Renu Madan

Radiation induced liver disease: A clinical update

Radiation-induced liver disease (RILD) or radiation hepatitis is a sub-acute form of liver injury due to radiation. It is one of the most dreaded complications of radiation which prevents radiation dose escalation and re-irradiation for hepatobiliary or upper gastrointestinal malignancies. This complication should be kept in mind whenever a patient is planned for irradiation of these malignancies. Although, incidence of RILD is decreasing due to better knowledge of liver tolerance, improved investigation modalities and modern radiation delivery techniques, treatment options are still limited. In this review article, we have focussed on patho-physiology, risk factors, prevention and management of RILD.

Radiation induced heart disease: Pathogenesis, management and review literature.

Radiation therapy (RT) is a very important part of multimodality cancer therapy. Addition of RT improves survival in many cancers, but there are some accompaniments of radiation. One of them is radiation induced heart disease (RIHD). RT for mediastinal lymphoma, breast, lung and oesophageal cancer is associated with the development of RIHD. The problem can be intensified with the addition of chemotherapy. Therapeutic modalities for RIHD are the same as in the non-irradiated population. However, surgery may be difficult in the irradiated patients. The long latent period is the reason why RIHD is not extensively studied. Survival of cancer patients has improved over past few decades, so RIHD is a growing concern especially in younger patients. In this review article, we have discussed the pathogenesis, clinical manifestation and management of RIHD along with impact of chemotherapeutic agents.

Compliance to Therapy—Elderly Head and Neck Carcinoma Patients

Background Treatment compliance of elderly patients to intensive multi-modality cancer therapy can be challenging and has not been adequately addressed in developing countries. The present study evaluated compliance of elderly head and neck carcinomas patients to cancer-directed therapy. Methods Forty-seven elderly HNSCC patients were evaluated in the present study. Patients were assessed as per stage and site of disease, general condition, performance status, and any pre-existing co-morbidities. Compliance was defined as patients who were able to complete cancer therapy as intended at primary clinic. Non-compliance to therapy was stratified as early, mid- and late-course non-compliance. Statistical analysis was done using STATA 9.1 software, chi-square/Fischer’s exact test to see strength of association between two categorical variables that could possibly affect compliance in elderly patients. Results Sixty-eight per cent of elderly patients were subjected to radical treatment, majority (42/47) presented in loco-regionally advanced stage (III–IV), most common site of malignancy was oropharynx (21/47). Sixty-two per cent of elderly HNSCC patients were compliance to cancer therapy. Median overall treatment time for patients subjected to radical radiation therapy was 52 (range 47–99) days, and for radical surgery and adjuvant radiotherapy was 109 (95–190) days. Compliance to therapy for elderly HNSCC patients was not significantly associated with advanced stage, poor general condition, intent of treatment or presence of co-morbidity. As regards to non-compliance, majority (14/18) of elderly patients showed mid-course treatment non-compliance. Conclusions Nearly two-thirds of elderly head and neck carcinoma patients were compliant to cancer-directed therapy.

Comparative Evaluation of Two-dimensional Radiography and Three Dimensional Computed Tomography Based Dose-volume Parameters for High-dose-rate Intracavitary Brachytherapy of Cervical Cancer: A Prospective Study

