ESTRO / TMH EBM 2005 International Symposium

Abstracts

A Case of Melanotic Neuroectodermal Tumour of Infancy: Surgical Management

The Case and Management: Five month old female child was brought to the Oncology Center Army Hospital (R&R) N Delhi with complaints of a rapidly growing mass of the right maxillary region. CT scan showed the lesion to involve the right upper alveolus, adjacent palate, and anterior wall of the maxilla. There was no soft tissue extension or metastasis. Biopsy done revealed the lesion to be a Melanotic Neuroectodermal Tumour of Infancy.

Problem faced was of a child with a lesion needing surgical excision which had the potential of producing severe disfigurement and functional handicap especially in a breast and bottle fed child with undeveloped dentition.

Surgical excision was done with preservation of the lateral palatal flap and excision of the lower part of the right maxilla and the adjacent tumour bearing palate. The buccal mucosa and the palatal mucosa were sutured together to obturate the palatal defect. Post op recovery was uneventful. Child is under follow up and has now started developing milk teeth which will be used for anchoring the prosthesis to prevent growth related facial dyssymetry.

Discussion: MNTI is a rare lesion of the growing skeleton. Other differential diagnosis in such a case are odontogenic neoplasms and sarcomas. The tumour is a benign lesion with rapid growth potential. Approximately 200 cases are reported in English literature. The mainstay of treatment is surgical excision which is associated with a recurrence in approximately 15% cases in 1-2 yrs. The problem of surgical excision is that it is frequently deforming and disfiguring due to the removal of growing facial skeleton resulting in functional and social handicap. Surgical excison must always be accompanied by enthusiastic and energetic prothetic and orthotic support.

Chemotherapy is not known to be effective in management of these lesions however a recent series of successful chemotherapy has been reported in the Journal of medical paediatric Oncology.

The aim of presentation of the case is to highlight successful surgical management with minimal functional and facial aesthetic impairment.

Mahavir Cancer Sansthan Patna

Background: Since inception goal of radiotherapy is to deliver a high dose to tumor with sparing of normal tissue. With brachytherapy there is rapid fall of dose beyond implanted area, thus delivering high dose to tumor with sparing of surrounding normal tissue.In node negative lip cancers surgery & radiotherapy produces equal results but radiotherapy is considered superior as it causes less functional & cosmetic deficit.

Method: We present 20 cases of cancer lip treated with HDR BRACHYTHERAPY these include T1-5, T2-8,T3-5,T4-2. Interstitial implatation was done using flexible plastic tubings or rigid stainless steel needles with templates.All the implants were done under local anaesthesia.A dose of 45 to 51 GY in 15 to 17 fraction ,3GY per fraction ,two fractions per day with a gap of six hours between two fractions was delievered for T1 &T2 tumors.For T3 &T4 tumors A dose of 24 to 30 GY was delivered by HDR brachytherapy & 36 to 40 GY by EBRT.

Result: With A mean follow up of 18 months overall local control is seen in 85 % of the patients. One patient with T2 disease had nodal failure after 2 months & was salvaged by surgery.One patient with T3 disease had local residual disease & was salvaged by surgery . One patient with large T4 disease had persistent disease.All patients had localized Gr 111 mucositis wich healed in 4 weeks.

Conclusion: HDR brachytherapy is highly effective in cancer lip & it gives excellent functional & cosmetic results

A Phase II Study Evaluating the Role of Concomitant Paclitaxel (T) and Capcetabine (X) with Conventional External Beam Radiation Therapy (EBRT) in Locoregionally Advanced Squamous Cell Cancer Head & Neck (LASCCHN Stage III-IV)

Pranav Chadha, Ishu Sharma, Sandhya Sood, Parveen Kaur,
Rajesh Vashistha, Arvind Verma

Department of Radiation Oncology, Mohan Dai Oswal Treatment & Research Foundation, Ludhiana, Punjab, India

Purpose: To evaluate the efficacy & toxicity of Concomitant T+X with conventional EBRT in LASCCHN Stage III-IV.

Materials and methods: No. Of Patients (Pts) enrolled in the study=15.
Inclusion Criteria:
1. LASCCHN Stage III-IV, T3-T4, M0
2. Age <65 Years
3. Karnofsky Performance Scale >60
Exclusion Criteria:
1. Diabetes Mellitus, Hypertension, IHD
2. Salivary Gland Tumors, Sinus Tumors.
15 Pts as per the above criteria were treated with following treatment plan:
Conventional EBRT 65-72 Gy on TH-780 (Telecobalt) with Concomitant Chemotherapy:
T 40 mg/m2 weekly 6 cycles + X 450mg/m2 BID for 2 weeks followed by 1 week rest

Results: 15 male patients with Stage III/IV head and neck cancer were entered. 14 evaluable. 62% were T4 and 87 % were N2 or greater. The median age was 50(range 44-64). No. Of evaluable Pts = 14; 1 defaulted. The response (As per RECIST Criteria) assessed at 2 weeks of completion of therapy
Complete Response (CR): 9/14=64%
Partial Response (PR): 3/14=21%
Overall Response (CR+PR)=85%
Stable Disease (SD): 1/14=7%
Progressive Disease (PD): 1/14=7%
2 Months follow up 9/14 Pts. (CR) remain disease free.
1/14 Pt developed PD undergoing Chemotherapy. 4/14 Pts had PR+SD out of which 1PR+1SD underwent surgical intervention. Rest 2 PR were inoperable (fixed lymph nodes) & put on Adjuvant Chemotherapy.
TOXICITY (As per ECOG Criteria)
Hematological G3 Neutropenia 5/14,
Dermatological G3 4/14
Mucosal G3 6/14,
Gastrointestinal G3 2/14

Conclusion: The combination of RT with Capecitabine and weekly Paclitaxel is a highly effective regimen associated with acceptable toxicity.

Purpose: To evaluate whether hemoglobin concentration (Hb) has the prognostic value in postoperative radiotherapy for laryngeal cancer

Material/Methods: Medical records of 654 patients treated in Gliwice between 1980 and 2000 were analyzed retrospectively. This included 190 patients with glottic, 192 with supraglottic and 272 with transglottic cancer. All patients had squamous cell laryngeal cancer treated with surgery and postoperative radiotherapy. Patients with gross residual disease after surgery were not included. A multivariate Cox proportional hazard model was used to evaluate an influence of the following variables on loco-regional tumor control: age, sex, TN stage, Hb before and at the end of radiotherapy, total radiation dose, dose per fraction, overall radiation treatment time, interval surgery-radiotherapy and pathological margins in surgical specimen.

Results: A 5-year actuarial loco-regional control rate in a group of 654 patients was 77%. The following variables appeared to significantly and independently influence loco-regional tumor control: Hb at the end of radiotherapy, overall radiation treatment time, pathological margins and N stage. A decrease in Hb of 1.0 g/dl reduced the 5-year actuarial loco-regional tumor control rate by 5%, and such detriment was equivalent to protraction of overall radiation treatment time by 10 days. Hb at the end of radiotherapy appeared to better predict the local effect of therapy than Hb at the start of radiotherapy. The influence of Hb concentration on loco-regional control was most apparent in subgroups of patients with T3-T4 disease, and in patients without metastases to loco-regional lymph nodes (N0). In fact, in T3-4 N0 patients Hb at the end of radiotherapy appeared to be the strongest predictor of treatment outcome among all of the analyzed variables.

Conclusion: Hemoglobin concentration at the end of postoperative radiotherapy appears to be a strong and independent predictor of treatment outcome in combined modality treatment for laryngeal cancer.

Prevention of Head & Neck Cancer-How Much we Have Progressed?

Mahfuz Ariff, Abhijit Sarkar, Somnath Sorcer Saroj Gupta.

Cancer Centre Welfare Home & Research Institute, Thakurpukur, Kolkata
West Bengal, India.

Purpose: Head & Neck cancers are diverse group of malignancies with different etiopathologies, pattern of disease progression & management strategies. Of these Squamous Cell Carcinoma is the largest group and are preventable. It is well established that tobacco use is the primary cause of cancer in this area. There are many attempts to cut down tobacco uses like
• Compulsory warning in cigarette packets.
• Prohibition of sell to people below 18 years.
• Restriction of smoking in public places.
This study is done to assess the trend whether tobacco use restriction measures at all affected the general population which should reduce the numbers of cases in hospital Head & Neck Cancer Deptt.

