherapy for patients of carcinoma of uterine cervix

OBJECTIVE Transrectal ultrasound (TRUS) has been widely used for guiding prostate implants, but not much for interstitial brachytherapy (IBT) of cervix cancer. The aim of our study is to report our experience with TRUS guided high dose rate (HDR) IBT in patients with carcinoma of uterine cervix. METHODS During the year 2005-2006, 25 patients of cervical cancer not suitable for intracavitary radiotherapy (ICRT), were enrolled in this prospective study. We used B-K Medical USG machine (Falcon 2101) equipped with a TRUS probe (8658) having a transducer of 7.5 MHz for IBT. Post procedure, a CT scan was done for verification of needle position and treatment planning. Two weekly sessions of HDR IBT of 8-10 Gy each were given after pelvic external beam radiation therapy. RESULTS A total of 40 IBT procedures were performed in 25 patients. Average duration of implant procedure was 50 minutes. There was no uterine perforation in any of 11 patients in whom central tandem was used. CT scan did not show needle perforation of bladder/rectum in any of the patients. During perioperative period, only 1 procedure (2.5%) was associated with hematuria which stopped within 6 hours. Severe late toxicity was observed in 3 (12%) patients. Overall pelvic control rate was 64%. CONCLUSION Our experience suggests that TRUS is a practical and effective imaging device for guiding the IBT procedure of cervical cancer patients. It helps in accurate placements of needles thus avoiding the injury to normal pelvic structures.

Single Agent Versus Combination Chemotherapy in Recurrent Cervical Cancer

Objective:Cisplatin and ifosfamide are two most active agents in patients with recurrent and metastatic cervical cancer. Combination of bleomycin, ifosfamide and cisplatinum (BIP) was compared with cisplatinum alone.

High-dose-rate interstitial brachytherapy for T1-T2-stage penile carcinoma: short-term results.

PURPOSE Interstitial brachytherapy (IBT) is a preferred treatment option over partial penectomy in selected patients with T1-T2-stage penile carcinoma because of its organ preservation ability. Literature is mostly based on the use of low-dose-rate IBT, and experience with high-dose-rate (HDR) IBT is extremely limited. We studied the role of HDR-IBT alone in patients with T1-T2-stage penile carcinoma. METHODS AND MATERIALS Between April 2010 and July 2013, 14 patients with T1-T2-stage penile carcinoma were treated with HDR-IBT at our center. Size of the primary lesion ranged from 1.5 to 4.0cm. A two-to-four-plane free-hand implant was performed using plastic catheters. The prescribed dose of HDR-IBT was 42-51Gy in 14-17 fractions using twice-a-day fractionation schedule. Patients were followed up regularly for assessment of local control, survival, toxicity, and sexual function. RESULTS At a median followup of 22 months, 2 patients developed recurrent disease at locoregional site. The 3-year overall survival was 83% with penis preservation rate of 93%. All patients developed acute Grade III skin toxicity that healed during 6-8-weeks time. Urethral stenosis and soft tissue necrosis was not seen in any of the patients. A total of 4 patients experienced mild asymptomatic fibrosis in the implanted area. Around 10 patients had satisfactory sexual function status at the last followup visit. CONCLUSIONS Although it was a small sample size, our results have demonstrated excellent local control rate and acceptable toxicity with HDR-IBT in patients with T1-T2-stage penile carcinoma.

High Dose Rate Interstitial Brachytherapy using Two Weekly Sessions of 10 Gy Each for Patients with Locally Advanced Cervical Carcinoma

PURPOSE To evaluate the feasibility of high-dose rate interstitial brachytherapy (HDR-IBT) using two weekly sessions of 10 Gy in combination to pelvic external beam radiation therapy (EBRT) for patients with locally advanced cervical carcinoma. METHODS AND MATERIALS Between the year 2005 and 2007, 42 patients with locally advanced cervical carcinoma (International Federation of Gynecology and Obstetrics Stage IIB-IVA), not suitable for intracavitary radiotherapy after completing EBRT, were enrolled in this prospective study. Two weekly sessions of HDR-IBT with 10 Gy each were delivered 1 week after pelvic EBRT. Various parameters studied for evaluating the feasibility were procedure-related complications, delayed radiation toxicity, and recurrence-free survival. RESULTS International Federation of Gynecology and Obstetrics stage distribution of patients was as follows: Stage IIB (10), Stage IIIB (27), and Stage IVA (5). A total of 84 HDR-IBT procedures were performed in these 42 patients. Each session of brachytherapy treatment (from needle insertion to removal of template) was completed in less than 4 h. Frequency of various procedure-related complications were as follows: hematuria (3.5%), deep vein thrombosis (0%), and visceral puncture (0%). Overall delayed radiation toxicity (Grade III-IV) was 9%. Median followup was 23 months. The 3-y overall survival for all stages was 47% and the 3-y recurrence-free survival for stage IIB, IIIB, and IVA was 67%, 34%, and 20%, respectively. CONCLUSION Our clinical results have shown that weekly HDR-IBT schedule (10 Gy × 2) is associated with low toxicity, decent local control, and survival rates thereby proving its clinical feasibility.

