Kailash Narayan

Planned neck dissection as an adjunct to the management of patients with advanced neck disease treated with definitive radiotherapy: For some or for all?

Management of patients with head and neck carcinoma and advanced nodal disease is controversial. The purpose of this analysis was to evaluate the efficacy and toxicity of definitive radiotherapy followed by planned neck dissection in patients with bulky neck disease.

INTERNATIONAL BRACHYTHERAPY PRACTICE PATTERNS: A SURVEY OF THE GYNECOLOGIC CANCER INTERGROUP (GCIG)

PURPOSE To determine current practice patterns with regard to gynecologic high-dose-rate (HDR) brachytherapy among international members of the Gynecologic Cancer Intergroup (GCIG) in Japan/Korea (Asia), Australia/New Zealand (ANZ), Europe (E), and North America (NAm). METHODS AND MATERIALS A 32-item survey was developed requesting information on brachytherapy practice patterns and standard management for Stage IB-IVA cervical cancer. The chair of each GCIG member cooperative group selected radiation oncology members to receive the survey. RESULTS A total of 72 responses were analyzed; 61 respondents (85%) used HDR. The three most common HDR brachytherapy fractionation regimens for Stage IB-IIA patients were 6 Gy for five fractions (18%), 6 Gy for four fractions (15%), and 7 Gy for three fractions (11%); for Stage IIB-IVA patients they were 6 Gy for five fractions (19%), 7 Gy for four fractions (8%), and 7 Gy for three fractions (8%). Overall, the mean combined external-beam and brachytherapy equivalent dose (EQD2) was 81.1 (standard deviation [SD] 10.16). The mean EQD2 recommended for Stage IB-IIA patients was 78.9 Gy (SD 10.7) and for Stage IIB-IVA was 83.3 Gy (SD 11.2) (p = 0.02). By region, the mean combined EQD2 was as follows: Asia, 71.2 Gy (SD 12.65); ANZ, 81.18 (SD 4.96); E, 83.24 (SD 10.75); and NAm, 81.66 (SD, 6.05; p = 0.02 for Asia vs. other regions).The ratio of brachytherapy to total prescribed dose was significantly higher for Japan (p = 0.0002). CONCLUSION Although fractionation patterns may vary, the overall mean doses administered for cervical cancer are similar in Australia/New Zealand, Europe, and North America, with practitioners in Japan administering a significantly lower external-beam dose but higher brachytherapy dose to the cervix. Given common goals, standardization should be possible in future clinical trials.

Effect of neuraxial anaesthesia on tumour progression in cervical cancer patients treated with brachytherapy: a retrospective cohort study

BACKGROUND Recent evidence suggests that neuraxial and regional anaesthesia may influence the progression of the underlying malignant disease after surgery. METHODS This retrospective cohort study assessed whether neuraxial anaesthesia would affect the progression of cervical cancer in 132 consecutive patients who were treated with brachytherapy in a tertiary cancer centre in Australia. RESULTS Age, American Society of Anesthesiologists status, International Federation of Gynecologists and Obstetricians (FIGO) cancer staging, invasion into the uterus, tumour volume, and tumour cell types were not significantly different between patients who received neuraxial and general anaesthesia during their first brachytherapy treatment. The use of neuraxial anaesthesia during the first brachytherapy was not associated with a reduced risk of local or systemic recurrence [hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.54-1.67; P=0.863], long-term mortality from tumour recurrence (HR 1.46, 95% CI 0.75-2.84; P=0.265), or all-cause mortality (HR 1.46, 95% CI 0.81-2.61; P=0.209), after adjusting for other prognostic factors. Tumour recurrence and long-term survival were only significantly associated with the tumour cell type, tumour volume, and FIGO tumour staging. Sensitivity analyses using proportions of all brachytherapy sessions performed under neuraxial anaesthesia also did not show any beneficial effects of neuraxial anaesthesia on tumour recurrence and long-term survival. CONCLUSIONS Using neuraxial anaesthesia during brachytherapy for patients with cervical cancer was not associated with a reduced risk of tumour recurrence and mortality when compared with general anaesthesia.