Material & Method: Number of Squamous Cell Carcinoma cases in tobacco
users are studied in Cancer Centre Welfare Home & Research Institute, Thakurpukur, Kolkata, West Bengal. Since 1996 to 2003. All new cases studied & ratio of all types of cancer in all age groups to tobacco related Head & Neck cancer assessed.

Result & Conclusion: It is seen that in 1996 among 4625 newly registered
patient 928 were tobacco related Head & Neck cancer (21%). In 2003 the incidence is 811 among 4008 patient (22%). It is observed by this acid test that all attempts to restrict tobacco use has not been able to reflect it?s success in reducing tobacco related Head & Neck Cancer.
In India, tobacco is used in different forms like Khaini, Nassi, Guraku, Jarda, Bidi, Cigarette. Most of the oral cancer is preceeded by precancerous lesion hence primary prevention is possible. Among different methods one to one interaction is the most helpful method. Our dream of Smokeless Society may be achieved if there is complete ban on sell and promotional activity of tobacco use. Can we afford it by loosing million Rupees Govt. income from the industry !?

Safety and Efficacy of Concomitant Boost Radiotherapy with Concurrent Weekly Cisplatin in Advanced Head and Neck Cancers

Manish Pandey ,Shaleen Kumar , Punita Lal, Neeraj Rastogi, K. Joseph Maria Das, Kislay Dimri

Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India

Background and purpose: To determine the safety and efficacy of concomitant boost radiotherapy (CBRT) with concurrent cisplatin chemotherapy (CT) in advanced head and neck cancers.
Patients and methods: Between February 2000 and June 2001, 77 previously untreated patients of advanced head and neck cancers(pharyngeal region) were treated with EBRT and concurrent cisplatin CT. CBRT consisted of: phase I-44 Gy/22fx/4.5 weeks, phase IIa-16 Gy/8fx/1.5 weeks and phase IIb-10 Gy/8fx (delivered as a second daily fraction after a gap of 6 h along with phase IIa). CT (cisplatin 35 mg/m2) was administered weekly usually preceding EBRT by an hour.

Results: The median follow-up was 39 months (range 8-50 months). EBRT compliance (70 Gy in 40-44 days) was seen in 71% (52/77). Six cycles of CT was delivered in 61% (47/77). Acute grade III/IV mucosal toxicity was seen in 69% and resulted, on average, in a total weight loss of 6.9 kg from a mean pretreatment weight of 54 kg. Nasogastric tube placements were required in 16%(12/77). Grade III leucopenia was seen in 2%. Crude incidence of late subcutaneous fibrosis (grade III) was 18% (09/77) and a case of mandibular necrosis and thyroid cartilage necrosis each were seen. Initial loco regional disease clearance was seen in 72% (55/77) and the Kaplan-Meier estimates of 3-year loco-regional control rate and overall survival were 45% and 50% respectively.

Conclusions: Study highlights the need for extreme caution when using CBRT with concurrent cisplatin in a population of the advanced ,unrescetable head and neck cancers treated in a setting of developing countries.

Suparna.H.C., Vidyasagar.M.S., Rao Koteshwer.K., Fernandes D.J.,Choudhary Rajiv, Vadiraja B.M., Seetharamiah T.S.

Purpose: Cancers of head and neck region constitute more than 50 % of cancers diagnosed in India. Advanced head and neck cancers are treated with combined modality with radiation and surgery. When surgery is not feasible, radiation has been used as a sole modality with 5-year survival of less than 10 %. Main factor for failure is loco regional failure. Rapid repopulation has been identified as one of the major cause for this. Various accelerated fractionation schedules have been tried to overcome this. A prospective study was conducted to compare the immediate response of the tumor and normal tissue reactions in patients treated with accelerated fractionation regimen with conventional fractionation.

Materials and methods: Patients with squamous cell carcinomas of head and neck, with Stage III and stage IV a/b were included. Each arm had 25 patients. Study group patients received total dose of 60 Gy/30 # over 4 ½ weeks, 7 days a week (continuous accelerated irradiation- CAIR). Control group patients received 66 Gy/33 # over 6 ½ weeks. Tumor response was assessed at the end of treatment and monthly for 3 months. Acute reactions were scored according to RTOG radiation morbidity scoring criteria and assessed during the treatment.

Results: Tumor control at first month and at the end of 3 months in study group was better, by 10 % and 11 % respectively. But this difference was statistically not significant. Skin reactions were significantly lesser in study group whereas mucosal and salivary reactions were higher.

Conclusion: Response of the tumor to CAIR did not show any statistically significant difference compared to conventional radiotherapy. Assessment of reactions in CAIR group showed reduced skin reactions and more mucosal and salivary reactions. A larger sample size and longer follow up is required for assessment of survival benefit.

Near Total Laryngectomy for Advanced Cancers of the Larynx and Pyriform Sinus: Is It Here To Stay?

Aim: The study of Pearson near total laryngectomy (NTL) highlights the efficacy in T2, T3 and early T4 lesions of the larynx and pyriform sinus (PF), which were deemed “too big” for control with either definitive RT or function preserving partial laryngectomy.

Materials and Methods: Till date 172 cases (60-larynx, 112-PF) were prospectively analysed with respect to disease control at 5 years, morbidity and functional outcome associated with the procedure. The material was analyzed after completion of 55 cases, then 105 and 172 cases. The 3-year projected Kaplan Meier survival analysis has yielded 71% and 66% for larynx and PF tumors respectively at the end of first analysis.

Results: At the completion of 105 cases, there was a decline in wound related morbidity from 68% to 28% in lesions of PF and from 21% to 12% for larynx. This was maintained at final analysis. Three perioperative deaths due to other co-morbid conditions at the end of 105 cases and none thereafter. Shunt related transient symptomatic aspiration declined from 44% to 36% and 10.25% to 9.8% in larynx and PF lesions respectively. Three patients required surgical closure. Shunt stenosis, impeding speech was seen in 10 cases of PF and 2 of larynx cases. Intelligible speech was found in 68% and 83% of PF and larynx cases respectively.

Conclusion: Authors feel that Pearson NTL offers comparable disease control to total laryngectomy. Additionally, there seems to be a learning curve for minimizing local wound problems. Finally, gratifying functional outcome with 75% to 80% patients achieving prosthesis free high quality speech and aspiration free swallowing in more than 90% patients makes a strong case for propagation and practice of NTL in Indian subcontinent.

Chemo-Radiotherapy for Advanced Larynx and Pyriform Cancers- Is it Practical in Developing Nations?

Purpose: Chemo-radiotherapy (CT+RT) is gaining popularity globally in an attempt to preserve larynx. There are certain reservations in accepting this larynx preservation protocols (LPP) in its current forms in developing nations.

Material and Method: A systematic review of the chemo-radiotherapy based larynx preservation randomized trials (VA study, EORTC study, RTOG study, MACH NC meta -analysis) was done. A review of other related literature was also done.

Results: CT+RT has a potential role in larynx preservation and concomitant CT+RT offers the best results. The reservations in accepting CT+RT as standard of care in advanced larynx cancer patients in developing countries are as follows-

- Concomitant CT+RT has a definite benefit over RT alone and Induction CT+RT. However its superiority over surgery followed by post operative RT has not been proven. It requires an excellent performance status ( KPS> 80 in 90% of the patients in RTOG trial). Therefore, the poor nutritional status of patients in developing countries is a significant deterrent.
- It is accompanied by significant increase in overall toxicity that warrants increased need for supportive care and patient motivation. It is accepted that incidence of treatment modification, treatment interruption and hospitalizations increase significantly.
- The benefit of LPP is maximum in low volume diseases (> two third of the lesions in RTOG trial were T2/T3 and N0/N1). Its role in high volume disease (T3/ T4 and N2 / N3 ) is still unproven.
- Majority of the lesions in published CT+RT trial are laryngeal cancers. There is no robust evidence that it is equally effective in pyriform cancers, which forms a major component of laryngo-pharyngeal cancers in such countries.
- The indirect costs due to frequent expensive imagings, duration of treatment, duration of recuperation, enhanced need for supportive care and stringent follow up may be exorbitant.
- Given the compliance of our patients a stringent follow-up, a must for LPP, is difficult.
- Post operative morbidity significantly increases when laryngectomy is performed after failure of CT+RT.
- It requires not only a motivated patient but also a team of dedicated oncologists and good infrastructure. Very few cancer centers in India have a specialized Head and Neck service.

