Rohini Khurana

Prospective evaluation of Intensity Modulated Radiation Therapy with Simultaneous Integrated Boost (IMRT-SIB) in head and neck squamous cell carcinoma in patients not suitable for chemo-radiotherapy

BACKGROUND With conformal radiotherapy techniques, acute and late toxicities can be reduced because of better dose conformity and reduced doses to normal tissue. With Intensity Modulated Radiation Therapy (IMRT) further dose escalation is possible and one of the methods is IMRT with simultaneous integrated boost (IMRT-SIB). AIM To evaluate feasibility, toxicity patterns and loco-regional control rates of IMRT-SIB technique in head and neck cancer patients who are not suitable candidates for concurrent chemoradiation. STUDY DESIGN Prospective study of 30 patients treated with IMRT-SIB technique and evaluation of clinical results. METHOD AND MATERIALS 30 patients received definitive treatment using IMRT-SIB without concurrent chemotherapy. Patients were monitored during and after treatment for toxicity using the Radiation Therapy Oncology group (RTOG) criteria. Analysis of acute and late toxicity and early efficacy is presented. RESULTS The median treatment duration was 42days (range 41-43days). Overall, maximum acute Grade 3 toxicity of mucositis, skin, pharynx/esophageal toxicity and laryngeal were 56.66%, 30%, 26.67%, and 6.67% respectively at treatment completion. None of the patients had Grade 4 acute toxicity. No haematological toxicity was seen. Overall, grade 2 late toxicities were 7% (subcutaneous toxicity) and 13.3% (Xerostomia). Loco regional control rate at a median follow up of 13months was 86%. CONCLUSION IMRT-SIB is a safe and acceptable treatment option for patients of head and neck squamous cell carcinoma unsuitable for definitive chemo-radiotherapy.

Retrospective Analysis of Efficacy and Toxicity of Hypo-fractionated Radiotherapy in Breast Carcinoma

INTRODUCTION The conventional dose fractionation of adjuvant radiotherapy (RT) to whole breast is 45-50 Gy in 25 fractions as 1.8-2.0-Gy per fraction. Lumpectomy cavity with a 1.5-2-cm margin receieves additional 10- 16 Gy doseas boost. Alternative dose fraction schedules used in various randomised trials have established the role of hypofractionated radiotherapy (HRT) in early breast cancer. HRT allows time and cost saving thus better patient compliance. However the efficacy and toxicity of HRT in locally advanced breast cancer is still under evaluation. AIM To study the toxicity and efficacy of Hypofractionated Radiotherapy (HRT) as compared to Conventional Radiotherapy (CRT) in breast cancer at our centre. MATERIALS AND METHODS A retrospective analysis of breast cancer patients treated between October 2012- September 2014 with adjuvant radiation therapy as CRT or HRT. The data of these patients was retrieved and analysed regarding demographic profile, stage at presentation, pathological type, extent of surgery, chemotherapy, efficacy and toxicity of HRT. The toxicity assessment was done as per RTOG toxicity criteria. The data were analysed using SPSS software version 20.0. RESULTS A total of 100 patients with carcinoma breast who received radiotherapy over two years were analysed. Age ranged from 18-90 years, mean 49.15 ± 12.7 years. Fifty-five patients were post-menopausal, predominant clinical feature was painless lump in the breast (98%). Early stage (Stage I and II) constituted 41%, locally advanced disease in 59%. Modified radical mastectomy was done in 75%, breast conserving surgery in 25%. A 56 patients received HRT and 44 were treated with CRT. The most common acute toxicity was skin grade I. An 18% patients in HRT arm and 30% patients in conventional arm developed grade II skin toxicity (p=0.23). Dysphagia grade I was seen in 10% cases in CRT arm and 12% in HRT arm. The median follow-up period was 11.3 months with 2 loco-regional failures in each arm. CONCLUSION HRT seems to be equally efficacious and no more toxic than CRT in carcinoma breast even in unselected sub-group of patients.