High-dose-rate interstitial brachytherapy for liver metastases: first study from India

Purpose To study the safety and efficacy of high-dose-rate interstitial brachytherapy (HDRIBT) in patients with liver metastases (LM). Material and methods Between 2009 and 2011, 10 patients with 12 metastatic lesions in the liver were enrolled in this prospective trial. All patients had either refused surgery or found ineligible for surgery due to various factors. Under CT guidance, 16 gauze blind end stainless steel or rigid plastic brachytherapy needle was inserted in the center of lesion through the percutaneous route. Generally, a single interstitial brachytherapy (IBT) needle for lesions up to 3 cm and multiple needles for lesions more than 3 cm in diameter were inserted. Treatment was delivered with a single high-dose-rate (HDR) dose of 20 Gy prescribed to the target. The needles were removed immediately after the treatment. The endpoints of study were acute complications and local control of the disease. Results The median size of the lesion was 3.8 cm (2.7-7.0 cm). The average time for the entire IBT procedure was 65 minutes (50-105 minutes). Median follow up was 9 months (3-17 months). None of the patients had fatal complications. Minor complications like pain, nausea/vomiting, and asymptomatic pleural effusion were observed in 3, 2 and 1 patients, respectively. Local control rate at 12 months was 75%. The 1-year local progression free survival (LPFS) was 33%. Conclusion Although limited by small sample size, the results of our first study from India suggest that HDRIBT is a safe and effective non surgical option for LM.

Postoperative treatment of glioblastoma multiforme with radiation therapy plus concomitant and adjuvant temozolomide : A mono-institutional experience of 215 patients.

OBJECTIVE To study the clinical results and prognostic factors of patients with glioblastoma multiforme (GBM) treated by postoperative radiation therapy (PORT) and concomitant temozolomide followed by adjuvant temozolomide. METHODS From 2005 to 2008, 215 patients (median age 48 years) with GBM were treated with PORT plus temozolomide chemotherapy. Radiation therapy (RT) was employed with a dose of 60 Gy in 30 fractions over 6 weeks by conventional fractionation with concomitant temozolomide (75 mg/m(2)/day). Adjuvant therapy consisted of 6 cycles of temozolomide (150 mg/m(2) for 5 days, 28 days cycle). The primary end point of the study was overall survival (OS), and the secondary end points were progression free survival (PFS) and toxicity. OS was determined with respect to different variables to study the prognostic significance. RESULTS Median follow up was 11 months (range 2-50 months). Median OS and PFS were 13 months and 11 months respectively. The 1-year and 2-year OS was 44% and 18% respectively. There was no statistical significant impact of age, sex, KP score, anatomical location and extent of surgery. Presentation without seizures (on univariate analysis) and 6 cycles of adjuvant temozolomide therapy (on univariate as well as multivariate analysis) were found significant prognostic factors. Sixteen patients developed grade III-IV neutropenia/thrombocytopenia during the course of RT. CONCLUSION Our results authenticate the role of concomitant and adjuvant temozolomide chemotherapy in combination with PORT for the management of GBM patients. We strongly recommend complete 6 cycle of adjuvant temozolomide since it significantly improved the survival in our study.

Clinical outcome of patients with uterine sarcomas

PURPOSE The aim of our retrospective analysis was to study and report the clinical outcome of patients with uterine sarcoma (US) treated at our center; and to share our experience with literature. MATERIALS AND METHODS We retrieved the information regarding the patients demography, clinico-pathological details, treatment given, survival, and complications of all the US patients treated at our center between the years 2000-2008. The three-year overall survival (OS) was determined with respect to various prognostic factors like age, stage of disease, histopathological type, adjuvant RT etc. RESULTS A total of 50 case records were retrieved for this retrospective analysis. Age ranged from 24 to 75 years with a median of 50 years. Carcinosarcoma was the commonest histopathological type (23/50 patients). FIGO stage distribution was: stage I, 27; stage II, 7; stage III, 12; stage IV, 2; and unknown stage, two patients. Forty-eight patients underwent surgery; 31 received postoperative radiation therapy (PORT) and 16 received chemotherapy therapy. Median follow-up period was 34 months (range 2-69 months). The three-year OS for the entire group of patients was 42%. Stage of the disease, histopathological type, and use of PORT were found significant prognostic factors for survival. CONCLUSION Although limited by small sample size and retrospective nature, ours is the only study on US being reported from India. Our results have demonstrated FIGO stage of the disease, histopathology and use of PORT to be the significant prognostic factor for survival. Use of chemotherapy in future trials is warranted.

Positron emission tomography scan for predicting clinical outcome of patients with recurrent cervical carcinoma following radiation therapy.

PURPOSE To evaluate the role of positron emission tomography (PET) for predicting the clinical outcome of patients with recurrent cervical carcinoma following definitive radiation therapy (RT). MATERIALS AND METHODS Twenty two patients of post irradiated recurrent cervical carcinoma (PIRCC) were enrolled in this prospective study. 18-fluorodeoxyglucose (FDG) PET imaging was performed in each patient before the salvage therapy. The maximum standardized uptake value (SUVmax) and metabolic tumor volume (MTV) were measured and correlated with cumulative progression free survival (PFS). RESULTS Median age of patients was 42 years. Majority of patients had stage III disease at the initial presentation and all 22 patients had received prior definitive RT. The median recurrence free period was 11 months. Salvage therapy consisted of surgical resection or re-irradiation depending upon the various clinical and radiological factors. Median SUVmax was 5.8 (range 1.8-50.6) and median MTV was 43 cm³ (range 5.8-243). The cumulative PFS for all patients was 20% at 30 months. The one-year PFS was 28% for patients with SUVmax value of >5.8 versus 42% for those with SUVmax value of <5.8 (P value 0.01). The one-year PFS was 43% for patients with MTV value of >43 cm³ versus 45% for those with MTV value of <43 cm³ (P value 0.8). CONCLUSION Our preliminary experience has suggested that FDG uptake on PET scan can predict the clinical outcome of PIRCC patients. Further randomized studies may be conducted with large sample size and longer follow up to establish its definite predictive value.