Conclusion: Role of CT+RT is not proven in hypopharynx cancers, T4 lesion and N2/N3 lesions. The protocol is feasible in highly selected patients only in good institutions. It would be premature to follow the western “standard of care” in our subset of patients unless its efficacy is proven.

A Prospective Study of Pharyngo-Cutaneous Fistulas Following Total Laryngectomy.

Purpose: Pharyngo-cutaneous fistulas (PCF) is one of the major complications following laryngectomy. Varying rates have been reported and majority of these studies are retrospective.

Material and Method: We critically and prospectively studied PCF with respect to patients, tumor and technique related parameters. The study analyzed 164 consecutive laryngectomies performed by consultants, residents and fellows. 2/3rd were pyriform cancers, 90% were T3/T4 lesions and almost 80% required total laryngectomy (TL) with or without partial pharyngectomy. 80% of the TL had primary closure and remaining required reconstruction depending on the extent of pharyngeal excision. We included frank fistula as major leak and minor leak was defined as – delayed initiation of oral feeds.

Results: In 164 consecutive total laryngectomies we encountered overall 33 PCF (20%) of which 15 (9%) were major and 18(11%) were minor.

All the minor leaks stopped spontaneously within 2-4 weeks of detection.
15 patient with major leak required > 4 weeks of naso-gastric feeding. Eight of these patients had spontaneous closure of the fistula while 7 required pectoralis major myocutaneous flap (PMMC) to reconstruct the pharyngeal dehiscence. Overall, 5 of these patients with major PCF could not undergo adjuvant RT.
Of the 7 patients with major leak who underwent PMMC to reconstruct the pharyngeal dehiscence , 3 had massive leak alone and other 4 were associated with haemorrhage.

PMMC appeared to reduce the fistula output in only in those where PCF appeared within 72 hrs of surgery. PMMC prevented re-bleed in patients who presented with haemorrhage.

3/4th of the PCF occurred with in 2 weeks of surgery and most (87%) were lateralized. Patients with PCF had an average hospital stay of 28 days. Extended pharyngectomy, soft tissue infiltration and a pyriform disease were significantly related to PCF. PCF rates were highest (60%) when extended pharyngeal resection was done that required PMMC for reconstruction of neo-pharynx. While In patient with TL with primary closure the PCF rate was only 14%. Other variables such as surgeon ( Resident Vs Consultant ), type of suture, prior treatment ( RT+/- CT), type of closure, age, sex, nutritional status and stage had no association with PCF.

Conclusion: We witnessed a higher PCF rate because majority of our patients were pyriform cancers with extensive soft tissue invasion that necessitates removal of some part of the pharynx. this results in either a tight closure or reconstruction of neo-pharynx with PMMC. Extensive soft tissue removal during a laryngectomy probably leads to loss of support and vascularity of the remaining mucosa. Unless the leak manifests within 72 hours or manifests as hemorrhage, surgical intervention is futile.

Post-Resection Mucosal Margin Shrinkage in Oral Cancer- Quantification and Significance.

Department of Surgical Oncology. Tata Memorial Hospital. Ernest Borges Road, Parel. Mumbai. India.

Background: Importance of tumor free surgical margin in outcome of oncologic surgery is well known. However, often the pathological margin is reported to be significantly smaller than the in situ margin. This discrepancy is due to margin shrinkage the quantum of which has not been studied in patients with oral cancer.

Objectives: Quantify the shrinkage in mucosal margin following excision in patients with tongue and buccal mucosa cancer.

Methods: In 27 patients with carcinoma of the buccal mucosa/tongue, mucosal margins were measured prior to resection and half an hour after excision. The mean margin shrinkage was assessed and the variables affecting the quantum of shrinkage were analyzed.

Results: The mean shrinkage from insitu status to post resection margin status was 22.7 %. [P<0.0001].The mean shrinkage of tongue margin was 23.5%, compared to 21.2% in buccal mucosa margin. The mean shrinkage in T1/T2 tumors [25.6%] was significantly more than in T3/T4 [9.19%, P<0.01).

Conclusions: There is significant shrinkage of mucosal margins after surgery. Hence this should be considered and appropriate margins should be taken at initial resection to prevent the agony of positive surgical margins.

Qureshi Sajid S 2 MS, DNB, Mistry Rajesh C 1 MS, Gupta Shaikat 3 MS, FRCS, Gupta Sameer4 MS

1, 2, 3, 4 Department of Head and Neck services Tata Memorial Hospital. Ernest Borges Road, Parel. Bombay. India.

Background: Juvenile nasopharyngeal angiofibroma is a rare tumor of adolescent males with a paucity of Indian studies on the subject.

Aims: To present experience of management of juvenile nasopharyngeal angiofibroma at a single institution.

Setting and Design: This is a retrospective observational study of patients with juvenile nasopharyngeal angiofibroma who presented at the Tata Memorial Hospital between May 1988 and August 2001.

Materials and methods: Thirty two patients with juvenile nasopharyngeal angiofibroma were treated in the study period. Since the time period was prolonged and diagnostic and therapeutic protocols had undergone many changes, the patients were divided into two groups, namely 1988-1996 and 1997-2001. The age distribution, disease patterns, management approaches and treatment outcomes of patients in the two groups were recorded. Statistical analyses were done using students‘t’ test and test for proportion.

Results: The mean age at presentation was 16 years and more than 90% of the patients had stage 3 or 4 disease. Preoperative embolisation was carried out in 19 patients. The surgical approaches used were median maxillectomy, infratemporal fossa, transpalatal, maxillary swing and craniofacial approach. The recurrence rate, complete resection rate and cure rates were 12.5%, 41% and 63% respectively.

Conclusion: Surgery is the mainstay of treatment of JNA. Preoperative embolisation and newer surgical approaches results in less blood loss and complete resection. Aggressive re-resection should be done for resectable recurrences reserving radiotherapy for unresectable, recurrent/ residual disease.

Squamous Cell Carcinoma of the Maxillary Sinus:
A Tata Memorial Hospital Experience

Qureshi Sajid S. 1 MS, DNB, Devendra Chaukar A.2 MS, DNB,
D’Cruz Anil K. 3 MS, DNB, Talole Sanjay D 4 MSc, DCM

1-3 Department of Head and Neck services, 4 Department of Biostatistics, Tata Memorial Hospital. Parel, Mumbai, India

Context: The optimal treatment of maxillary sinus carcinoma remains to be defined and there is a paucity of Indian studies on the subject.

Aim: To present experience of management of squamous carcinoma of maxillary sinus treated with curative intent at a single institution.

Settings and Design: Retrospective study of patients with squamous carcinoma of maxillary sinus who presented between 1994 to 1999.

Methods and Material: The records of 73 patients with squamous cell carcinoma of maxillary sinus were analyzed. Sixty-two patients were evaluable. Forty patients were treated with surgery followed by postoperative radiotherapy, five patient were treated with radiotherapy alone, five patients were treated with surgery alone; 19% patients received chemotherapy. Statistical analysis used: Statistical analysis was done using Kaplan-Meier method.

Results: The majority of patients presented with locally advanced disease (83%); nodal involvement was observed in 8%. The most common site of recurrence was at the primary site, which was observed in 45% and regional failures occurred in 16%. The 3 and 5-year overall survival was 38% and 35% and the disease free survival was 29% and 26% respectively. The 5-year overall survival after surgery and postoperative radiotherapy was 42%.

Conclusions: Majority of patients present with advanced disease resulting in poor outcomes to conventional treatment modalities. Locoregional tumor progression remains a significant pattern of failure. New approaches such as neoadjuvant or concomitant chemoradiotherapy with aggressive surgery need to be considered and evaluated in prospective studies.