Patterns of failure and prognostic factor analyses in locally advanced cervical cancer patients staged by positron emission tomography and treated with curative intent.

Purpose: The aim of this retrospective analysis was to assess whether parameters derived from magnetic resonance imaging (MRI) and positron emission tomography (PET) provide incremental prognostic value compared with International Federation of Gynecology and Obstetrics (FIGO) stage in cervix cancer patients treated with curative intent using concurrent chemoradiotherapy. Materials and Methods: This was a retrospective study of patients with locoregionally advanced cervical cancer staged by examination under anesthesia and pretreatment MRI and PET. Potential prognostic factors examined were derived from either clinical evaluation (age, FIGO stage, clinical diameter, histology), MRI (corpus invasion, tumor volume), or PET (lymph node metastasis). Outcome measures examined were overall survival, relapse-free survival, time to failure, local failure, nodal failure, and distant failure. Results: There were 206 eligible patients. The mean potential follow-up was 4.4 years. At 5 years, for all patients, overall survival rate was 59%. For all outcome measures apart from local failure, for which adenocarcinoma histology was the most powerful adverse prognostic factor (HR, 4.29; P < 0.0001), lymph node status on PET was the dominant unifactor and multifactor prognostic factor. Corpus involvement on MRI was significantly associated with nodal involvement on PET but of MRI-derived parameters only tumor volume has prognostic value, limited to time to failure and nodal failure. Conclusions: Nodal status on PET was the major predictor of outcome in locally advanced cervix cancer treated with chemoradiation and was superior to FIGO staging. Tumor volume measured from MRI appears to be an important predictor of loco-regional relapse.

A randomized trial comparing 35 Gy in ten fractions with 60 Gy in 30 fractions of cerebral irradiation for glioblastoma multiforme and older patients with anaplastic astrocytoma

A randomized prospective clinical trial was conducted to compare conventional high dose radiotherapy with hypofractionated, short course radiotherapy in poor prognosis patients with high grade glioma. The primary endpoint was overall survival.

Conformal Brachytherapy Planning for Cervical Cancer Using Transabdominal Ultrasound

PURPOSE To determine if transabdominal ultrasound (US) can be used for conformal brachytherapy in cervical cancer patients. MATERIALS AND METHODS Seventy-one patients with locoregionally advanced cervix cancer treated with chemoradiation and brachytherapy were included in this study. The protocol consisted of US-assisted tandem insertion and conformal US-based planning. Orthogonal films for applicator reconstruction were also taken. A standard plan was modified to suit the US-based volume and treatment was delivered. The patient then underwent a magnetic resonance imaging (MRI) scan with the applicators in situ. Retrospectively, individual standard (STD), US, and MRI plans were extrapolated for five fractions and superimposed onto the two-dimensional sagittal MRI images for comparison. Doses to Point A, target volume, International Commission on Radiation Units and Measurements (ICRU) 38 bladder and rectal points, and individualized bowel points were calculated on original implant geometry on Plato for each planning method. RESULTS STD (high-dose-rate) plans reported higher doses to Point A, target volume, ICRU 38 bladder and rectal points, and individualized bowel point compared with US and MRI plans. There was a statistically significant difference between standard plans and image-based plans-STD vs. US, STD vs. MRI, and STD vs. Final-having consistent (p <or= 0.001) respectively for target volume, Point A, ICRU 38 bladder, and bowel point. US plan assessed on two-dimensional MRI image was comparable for target volume (p = 0.11), rectal point (p = 0.8), and vaginal mucosa (p = 0.19). Local control was 90%. Late bowel morbidity (G3, G4) was <2%. CONCLUSIONS Transabdominal ultrasound offers an accurate, quick, accessible, and cost-effective method of conformal brachytherapy planning.

Estimation of tumor volume in cervical cancer by magnetic resonance imaging.

