Parmod Kumar Julka

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.

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.

Pulsed-dose-rate intracavitary brachytherapy for cervical carcinoma: the AIIMS experience.

Objective:The aim of present study was to analyze the results of pulsed-dose-rate (PDR) brachytherapy in patients with cervical carcinoma treated at our center. Methods:From September 2003 to September 2005, 48 patients with histopathologically proved cervical carcinoma, stages IB to IVA, were treated with PDR intracavitary radiotherapy (ICRT) and pelvic irradiation at our center. Radiotherapy consisted of whole pelvis external beam radiation therapy (EBRT) with a dose of 40 Gy in 22 fractions over 4.5 weeks followed by 10 Gy in 5 fractions over 1 week with midline shielding. Weekly chemotherapy (Cisplatin, 40 mg/m2) was administered during the course of EBRT to suitable patients. After an interval of 1 to 2 weeks, a single session of standard ICRT application was done to deliver a dose of 27 Gy to point A by PDR (hourly pulse, 70 cGy). Results:Median age was 50 years (range: 30–65). FIGO stage distribution of the patients was as follows: stage IB, 6; stage IIA, 1; stage IIB, 15; stage IIIB, 25; and stage IVA, 1. Follow-up period ranged from 3 to 50 months (median: 15 months). Ten patients had disease recurrence (5 each in stage IIB and stage IIIB). Eight patients had pelvic failure, 1 had bone metastases, and 1 had supraclavicular node metastases. Overall grades III to IV late toxicity rate at 50 months was 6%. For the median follow-up period of 15 months, the actuarial recurrence-free survival in stages I to II was 82% and stages III to IV was 78%. Conclusion:Our results reveal that PDR ICRT in combination with pelvic EBRT provides excellent pelvic disease control, survival, and low radiation related morbidity rate in the patients with cervical carcinoma.

Pleomorphic xanthoastrocytoma – a clinico-pathological review

Pleomorphic xanthoastrocytoma (PXA) is a rare primary brain tumour which occurs in children and young adults. PXA is designated as low-grade astrocytoma (WHO II), although an anaplastic variant and malignant potential have been described. Pathologically, cellular pleomorphism is the rule and includes spindle cells, mononucleated and multinucleated giant cells, and granular bodies in a reticulin-rich background with few mitoses; necrosis is usually absent. The tumour cells stain positive for glial fibrillary acidic protein (GFAP). Surgery is the mainstay of treatment with gross surgical resection being accomplished due to its well-circumscribed nature and peripheral location. The role of adjuvant treatment remains yet to be clearly defined. To date, the majority of PXAs have been reported as single or small case series; consequently data of this rare brain tumour are fragmentary. The present paper reviews the pathogenesis, neuroradiological features, prognostic factors and treatment options for PXA.

Revisiting the role of computerized tomographic scan and cystoscopy for detecting bladder invasion in the revised FIGO staging system for carcinoma of the uterine cervix.

Introduction: Recent revision of the International Federation of Gynecology and Obstetrics (FIGO) staging system for the cervix encourages use of computerized tomography (CT) and magnetic resonance imaging and does not recommend cystoscopy as a mandatory investigation. But the revision has not defined which patients should undergo cystoscopy. Our study aims to revisit the role of CT scan and cystoscopy for detecting bladder invasion so that we can select patients for cystoscopy. Methods: We reviewed case records of all cervical cancer patients who underwent abdominopelvic CT scan besides standard FIGO staging workup (including cystoscopy) and treatment with radiotherapy or concurrent chemoradiotherapy between years 2003 and 2005. Patients showing bladder invasion on CT scan or cystoscopy were identified and separately analyzed. Considering cystoscopy as the standard reference investigation, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CT scan for bladder invasion were calculated. Results: A total of 305 case records were analyzed. Median age of the patients was 50 years (range, 25-85 years). Forty-three (14%) patients had bladder invasion on CT scan, and 17 (5.5%) had cystoscopy-confirmed invasion. No patient showing absence of bladder invasion on CT scan showed cystoscopy-confirmed invasion. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CT scan for bladder invasion were 100%, 92%, 40%, 100%, and 92%, respectively. The median overall survival of patients with CT-detected bladder invasion versus cystoscopy-confirmed invasion was 13 months versus 4 months, respectively (P = 0.007). Conclusions: Our results show that for cervical cancer, cystoscopy is not required in patients without any bladder invasion on CT scan. In the revised FIGO staging system, use of cystoscopy may be limited to patients having suspicious bladder invasion on CT scan. This will benefit both patient population and gynecologic oncologists, especially in developing countries with limited resources.