The Role of Subcutaneous Amifostine as a Radioprotector in Head and Neck Carcinoma patients

Department of Radiation OncologyM.G.M. Medical College and Govt. Cancer Hospital, Indore

Head and neck carcinomas constitute 5% of all tumours worldwide and are rather more common in our country. External radiotherapy is the standard modality of treatment for these cases irrespective of the site. The treatment modality is, however, an uphill task for the patient due to many side effects of radiotherapy viz. xerostomia, mucositis, dysphagia and skin toxicity, etc. which sometimes prove to be intolerable and thus lead to non-compliance of the patients. This study aims to ameliorate these side effects by use of amifostine (WR 2721) and test its efficacy as a radioprotector of normal tissues. It also aims to test the advantage of subcutaneous route of administration of amifostine over other routes. 23 patients were included in this study, both in study arm and control arm. Both study and control arm patients received 50-70 Gy by external radiotherapy using bilateral or wedge-paired fields in accordance with stage and status of the disease. The study arm patients, in addition received Inj. Amifostine (250 mg/m2) subcutaneously, 15-20 minutes prior to each fraction. Patients were reviewed daily for tumour response to therapy, acute mucositis and xerosis, skin reaction, dysphagia and haematological toxicity. They were followed-up monthly after completion of therapy for persistence of any side effects and response. At the end of the study it was concluded that Amifostine not only reduces the severity of the side effects of radiotherapy but also delays them, also, subcutaneous route of administration is efficacious, safe and practical.

Laryngeal Preservation: Brachytherapy. A Novel Approach in Suprahyoidal Supraglottic (Epiglottis) Cancers

Rajendra L. Bhalavat, MD• A. R. Fakih, FRCS• Rajesh C. Mistry, MS • Umesh Mahantshetty, MD•

• Department of Radiation Oncology, • Surgical Oncology Tata Memorial Hospital Mumbai, India

Introduction: Radical radiotherapy remained an option without question to surgical treatment for this lesion but with resultant xerostomia and poor quality of life post RT. Brachytherapy with a novel approach through thyrohyoidal membrane was introduced particularly for lingual epiglottis and vallecular lesion to lower the external radiation dose. Aim: To report my experience with the use of interstitial Iridium 192 implant combined with external radiotherapy in the treatment of carcinoma of the epiglottis.

Materials and Methods: Between 1990 and 1999, 20 patients with carcinoma of the epiglottis were treated with a radical intent using moderate dose external radiotherapy and interstitial implant. The mean and median age at presentation was 61 years respectively (Range 40 013 86). There were 17 males and 3 female patients. All patients had squamous cell carcinoma of the epiglottis with varying degrees of adjacent spread. One patient (T1) was treated with a radical implant. Other patients (10 with T2 and 9 with T3) were treated with external radiotherapy and implant, with a mean delay of 30 days. There were five patients with nodal disease (N1). Mean external RT dose was 47 Gy and the mean brachytherapy dose was 28 Gy. Technique: The epiglottis was approached through the thyrohyoidal membrane and two different techniques were used for implant.

Results: Twenty patients were analyzed to determine local control and complications. Complete Response (CR) was observed in 65% (13/20) and Partial Response (PR) was seen in 30% (6/20). After the implant Complete Response was seen 95%(19/20) patients.There were 5 loco-regional recurrences one of which was salvaged. Six patients had edema of the epiglottis and 3 patients had ulcers/necrosis of the epiglottis. Median Disease Free Survival (DFS) and Overall Survival (OAS) was 36 months. There were a total of 7 deaths, 2 due to disease and 5 due to other causes. Five-year DFS and Cause Specific Survivals were 65% and 85% respectively.

Conclusion: Brachytherapy is a viable organ salvage approach to mutilating surgery for cancer of the Epiglottis.

Radical Radiation Vs Surgery Plus Post-Operative Radiation in Advanced (Resectable) Supraglottic Larynx and Pyriform Sinus Cancers - A Prospective Randomized Study

Rajendra L. Bhalavat, MD• A. R. Fakih, FRCS• Rajesh C. Mistry, MS •
Umesh Mahantshetty, MD•

Department of •Radiation Oncology, • Surgical Oncology Tata Memorial Hospital Mumbai, India

Background and Purpose: Survivals in Head and Neck cancers are a reflection of loco-regional control. With an aim of organ and function preservation present study was undertaken to compare local failure and survivals.

Material and Methods: Between Aug '91 - Dec '95, 72 patients with resectable advanced supraglottic cancers, were randomized to radical surgery followed by post-operative radiation therapy [Sx+PORT] (Arm I) or radical radiation therapy followed by salvage surgery [RRT+/-SSx] (Arm II).

Results: Sixty-four of 72 patients were evaluable, 55 were T3 (86%) & 9 - T4 (14%) tumors. In Arm I (n=35), with a mean follow-up of 24 months (2 - 86 months), 21 patients were alive without disease. Six patients had recurrence, 1 each at local and tracheostomy stoma, four had nodal recurrence only and 2 developed 2nd primary in soft palate / tonsil and parotid at 15 months and 18 months resp. In Arm II (n=29), with a mean follow-up of 24 months (3-81 months), 14 patients were alive without disease. Thirteen patients had recurrence, 8 had local (1 patient had persistent disease), 2 nodal only, 3 loco-regional and 2 patients developed distant metastasis (lung). One out of eight local recurrence & 2/2 nodal recurrences were salvaged with Sx. There was a significant difference in disease-free survival between the two treatment arms, DFS (5 years) of 70% in Arm I Vs 50% in Arm II (p= 0.04), but did not have any impact on overall survival OAS (5 years); 73% Vs 77% (p= 0.79). Voice/laryngeal preservation was possible in 18/29 patients (60%) treated with RRT +/- Sx, without significantly affecting the OAS. ‘Pathological upstaging’ was another significant finding seen in 64% of clinical T3 after radical surgery.

Conclusion: RRT+/-SSx can be a feasible option in low volume, favourable resectable stage III and IV supraglottic lesions for better quality of life.

Head & Neck Squamous Cell Carcinoma: The Role of Post-Operative Adjuvant Radiotherapy

*K.A.Dinshaw, *S.K.Shrivastava, *J.P.Agarwal, *S.Ghosh Laskar, *T.Gupta, $A.K.D’cruz

Department of Radiation Oncology $ Department of Head & Neck Surgical Oncology Tata Memorial Hospital, Mumbai, India.

Introduction: Head and Neck Squamous Cell Carcinoma (HNSCC) is one of the leading cancers in India. Since a large majority present in loco-regionally advanced stages, surgery followed by adjuvant post-operative radiotherapy (PORT) has been the mainstay of treatment for resectable HNSCC.

Aim: To identify clinicopathologic factors that could have an impact on outcome in HNSCC in the post-operative setting.

Material & Methods: A retrospective review of 348 previously untreated HNSCC who received PORT following curative surgery. The outcome measures were local control, loco-regional control and disease free survival (DFS).

Results: With a median follow-up of 36 months (range: 2-127 mths) for surviving patients, the 5-year local control, loco-regional control, and DFS was 79%, 63% and 56%, respectively for the entire group. On univariate analysis site of primary was an independent prognostic factor for all outcome measures (p=0.005;0.02;& 0.04, respectively) with oral cavity lesions faring the worst. Peri-nodal extension (PNE) affected loco-regional control (p=0.002) and DFS (p=0.0005) but was not predictive for local control (p=0.9852). Cut margin positivity predicted for inferior local control alone (p=0.03), the significance of which was lost on multivariate analysis. Cox regression analysis however confirmed the significance of primary site and PNE as independent prognostic factors. Conclusion: Primary site and PNE are independent factors predicting outcome in the post-operative radiotherapeutic management of HNSCC.