In 32 patients with stage 1 or 2 cervical cancer, preoperative magnetic resonance imaging (MRI) images were compared with corresponding linear measurements made on fresh histopathology specimens. Their clinical tumor diameters recorded as a part of Federation of International Gynecologists and Obstetricians (FIGO) staging were also correlated with the MRI-derived tumor volumes. The locations of neoplastic lesions within the cervix and uterus were identified accurately by MRI as verified in subsequent histopathology examinations. The examination under anesthesia (EUA) diameter (tumor size) was not related to the MRI-derived tumor diameter. Pathologic tumor diameter correlated well with the corresponding diameter in T2-weighted MRI. Tumor volume as measured by MRI was an accurate representation of the local extent of the disease and can be used as an objective measure of cervical cancer at the primary site. Substituting MRI-derived volume in place of clinical tumor diameter in the FIGO staging system will help refine its prognostic significance in patients with both operable and nonoperable cervical cancer.

Impact of post-therapy positron emission tomography on prognostic stratification and surveillance after chemoradiotherapy for cervical cancer

A study was undertaken to investigate the detection of relapse and survival outcomes in patients with cervical cancer treated with curative intent chemoradiotherapy, and evaluated with a post‐therapy 18F‐fluorodeoxyglucose positron emission tomography (FDG‐PET) scan.

Comparative Study of LDR (Manchester System) and HDR Image-guided Conformal Brachytherapy of Cervical Cancer: Patterns of Failure, Late Complications, and Survival

PURPOSE To compare patterns of failure, late toxicities, and survival in locally advanced cervical cancer patients treated by either low-dose-rate (LDR) or conformal high-dose-rate (HDRc) brachytherapy as a part of curative radiotherapy. MATERIALS AND METHODS A retrospective comparative study of 217 advanced cervix cancer patients was conducted; 90 of these patients received LDR and 127 received HDRc brachytherapy. All patients were staged using International Federation of Gynecology and Obstetrics (FIGO) rules, had pretreatment magnetic resonance imaging (MRI), and were treated with concurrent cisplatin chemoradiotherapy. Both groups matched for FIGO stage, MRI tumor volume, and uterine invasion status. RESULTS Local and pelvic failures were similar 12-13% and 14% both in both groups. Abdominal and systemic failures in LDR group were 21% and 24%, whereas corresponding failures in HDRc group were 20% and 24%. Sixty-eight percent (87/127) of patients treated by HDRc remained asymptomatic, whereas 42% (38/90) of patients were asymptomatic from the bowel and bladder symptoms after treatment with LDR. The 5-year OS rate was 60% (SE = 4%). The 5-year failure-free survival rate was 55% (SE = 3%). There was no significant difference between the groups. CONCLUSIONS Image-guided HDRc planning led to a large decrease in late radiation effects in patients treated by HDRc. Patterns of failure and survival were similar in patients treated either by LDR or HDRc.

Ultrasound guided conformal brachytherapy of cervix cancer: survival, patterns of failure, and late complications

Objective The aim of this study was to report on the long-term results of transabdominal ultrasound guided conformal brachytherapy in patients with cervical cancer with respect to patterns of failures, treatment related toxicities and survival. Methods Three hundred and nine patients with cervical cancer who presented to Institute between January 1999 and December 2008 were staged with magnetic resonance imaging and positron emission tomography and treated with external beam radiotherapy and high dose rate conformal image guided brachytherapy with curative intent. Follow-up data relating to sites of failure and toxicity was recorded prospectively. Results Two hundred and ninety-two patients were available for analyses. The median (interquantile range) follow-up time was 4.1 years (range, 2.4 to 6.1 years). Five-year failure free survival and overall survival (OS) were 66% and 65%, respectively. Primary, pelvic, para-aortic, and distant failure were observed in 12.5%, 16.4%, 22%, and 23% of patients, respectively. In multivariate analysis, tumor volume and nodal disease related to survival, whereas local disease control and point A dose did not. Conclusion Ultrasound guided conformal brachytherapy of cervix cancer has led to optimal local control and OS. The Melbourne protocol compares favorably to the more technically elaborate and expensive GEC-ESTRO recommendations. The Melbourne protocols technical simplicity with real-time imaging and treatment planning makes this a method of choice for treating patients with cervical cancer.