Rare case of subependymal giant cell astrocytoma without clinical features of tuberous sclerosis: Case report and literature review: AZAM et al.

Subependymal giant cell astrocytoma (SEGA) is a slow‐growing tumor originating in the walls of the lateral ventricles, usually presenting in the first two decades of life, and is often associated with tuberous sclerosis complex. However, few cases of SEGA without any clinical features of tuberous sclerosis complex have been reported. Here, we present a case of an 11‐year‐old boy with right hemibody weakness and headache for 1.5 years. He was diagnosed with solitary SEGA without any clinical features of tuberous sclerosis complex. Magnetic resonance imaging of the brain showed an intracranial space‐occupying lesion in the left internal capsule. Biopsy was consistent with SEGA. There were no stigmata of tuberous sclerosis complex. The patient was treated with curative intent by radiotherapy.

Pelvic bone anatomy vs implanted gold seed marker registration for image-guided intensity modulated radiotherapy for prostate carcinoma: Comparative analysis of inter-fraction motion and toxicities

OBJECTIVES We compared the prostate motion variability and toxicities between patients treated with gold marker registration based IG-IMRT (IG-IMRT-M) and bony landmark registration based IG-IMRT (IG-IMRT-B). METHODS T1c-T3b (node negative), intermediate and high risk (non-metastatic) adenocarcinoma of prostate, age ≥18years, Karnofsky Performance Status of ≥70 were included in this retrospective study. The prostate motion variability, acute and late radiation toxicities between the two treatment arms (IG-IMRT-M versus IG-IMRT-B) were compared. RESULTS Total of 35 patients (17 for IG-IMRT-M and 18 for IG-IMRT-B) were treated with a median radiotherapy dose of 76 Gray. The prostate variability observed with and without markers in millimeter was 4.1±2.3 vs 3.7±2.1 [Antero-Posterior (A-P); p=0.001], 2.3±1.5 vs 2.1±1.2 [Superior-Inferior (S-I); p=0.095] and 1.1±1.7 vs 0.4±1.4 [Left-Right (L-R); p=0.003]. There was higher acute toxicity in IG-IMRT-B arm compared to IG-IMRT-M arm in terms of grade ≥2 diarrhea [50% vs 11% OR=7.5 (1.3-42.7); p=0.02] and grade ≥2 proctitis [38% vs 5.8%, OR=10.1 (1.09-94.1); p=0.04]. At a median follow up of 36months, the late genitourinary toxicities grade ≥2 [27% vs 0%; p=0.04] were higher in the IG-IMRT-B arm compared to IG-IMRT-M arm. CONCLUSIONS IG-IMRT-M detects higher prostate motion variability as compared to IG-IMRT-B, inferring a significant prostate motion inside fixed pelvic bony cavity. The addition of marker based image guidance results in higher precision of prostate localization and lesser acute and late toxicities.

Carcinoma of the oesophagus, with multiple cutaneous metastases

A 42-year-old woman was referred, for adjuvant treatment, by an oncosurgeon (outside our centre) after a transhiatal oesophagectomy and gastric pull-up for middle one-third squamous cell carcinoma of the oesophagus pT3N1M0. She underwent adjuvant chemoradiotherapy (CRT) to the tumour bed, regional nodes and scar. RT dose planned was 45 Gy in 25 fractions over 5 weeks. During the second week of RT, a painful nodule was observed over the lower back and cytology was positive for squamous cell carcinoma. Hypofractionated radiotherapy (RT) was planned for this skin nodule as 30 Gy in 10 fractions over 2 weeks using electron beams for pain palliation. Two months later, another nodule developed at the surgical scar on the anterior abdominal wall along with lung and liver metastases. This nodule was also given palliative RT. The patient tolerated the treatment well and had partial pain relief, and, in view of poor prognosis, was advised best supportive care.