Submandibular Salivary Gland Transfer (SMSGT) in Patients Undergoing Radical Radiation Therapy for Head and Neck Cancer: A Pilot Study

R.L.Bhalavat1, A Budrukkar1, K A Pathak1, M S Deshpande1, B.L.Malpani2, S.R.Desai1,

Introduction: Permanent xerostomia is a reflection of damage to salivary glands and is invariably observed in patients with head and neck cancers treated with radical radiation therapy (rRT). Submandibular salivary gland transfer (SMSGT) is a novel technique of transferring one of the submandibular salivary glands into the submental space so as to improve the salivary function. Here we report our experience with upfront SMSGT for patients with early oropharyngeal or laryngeal cancers treated with rRT+/-brachytherapy.

Aim: To assess the feasibility of SMSGT prior to rRT in patients with early oropharyngeal and laryngeal cancers and evaluate its impact on salivary output, radiation compliance and QOL post radiation.

Patients and methods: From April 2000, 32 patients of SCC of oro-hypopharynx T3/2, N0-1 receiving curative radical radiotherapy were considered suitable for SMSGT. Baseline salivary function was assessed through salivary scintigraphy (SCT), sialography (SG) and sialometry for each patient and was repeated after the surgery and at subsequent follow ups. Contralateral submandibular salivary gland was transferred to the submental space and radio-opaque markers were placed to identify the transferred gland. Patients were planned for rEBRT with simulated bilateral portals and the transferred salivary gland was blocked during the treatment. Subjective evaluation of quality, quantity with resultant xerostomia, odyno/dysphagia, speech and taste disturbances were recorded for each patient at 20Gy, 40Gy, 60Gy, and at subsequent follow-ups (3,6,12,18---months).

Results: Quantity and quality of saliva was found to be practically normal in 53% at 20Gy, viscous (sticky) in 78% at 60 Gy and improved to near normal by 1 year. Xerostomia was none to acceptable in 49% at 20Gy while grade II / III xerostomia was observed in 50 % of the patients at completion of R T, 23% at 6 months and 11% at 1 year. There was improvement in both the mean salivary output as measured by suction method in the transferred gland which is a reflection of total salivary output as measured by spit method.

Conclusion: SMSGT is a surgically feasible procedure (oral oncology 04). SMSGP of contralateral side as an adjunct to rRT leads to improved compliance during radiation and possibly helps in reducing xerostomia Early results show both subjective & objective improvement of xerostomia. Long term improvement of xerostomia and it’s translation into improved QOL is a subject of long follow up.

Carcinoma of Cervix: External Beam Radiotherapy alone External Beam with HDR Brachytherapy: A GMC Experience

Dr. Vijay K Mahobia, Dr. O P Singh, Dr. HU Ghori, Dr. Ashok Diwan

Dept. of radiation oncology, Gandhi Medical College and Hamidia Hospital, Bhopal, M. P

Carcinoma of cervix is most common malignancy seen among the Indian women. Due to lack of awareness low socioeconomic status and shyness, these patients present with advanced stage. In our department too, carcinoma of cervix is a common malignancy. Before HDR installation they were treated with external beam radiotherapy because they do not want to go for intracavitary elsewhere. After HDR installation, suitable patients of these were treated with combination of external beam radiotherapy and HDR intracavitary application. 30 patients in each arm were compared and it was observed that patient receiving combination radiotherapy responded better in terms of tolerance survival and quality of life.

A Prospective Study of Various Regimens using External Radiation Therapy and HDR Brachytherapy in Locally Advanced Carcinoma Cervix

Methods: From June 2000 to August 2002, 55 patientswere enrolled in a study to evaluate the variousregimens of external radiation therapy and HDR Brachytherapy with (or) without platinum based chemotherapy. External radiation
therapy of 50- 60 Gywas given followed by brachytherapy by Nucletron Microselectron HDR machine, 5 - 8 Gy/ fraction x 2 fractions to point A depending on the bladder and rectal dose was delivered.

Results: The Bladder dose by Brachytherapy was < 40% in 3 patients, 41-60% in 15 patients, 61 - 80 % in 20 patients, 81 - 100% in 10 patients, > 100% in 6 patients. The Rectal dose by Brachytherapy were < 40% in 1 patient; 41 - 60% in 10 patients; 61-80% in 31 patients; 81-100% in 11 patients and > 100% in 1 patient. Total doses were 1-62 Gy eq ; 3 -70 Gy eq; 2 -72 Gy eq; 2 -74 Gy eq; 37-76 Gy eq; 4 -78 Gy eq; 4 -80 Gy eq and 1 -85 Gy eq.

Response and Survival: 4(7.5%) Patients had residual disease. 6 (11%) patients had local recurrence. 3 (6%) patients had nodal failure. 3 (6%) patients had distant failure. The follow-up ranged from 24 months to 51 months, The average disease free survival was 22 months and average overall survival was 31 months.

Conclusion: External radiation dose of 60 Gy in 30 fractions by 4 field box technique, 200 c Gy /fraction, 5 days a week followed by 2 fractions of HDR Brachytherapy of 5 - 7 Gy/fraction with (or) without chemotherapy gives a good local control of 82%at 2 years for locally advanced Carcinoma Cervix. The bladder and rectal toxicities were acceptable.

A Prospective Comparative Study of Concurrent Chemoradiation Vs Radiotherapy Alone in Locally Advanced Carcinoma of Cervix

Aims: To compare overall survival, disease free survival and local control rate in patients receiving concurrent Chemoradiation Vs Radiotherapy alone in locally advanced Carcinoma of Cervix.
To define pattern of failure
To assess treatment related toxicity.

Materials and methods: Women with locally advanced carcinoma of cervix seen at Regional cancer centre Trivandrum between May 200 and May 2001 were included in the study. Locally advanced disease was defined as International Federation of Gynaecology and Obstretics (FIGO) stages IIB – IVA and those with stage IB/ IIA lesions >/= 4 cm in diameter
Patients meeting above criteria were divided into two arms:
Arm I: Radical radiotherapy with concurrent chemotherapy using Inj. Cisplatin 40 mg/m2 weekly x 5 cycles.
Arm II: Radical radiotherapy alone.

Results: A total of 141 patients satisfied the eligibility criteria and were enrolled in the study. 72 patients were assigned to receive concurrent Chemoradiation and 71 patients were assigned radiotherapy alone. 6 patients were excluded from study due to various reasons, thus leaving a total of 137 patients for analysis. Maximum follow time was 27 months and median follow up was 18 months. 61 patients in Chemoradiation arm (89.7%) and 53 patients (76.8%) were alive at the time of analysis. (7 patients in Chemoradiation arm and 16 patients in RT alone arm died). Kaplan –Meier analysis was used to calculate survival rates. 2 years overall survival was 73.5 % in Chemoradiation arm compared to 61.2 % in radiation alone arm (p=0.52). Disease free survival at 2 years was 75.1 % in Chemoradiation arm and 65.8 % radiation alone arm (p=0.19). Local failure occurred in 5 patients (7.4 %) in Chemoradiation arm and 10 patients (27.5 %) in radiation alone arm. Kaplan –Meier analysis revealed that 2- year local control was 91.8 % for Chemoradiation arm compared to 82.8 % for radiation alone arm (p=0.14). Acute toxicity was more frequent with combined arm than with radiotherapy alone.

Conclusion: This prospective study revealed a tendency towards improved survival in patients with locally advanced carcinoma of cervix receiving concurrent Cisplatin based chemotherapy along with pelvic radiation. However long term follow up is necessary to evaluate whether this improvement in survival is of statistical significance.

Carcinoma uterine cervix is the most common malignancy among female in our setup. Most of them report to hospital in advanced stage of their disease. Hence external radiotherapy followed by brachytherapy remains the best treatment for them. Many times due to poor geometry of pelvis, dose delivered by intrcavitary method is not adequate. Hence for better dose homogeinty, interstitial brachytherapy using HDR Microselectron and MUPIT [Martinez Universal Perineal Interstitial Template is performed. So far we have treated 160 patients in last 5 years. Maximum followup is 45 months and 5 years control rate is about 35%. Complications were observed in 8 to 10 % of cases.
It appears that MUPIT is very useful method of internal radiation among patients with poor pelvis geometry.

Govt.Arignar Anna Memorial Cancer Hospital Karapettai, Kancheepuram.
Tamil Nadu State.