BACKGROUND Dosimetric comparison of two dimensional (2D) radiography and three-dimensional computed tomography (3D-CT) based dose distributions with high-dose-rate (HDR) intracavitry radiotherapy (ICRT) for carcinoma cervix, in terms of target coverage and doses to bladder and rectum. MATERIALS AND METHODS Sixty four sessions of HDR ICRT were performed in 22 patients. External beam radiotherapy to pelvis at a dose of 50 Gray in 27 fractions followed by HDR ICRT, 21 Grays to point A in 3 sessions, one week apart was planned . All patients underwent 2D-orthogonal and 3D-CT simulation for each session. Treatment plans were generated using 2D-orthogonal images and dose prescription was made at point A. 3D plans were generated using 3D-CT images after delineating target volume and organs at risk. Comparative evaluation of 2D and 3D treatment planning was made for each session in terms of target coverage (dose received by 90%, 95% and 100% of the target volume: D90, D95 and D100 respectively) and doses to bladder and rectum: ICRU-38 bladder and rectum point dose in 2D planning and dose to 0.1cc, 1cc, 2cc, 5cc, and 10cc of bladder and rectum in 3D planning. RESULTS Mean doses received by 100% and 90% of the target volume were 4.24 ± 0.63 and 4.9 ± 0.56 Gy respectively. Doses received by 0.1cc, 1cc and 2cc volume of bladder were 2.88 ± 0.72, 2.5 ± 0.65 and 2.2 ± 0.57 times more than the ICRU bladder reference point. Similarly, doses received by 0.1cc, 1cc and 2cc of rectum were 1.80 ± 0.5, 1.48 ± 0.41 and 1.35 ± 0.37 times higher than ICRU rectal reference point. CONCLUSIONS Dosimetric comparative evaluation of 2D and 3D CT based treatment planning for the same brachytherapy session demonstrates underestimation of OAR doses and overestimation of target coverage in 2D treatment planning.

Aspiration pneumonia related deaths in head and neck cancer patients: a retrospective analysis of risk factors from a tertiary care centre in North India.

BACKGROUND Aspiration pneumonia is an important cause of death in head and neck cancer patients. This study therefore aimed to evaluate the risk factors associated with aspiration pneumonia in head and neck cancer patients. METHODS Hospital death records from 12 years (2000-2012) were reviewed to obtain the number of deaths. Treatment details and cause of death were analysed. Statistical analysis was performed to identify the risk factors for aspiration pneumonia. RESULTS The records revealed that aspiration pneumonia was the cause of death in 51 out of 85 patients. Primary tumour site (oropharynx and hypopharynx, odds ratio 3.3; 95 per cent confidence interval 1.17-9.4, p = 0.02) and advanced tumour stage (odds ratio 4.2, 95 per cent confidence interval 1.16-15.61, p = 0.02) had significant negative impacts on aspiration pneumonia related mortality. CONCLUSION Advanced pharyngeal cancer patients are at an increased risk of aspiration pneumonia related death. Investigations for the early detection of this condition are recommended in these high-risk patients.

Primary spinal glioblastoma treated with adjuvant radiation and temozolomide: Report of two cases.

Primary spinal glioblastoma multiforme (GBM) is a rare entity, which is invariably associated with poor outcome. Standard treatment is surgery followed by post-operative radiotherapy. Due to paucity of cases role of chemotherapy is investigational. We intend to report two cases of primary spinal GBM treated with radiation and adjuvant temozolomide.

Radiation Induced Cystitis and Proctitis - Prediction, Assessment and Management.

Cystitis and proctitis are defined as inflammation of bladder and rectum respectively. Haemorrhagic cystitis is the most severe clinical manifestation of radiation and chemical cystitis. Radiation proctitis and cystitis are major complications following radiotherapy. Prevention of radiation-induced haemorrhagic cystitis has been investigated using various oral agents with minimal benefit. Bladder irrigation remains the most frequently adopted modality followed by intra-vesical instillation of alum or formalin. In intractable cases, surgical intervention is required in the form of diversion ureterostomy or cystectomy. Proctitis is more common in even low dose ranges but is self-limiting and improves on treatment interruption. However, treatment of radiation proctitis is broadly non-invasive or invasive. Non-invasive treatment consists of non-steroid anti-inflammatory drugs (NSAIDs), anti-oxidants, sucralfate, short chain fatty acids and hyperbaric oxygen. Invasive treatment consists of ablative procedures like formalin application, endoscopic YAG laser coagulation or argon plasma coagulation and surgery as a last resort.