Computerized tomography-guided percutaneous high-dose-rate interstitial brachytherapy for malignant lung lesions

PURPOSE To study the feasibility of computerized tomography (CT)-guided percutaneous high-dose-rate interstitial brachytherapy (HDRIBT) in patients with malignant lung lesions (MLL), not suitable for surgery. MATERIALS AND METHODS From June 2007 to December 2008, eight patients with MLL (primary lung carcinoma, two; solitary lung metastases, six); were enrolled in this prospective trial. All patients had either refused surgery or had been found ineligible due to comorbidities. Under CT guidance, a single stainless steel needle for lesions up to 4 cm and two needles for lesions up to 6 cm in diameter were inserted percutaneously through the intercostal space. A single dose of 20 Gy with HDRIBT was prescribed at the periphery of the lesion. The needles were removed immediately after treatment. The endpoints of the study were acute perioperative complications like pneumothorax, hemothorax, hemoptysis, and so on, and short term (six-month) tumor control. RESULTS There were six males and two females with a median age of 55 years. The lesion size ranged from 3.0 - 5.5 cm (median 4.0 cm). The average time taken for the interstitial brachytherapy (IBT) procedure was 50 minutes. None of the patients had fatal complications. Two patients had minor complications (one hemoptysis and one minimal pleural effusion). Six of the eight patients had more than 50% reduction in the tumor dimensions at the end of six months. CONCLUSIONS CT-guided HDRIBT is a safe and feasible non-surgical treatment option for patients with MLL. It provides effective tumor control and needs to be studied further.

Clinical Investigations A study on the variation of bladder and rectal doses with respiration in intracavitary brachytherapy for cervix cancer

Purpose In cervical intracavitary brachytherapy, it is mandatory to evaluate if the doses to bladder and rectum are within tolerance limits. In this study, an effort has been made to evaluate the effect of respiration on the doses to bladder and rectum in patients undergoing brachytherapy. Material and methods Fifteen patients with cervix cancer treated with concurrent chemoradiation followed by intracavitary brachytherapy were included in this study. At the time of brachytherapy, all patients underwent 4D computed tomography (CT) imaging. Five out of fifteen patients were scanned with empty bladder while the rest had full bladder during sectional imaging. Four sets of pelvic CT image datasets with applicators in place were acquired at equal interval in a complete respiratory cycle. Treatment plans were generated for all the CT datasets on a PlatoTM Sunrise planning system. A dose of 7 Gy was prescribed to Point A. Doses to ICRU (Report No.38) bladder (IBRP) and rectal (IRRP) reference points were calculated in all the CT datasets. Results The mean of maximum dose to IBRP at four different respiratory phases for full and empty bladder were 53.38 ± 19.20%, 55.75 ± 16.71%, 56.13 ± 17.70%, 57.50 ± 17.48% and 60.93 ± 15.18%, 60.29 ± 16.28%, 60.86 ± 15.90%, 60.82 ± 15.42% of the prescribed dose respectively. Similarly, maximum dose to IRRP for full and empty bladder were 55.50 ± 18.66%, 57.38 ± 14.81%, 58.00 ± 14.97%, 58.38 ± 17.28% and 71.96 ± 6.90%, 71.58 ± 7.52%, 68.92 ± 6.21%, 71.45 ± 7.16% respectively. Conclusions Our study shows that respiration affects the dose distribution to the bladder and rectum in intracavitary brachytherapy of cervix cancer. It is advisable to reduce the critical organ dose to account for the dose variation introduced by respiratory motion.