Govt. Arignar Anna Memorial Cancer Hospital, Kancheepuram was conducting cancer screening for cancer cervix and oral cancers from 1969. The cervical cancer screening was started at Kancheepuram and extended to Districts. In 2003 screening was conducted in Govt.Arignar Anna Memorial Cancer Hospital, Kanchepuram, one at Head Quarters Hospital, one at Govt.Hospital (Taluk) and four taluk Head Quarters Hospital. Total No.of camps conducted 158. No.of pap smears done was 9861. 225 at risk cases and 99 cancer cervix cases were detected in the year 2003. The stage wise cancer cervix patients treated in Govt.A.A.M.Cancer Hospital, Karapettai, Kanchepuram was as follows:

In the year 2004 National Cancer Control Programme (NCCP) was taken to 4 Districts and screening was conducted in:
Govt.Arignar Anna Memorial Cancer Hospital, Kancheepuram
Two District Head Quarters Hospital
3. One Govt.Hospital
4. 9 Taluk Head Quarters Hospital
5. 10 Primary Health Centres.
Total no. of cancer screening done was 457, total no. of pap smear done was 21,812.The total no. of at risk cases detected was 267 and the total no. of cancer cervix cases detected was 243 (including 23 cases which were at risk cases turned ut to be malignant)

Cancer Cervix cases treated in 2004

Period	StageI (%)	Stage II (%)	Stage III (%)	Stage IV (%)	Total
Jan to June 2004	32(11.07)	122(42.21)	130(44.98)	5 (1.7)	289
July to Dec 2004	53(18.4)	115(40.06)	113(39.37)	6(2.09)	287
Total	83	237	243	11	576
Percentage	14.76%	41.15%	42.2%	1.9%

Due to effective screening the no.of late stages of cancer cervix was reduced and early stages like stage I & II were detected and treated. The District Cancer Control Program conducted effectively in all the Districts will be able to detect the at risk cases and by treating them and preventing them to proceed to cancer cases.

Concurrent Cisplatin with Radiotherapy in Carcinoma Cervix- A Report on Toxicity Profile and Outcome

Anu Tiwari, Punita Lal, Partha P Mohanty, Neeraj Rastogi, Saibish Kumar E P*, Shaleen Kumar.

Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Science, Lucknow.

Purpose: Impact of concurrent cisplatin(CDDP) with external radiotherapy (RT) on compliance, degree of acute and late toxicities and outcome.

Methods: Advanced /postoperative cervical cancer treated with concurrent CTRT (Single (108)/combination(8)) in 2 schedules i.e. 35mg/m2 at weekly or 100mg/m2 at 3 weekly interval in 2-5 cycles during external RT. Whole pelvis RT was given by a 4 field technique (50.0-50.4Gy/25-28 fr) followed by 3 intracavitary insertions using standard applicators or 2 sorbo applications (post operative). 6Gy to point A (0.5 cm from applicator surface for sorbo) was delivered in a once weekly fraction by a Microselectron HDR unit.

Results: 116 patients received concurrent CDDP and RT between February’98 to October’04. Median age was 50years. Definitive CTRT was administered in 108 cases; postoperative CTRT -8 cases. Planned 5 weekly cycles could be administered in 72 patients. Reasons for non compliance were obstructive uropathy (7); hematological toxicity (15); GI(13); extraneous reasons(5). Acute toxicity was 4% grade III upper GI; 9% grade III/IV lower GI ; 2% grade III/IV GU; 4.5% grade III hematologic. Late grade III/IV bladder and rectal toxicity were seen in 3.5% and 7% respectively; vaginal stenosis - 5%. No acute toxicity related death was seen; 2 patients died of grade IV late rectal toxicity. Complete response and good partial response (80% resolution) were seen in 63% and 28% respectively. At 3yrs, DFS and OS were 45% each.

Conclusions: Although acute and late morbidity were enhanced, but manageable. The outcomes are encouraging and is being compared in a randomized trial.

Identification of Molecular Markers in Carcinoma of the Uterine Cervix for the Predictions of Patients’ Response to Radiotherapy

Muhammad Jamal*, U. Samant*, H.D. Dani*, S.K. Shrivastava#, K.A. Dinshaw#,
D. Bandopadhyaya*

Division of Laboratory Medicine*, Department of Radiation Oncology#
Tata Memorial Hospital, Parel, Mumbai.

Radiotherapy is considered to be the most important non-surgical treatment option for the carcinoma uterine cervix. Several clinical markers such as stage, volume, histological type and grade, presence of lymphovascular invasion and lymph node status are known to correlate with radiation response. However, the benefit from radiotherapy in carcinoma cervix remains limited due to the association with radiation resistance.

Studies in last decade have indicated that knowledge of radioresponsiveness of individual tumors might influence the radiotherapeutic outcome. A number of assays have been developed for the assessment of radiosensitivity of tumors. Clonogenic assay quantitates the surviving fraction of the tumor cells after 2 Gy(SF2) and has been shown to be helpful in predicting the radiotherapeutic outcome mainly in arcinoma of cervix. However, conventional form of clonogenic assay is not suitable for routine clinical use due to longer assay time and high failure rates.

Identification of new radiobiological factors and predictive markers are therefore necessary for developing a simple, reliable and rapid assay that can predict the radiosensitivity of the tumor before the commencement of the radiation treatment. This knowledge willl help to individualize radiotherapeutic regimen and reduce normal tissue morbidity in patients with carcinoma cervix.

We are presenting here the differential expression pattern of different regulatory molecules of cell cycle, hypoxia and angiogenesis and their correlation with intrinsic radiation sensitivity and telomerase activity. The relationship of telomerase activity ith SF2 might be a useful predictor of radiation resistance in carcinoma cervix. A more detailed study on these molecules might also help in predicting radiation resistance in carcinoma cervix.

Combined Modality In Locally Advanced Early Invasive Cervical Cancer - Ten Years Of Kmio Experience.

*Dept of Gynaecogical Oncology, + Dept of Radiation Oncology, # Epidemiology & Hospital Cancer Registry, Dept of Pathology, Kidwai Memorial Institute of Oncology, Bangalore -560029, India.

Objectives: To study the clinico-pathological response, to assess the extent of Radical hysterectomy followed by preoperative irradiation and to review the treatment benefits with stage IB, IIA, &IIB Cervical Cancer.

Patients & Methods: Between July 1990 and December 2000, one hundred and fifty four patients with histologically confirmed stage IB-IIB Cervical carcinoma, who underwent Radical hysterectomy followed by preoperative radiotherapy were reviewed retrospectively. All these patients were clinically staged according to the guidelines of FIGO.Those patients with Endophytic / Barrel shaped lesions Ib1/ Ib2, IIa & IIb were subjected to preoperative external pelvic irradiation and clinically assessed at three to six weeks interval prior to Radical surgery. The data was analysed by using SPSS database.

Results: The mean age was 45.8years(ranged between 21-78). Majority of thses patients presented with bulky exophytic lesions (63.6%) of squamous cell carcinoma (89.8%) with large cell non-keratinising (63.2%) and grade III tumour (63.6%). Of the 154 patients, 61% had complete clinical response and overall clinical response was 82.4%. However, postoperatively no residual disease was found in 9.9%, 23.1% had full thickness stromal involvement, less than 2% had vascular emboli & 49 % had pelvic node involvement. The survival benefit was comparatively better in the high-risk patients subjected to Chemoradiation followedc by surgery. The followup ranged between 10 to 76 months.

Conclusion: The present study indicates that the preoperative pelvic radiotherapy helped in downstaging the disease and those patients who received highdose (45-50 Gy) radiotherapy preoperatively showed a complete histological response. However, more randamised study is required in the developing world to prove the benefits of chemoradiation VS preopertive irradiation followed by radical surgery in locally advanced early invasive Cervical Cancer.

Purpose: Cancer of Uterine cervix is the commonest malignancy in females in India (AAR =17 to 30 per 1,00,000). Most of he patients in our country are diagnosed in advanced stage and treated by radiotherapy. FIGO staging of cancer cervix includes basic radiological investigations like CxR , IVP and Ba enema. However with the advent of CT Scan and its widespread availability, this modality is increasingly being used in the staging workup. In view of its high cist this modality needs to be judiciously used based on its specificity and sensitivity.This study analyses the CT Scan abdomen findings in 50 patients of stage II/III ca cervix with emphasis on nodal mets which is a poor prognostic factor, though not included in FIGO staging.