Microvessel density and Ki-67 labeling index in esthesioneuroblastoma: is there a prognostic role?☆

Esthesioneuroblastoma (ENB) is a malignant neuroectodermal tumor. Hyams grading has an established role in its prognostication. The importance of microvessel density (MVD) and Ki-67 labeling index (Ki-67 LI) is well studied in various tumors, but the same remains understated in ENB. The aims of the study were to estimate proliferation index and MVD in ENB and to correlate them with Hyams grade. Twenty-six ENB cases diagnosed over a period of 5 years were included. Hyams grade, MVD, and Ki-67 LI were evaluated for each of them. The cases were categorized as low (Hyams grades 1 and 2) and high (Hyams grades 3 and 4) grades. Microvessel density and Ki-67 LI were correlated with grade. The treatment response was analyzed in different grades. The commonest histologic grade was 4 (42%). The mean Ki-67 LI was 2%, 8.2%, 30.8%, and 40.5% and mean MVD was 81.67/mm(2), 37/mm(2), 24/mm(2), and 25.2/mm(2) in grades 1, 2, 3, and 4, respectively. A statistically significant correlation of grade with Ki-67 LI (P < .001) and MVD (P < .007) was noted. Hyams grade in ENB correlates well with treatment response. Ki-67 LI is an important prognostic factor in ENB. We propose a cutoff of 25% for Ki-67 LI to differentiate low- vs high-grade ENB, but larger studies are needed for validation. Contrary to epithelial tumors, there is a decrease in MVD with increasing grade in ENB.

Malignant peripheral nerve sheath tumour of penis

Malignant peripheral nerve sheath tumour (MPNST) is a rare variety of soft tissue sarcoma that originates from Schwann cells or pluripotent cells of neural crest origin. They have historically been difficult tumours to diagnose and treat. Surgery is the mainstay of treatment with a goal to achieve negative margins. Despite aggressive surgery and adjuvant therapy, the prognosis of patients with MPNST remains poor. MPNST arising from penis is a very rare entity; thus, it presents a diagnostic and therapeutic challenge. We present a case of penile MPNST in a 38‐year‐old man in the absence of neurofibromatosis treated with surgery followed by post‐operative radiotherapy to a dose of 60 Gray in 30 fractions and adjuvant chemotherapy with ifosfamide and adriamycin.

Perioperative high-dose-rate interstitial brachytherapy boost for patients with early breast cancer.

AIMS AND BACKGROUND To evaluate the clinical results of perioperative high-dose-rate interstitial brachytherapy boost treatment preceding whole breast external beam radiation therapy in patients with early breast cancer. METHODS AND STUDY DESIGN From 2005-2010, 100 patients with early breast cancer who met the eligibility criteria were enrolled in the study. Brachytherapy implant was performed during the breast-conserving surgery procedure. The boost treatment was started on the 3rd postoperative day to deliver a dose of 15 Gy in 6 fractions over 3 days. Three weeks later, external beam radiation therapy to the whole breast was started for a prescription dose of 50 Gy. The study end points were local recurrence, acute toxicity and cosmetic outcome. RESULTS Median age of the patients was 46 years, and median follow-up was 52 months. No patient developed a local recurrence but 5 patients developed distant metastases. The 5-year overall survival and disease-free survival were 86% and 77%, respectively. Eleven patients had acute toxicity; 4 wound complications and 7 grade III skin toxicity. Nine of the 11 patients had breast size of more than 1500 cc. Except for the breast volume (>1500 cc), there was no statistically significant correlation between any of the patient or dosimetry-related factors and acute toxicity. Good-excellent cosmesis was observed in 87% of patients. CONCLUSIONS Perioperative high-dose-rate interstitial brachytherapy boost followed by whole breast external beam radiation therapy provides excellent local control, acceptable acute toxicity and good-excellent breast cosmesis in patients with early breast cancer.