Material and methods: 50 patients of locally advanced Ca Cervix treated with radical radiotherapy at our centre were retrospectively analysed. All patients underwent clinical workup and biopsy to confirm the diagnosis. The treatment included EBRT to pelvis with weekly concurrent chemotherapy ( Cisplatin based) followed by ICRT (HDR : 9 Gy X 2#, 1 week apart). After treatment response rate was CR in 37 patients, PR in 8 , while one patient died during treatment. Relapse was seen in 6 patients and was correlated with CT Scan. The pretreatment CT Scan findings were listed with respect to size of tumor, involvement of parametrium/ nodes/ bladder and rectum, hydronephrosis and hydroureter. CT scan was not used to upstage the disease as per FIGO recommendation. The bladder or rectal involvement was based on cystoscopy and procto-sigmoidoscopy, respectively. All patients were followed up for a period of 18-36 months.

Results: Host factors, tumor factors and treatment factors were also considered in our followup and outcome. Fifty patients, aged 34-67 years with clinical stage II or III were included. The KPS of our patients was 70-80 and Hb range was 5.6-14.2 gm% at presentation. The clinical tumor size was known in 43 patients and parametrial involvement was noted in all ( 9-unilateral para , 41- bilateral para). Nodal involvement in pelvis and paraaortic region was as per CT scan findings. All patients had Histologically confirmed squamous cell cancer of cervix and grad was known in 38 patients.
CT scan findings-
Systemic/ local relapse in patients with pelvic nodes positive : 2/0 patients
Systemic/ Local Relapse in Patients without pelvic nodes involved: 1/2 patients
Systemic/ Local relapse in patients with paraaortic nodes involved: 1/0 patients
Systemic/ Local relapse in patients without paraaortic nodes: 3/2 patients

Conclusions: CT Scan is a widely available, expensive imaging modality which has a moderate overall accuracy in staging and detection of nodal metastasis in patients of cancer cervix. Pelvic node involvement does appear to predict a slightly higher risk of systemic relapse in the follow-up, while paraaortic node involvement does not show a similar outcome in our patients. The standard staging procedures in use today are adequate at present to manage most of our patients and routine use of CT scan cannot be recommended.

Radiotherapy after inadequate surgery in invasive carcinoma cervix - A retrospective analysis from India.

Department of Radiotherapy, Post-Graduate Institute of Medical Education and Research, Chandigarh, India.

Purpose: To evaluate the results of radiotherapy after inadequate surgery in patients of invasive carcinoma cervix.

Materials and Methods: Between 1996 and 2001, 105 patients of carcinoma cervix (stage 1-IIIB) were treated at our center with radiotherapy after having undergone total or subtotal hysterectomy outside. All patients were treated with external radiation with or without intracavitary radiation (ICRT).

Results: Median follow up was 34 months. Gap between surgery and radiation ranged from 23 days to 198 days with a median of 80 days. Clinically visible residual disease was present in 71.1% of cases. Stage wise distribution of patients were as follows: stage I 14.3%;Stage IIA 31.4%;stage IIB 24.8% and stage IIIB 29.5%.5year OS, DFS and pelvic control of all patients were 55.2 %, 53.3 % and 72.4 % respectively. In univariate analysis; older age, Hb>10gm%, non squamous histology, early stage, use of ICRT, shorter gap between surgery & radiation and absence or small volume of residual disease were found to affect the outcomes favorably. In multivariate analysis by Cox’s proportional hazard model, use of ICRT and stage were the only factors emerged significant to influence OS.For pelvic control and DFS, use of ICRT was the only significant factor. 5year actuarial rates of late toxicities (RTOG) were 19% in rectum, 4.8% in bladder, 24.8% in skin and 14.3% in small intestine.

Conclusions: Inadequate and inappropriate surgery in invasive cancer cervix with gross residual disease is common in Indian scenario. Factors like use of ICRT, correction of anemia and shorter gap between surgery and radiation enable salvage radiotherapy to achieve acceptable results with minimum morbidity.

U Mahantshetty**, S Saju*, RA Kinhikar*, SV Jamema*, DD Deshpande*,
SK Shrivastava**, KA Dinshaw**

Department of *Medical Physics, **Radiation Oncology,Tata Memorial Hospital, Parel, Mumbai 400012.

Introduction: With an aim to evaluate the feasibility of IMRT in cervical cancers, a comparative dosimetric study of 3D-CRT and IMRT to pelvic fields was carried out and is the basis of this report.

Methods and Materials: Eleven patients of Carcinoma cervix treated with pelvic IMRT as a part of pilot study were evaluated for comparison. All these patients underwent immobilization, evaluation for set-up uncertainties and planning CT scan with oral, rectal and intravenous contrast. The Planning target volume (PTV) included gross disease, cervix, bilateral parametrium, pelvic nodes with margins. Critical organs (OAR) included Small Bowel Region (SBR), rectum and bladder. A Standard conformal four field box plan with MLC was compared to the accepted IMRT (5fields) plan for all these patients. Plan evaluation and comparison of 3D-CRT and IMRT was done using DVH, mean, maximum and minimum doses to various volumes in accordance with ICRU 50 recommendations. The doses of OAR were compared using V95% and V70% isodose lines.

Results: The IMRT plans provided an excellent PTV coverage. On average, 95% of the PTV received 96% of the prescribed dose. The hot-spot volume (V107%) was limited to <8% and were located in the GTV. The hot spot volume with IMRT was 25% less than the 3D-CRT plan. V70% is reduced by 23% for bladder, 22% for rectum and 18% for small bowel region as compared to 3DCRT plans. Also, IMRT pelvis significantly reduced the high dose volumes to the adjacent critical organs namely, small bowel region (SBR), rectum and bladder. Various doses received by rectum in 3DCRT (80-140cc) are 42, 57, 51 Gy (Min, max, mean) as compared to 25, 57, 42 Gy in IMRT plan. Similarly, Various doses received by SBR in 3DCRT (800-1100cc) are 25, 54, 48 (min, max, mean) as compared to 23, 50, 40 Gy in IMRT plan. In the case of bladder, the volume covered by 95% and 70% isodose lines are less by 72% and 23% respectively in IMRT plan.

Clinical Outcome: All patients tolerated the treatment well and completed the treatment within 6-8 weeks. None of the patients had Acute Grade III toxicity with 6 and 3 patients experiencing Grade II GI and GU acute toxicities respectively. Later 8 patients also received weekly scheduled cisplatin chemotherapy and none had any grade III hematological toxicity. With a median follow-up of 12 months (6 – 24 months) till date, all 11 patients are loco-regionally controlled. None of the patients has Grade III late sequelae documented so far, however, one patient has developed radiation proctitis Grade II at 16 months follow-up.

Conclusions: IMRT pelvis in patients with advanced carcinoma cervix results in good PTV Coverage and spares surrounding critical structures. IMRT Pelvis in patients with advanced carcinoma cervix is feasible and initial experience is enterprsing. So to further validate IMRT in advanced carcinoma cervix, we are currently conducting a Phase II Randomized Trial comparing IMRT to 3D-conformal radiation therapy.

Evaluation of CT - Based Treatment Planning with Conventional Radiography Based Treatment Planning for High Dose Rate (HDR) Intracavitary Brachytherapy for Carcinoma Cervix

S Saju*, SV Jamema*, S Deshpande*, U Mahantshetty**,DD Deshpande*,
SK Shrivastava**, KA Dinshaw**

Department of *Medical Physics, **Radiation Oncology,Tata Memorial Hospital, Parel, Mumbai 400012.

Introduction: The main stay of treatment for carcinoma cervix is radiation therapy. Brachytherapy can be delivered by either low dose rate (LDR) or high dose rate (HDR). All the ICA's are reported according to ICRU 38 recommendations. However, the bladder and rectal reference points defined may not always be a true representation of rectum and the bladder wall doses. Conventional dosimetric calculation uses orthogonal radiographs for the computation of dose to bladder and rectal points. Three - Dimensional CT planning with accurate delineation of OAR’s would suggest the actual radiation doses to bladder and rectum. In an attempt to compute and correlate 3-Dimensional CT planning with conventional radiography based treatment planning, we undertook this study and is the basis of this report.

Materials and Methods: A cohort of 15 patients with carcinoma cervix treated with radical radiation and HDR Brachytherapy were studied. After the HDR application using Modified Fletcher Suit Applicator, patients underwent simulation for orthogonal radiographs and planning CT Scans. Manchester system of dosimetry was used for the computation of dose to point A and B. The rectal and bladder points defined according to ICRU 38 recommendations. The CT Scan protocol included a 5mm axial CT images from 4cm superior to the tandem tip extending till anus inferiorly. Bladder and rectal volumes were delineated on all axial sections. PLATO 3D Planning system was used for the dose computation. The dose delivered to 5% volume of the OAR (D5%) was computed and compared with ICRU reference points. The dose prescribed for each fraction was 7Gy to point A (Optimized) and treatment delivered using Ir-192 high dose rate remote after loading machine (Micro Selectron - Nucletron).

Observation and Results: The mean volume of rectum and bladder on CT scans was 34cc and 61cc respectively. The mean of the maximum dose to rectal reference points from 2D planning was 68% the prescribed dose of 7Gy to point A (478cGy). 17.2% of the volume of rectum received a dose higher than 68% in 3D Planning. Similarly the mean of the maximum dose to bladder reference points from the 2D planning was 75% of the prescription dose (527cGy). When compared with 3D CT planning, 23% of the volume of bladder receives a dose higher than the maximum bladder dose. There was no difference in the volume encompassed by the prescription isodose line between 2D and 3D CT planning. Also, the average maximum dose from CT planning is 1.4 times higher for rectum and 1.63 times higher for bladder as compared to the ICRU reference points.

Conclusion: This study suggests that there is no difference in the target volume coverage between 2D and 3D planning. However, ICRU 38 reference points do underestimate the doses to the bladder and rectum. Although ICRU 38 recommendations for conventional radiography treatment planning are time tested and still continues to be used routinely, the advances in imaging and planning system does mandate for further refinement and alterations for prescribing, reporting and documentation of ICA application today.

K.S.Kirushna Kumar*, G. Amarnath*, T.R.Murali #, U Ravikumar $
*Radiation Oncologist. # Urologist, $ Pathologist.

Mr.K. aged 46 years diagnosed as a case of Carcinoma bladder in January 2002, Cystoscopy and TURBT done revealed growth in the right posterior wall and Right ureteric orifice. Biopsy reported as TCC Grade III. CT scan showed Bladder mass with seminal vesicle involvement. T4 disease. Patient received External Radiation therapy with Telecobalt 60Gy/ 30 fractions / 6 weeks from 30.04.02 to 15.06.02. Later presented here again on 05.08.03 with a nodular hard right Inguino scrotal swelling. On evaluation, US abdomen & TRUS was normal. Chest x.ray was normal. FNAC was positive for malignancy, Cystoscopy was normal. Biopsy from the mass - TCC Grade II. On 13.08.03, Right high orchidectomy and Hemiscrotectomy was done, proved to be transitional cell carcinoma. Testis was normal. IHC done showed CK positive, EMA – Locally positive - CEA negative.

Conclusion: Epididymis is a rare site of metastasis from bladder. Only 1 case is reported so far from bladder, that is also an autopsy finding.

A Modified Technique for Intracavitary Application In Advanced Cancer Cervix

• Department of Radiation Oncology, #Medical Physics Tata Memorial Hospital, Mumbai, India.

Cervical carcinoma FIGO Stage III accounts for >60% of all cervical cancers with radiation being the mainstay of treatment for most of the patients. After external radiation, cervix is usually flush with the vagina and shape of the vagina is conical with apex at the external os level. The standard high dose rate (HDR) intracavitary application may not be feasible in these patients with compromised vaginal capacity. We have devised a modification in the standard HDR intracavitary application for patients with compromised vagina. All patients receive 2 applications with HDR brachytherapy. In these patient’s at the intracavitary application after the placement of central tandem, only one ovoid was inserted and the other ovoid replaced by a rubber tube at first application and the applicator assembly fixed as usual. The contralateral ovoid was inserted in subsequent application. The mean dose to right and left point A was 93% (range: 86-100%, median: 93%) and 95% (range: 90-100%, median: 95%) respectively. The variation of doses to contralateral point A was 1-14%. The mean dose to rectal and bladder mucosa was 62% (range: 43-80%, median: 64%) and 80% (range: 50-110%, median: 71%) respectively. This modified HDR intracavitary technique if found suitable by other physicians may prove an alternative for centers where interstitial brachytherapy for cervix is not available.

HIV Infection and Invasive Cervical Cancers, Treatment with Radiation Therapy: Toxicity and Outcome

Reena Engineer, Shyam Kishore Shrivastava, *Sunil Rajadhyaksha,
Ketayun A.Dinshaw

Department of Radiation Oncology, *Department of transfusion medicine, Tata Memorial Hospital, Mumbai, India

Background & Purpose: To determine the effect of radiotherapy in HIV seropositive cervical cancer patients, tumour response and toxicity and compliance of patients to the treatment.

Material And Methods: This study is a retrospective review of 42 HIV seropositive patients diagnosed with carcinoma cervix, between 1997 – 2003 at the Tata Memorial Hospital. The age and symptoms of presentation, clinical stage, response, compliance and tolerance to radiotherapy were studied.

Results: Mean age at presentation was 41 years. All patients presented with the symptoms of cervical disease. Of these patients 32(76%) patients had ‘Karnofsky Performance Scale’ (KPS) more than 80%. Twenty one(50%) of the patients were of Stage IIb –IVa. Thirty-two (76%) were started on radiotherapy with radical intent. Compliance to radiotherapy was poor with 24% patients discontinuing after few fractions of radiotherapy. Seven (17%) patients were given palliative radiotherapy. Twenty-two patients completed prescribed radiotherapy and 50% of these achieved complete response. Grade III-IV acute gastrointestinal toxicity was seen in 14% of the patients, and grade III acute skin toxicity was seen in 27% of patients, leading to treatment delays.

Conclusion: Radiotherapy is effective in this set of patients. Palliative fractionation schedules are effective for patients with poor performance status and locally advanced cancers in relieving the symptoms related to carcinoma cervix. An emphasis should be given to the increased acute mucosal and skin toxicity and to improving compliance and clinical outcome of these patients.

Role of HDR Brachytherapy in Early stage Carcinoma Penis

S Jain, Major AK Singh, P Jain

Purpose: Carcinoma of penis accounts for less than 1 % of all cancers and usually surgery is the treatment of choice. But in early stage radiotherapy plays an important role by providing a reasonable chance of organ preservation, particularly in younger patients who are reluctant to penectomy. This study is analysis of 5 patients of node negative, early stage carcinoma of penis who were treated with HDR brachytherapy alone from September 2002 onwards.

Materials and methods: All patients were biopsy proven T1/ T2 tumours of penis without nodal involvement. Circumcision was done before implant. All the routine investigations and preanaesthetic check up was done for G. A. A dose of 45 Gy in 15 # was delivered over 8 days. Foleys catheter was left in place for 2 weeks to prevent any urethral stricture.

Observations and results: Complete response was observed in all the patients at 6 weeks of completion of RT. All patients had localized moist desquamation, which healed in 6 to 8 weeks. Mild urethral bleeding was seen in two patients. All patients complained of burning micturition, which was managed conservatively. Urethral stricture was seen two patients, which was managed by periodical dilatation. One patient developed nodal metastasis.

Conclusions: HDR brachytherapy is highly feasible in early carcinoma of pelvis. Overall results are equivalent to surgery with advantage of organ preservation.

Purpose: Surgical treatment of penile carcinoma involves amputation and hence alternative approaches are being explored for organ preservation. External beam radiotherapy and brachytherapy are the alternative options. We present the results of mould brachytherapy at Regional Cancer Centre (RCC), Trivandrum, India.

Materials and Methods: From Jan 1998-2003, 20 patients had penile mould brachytherapy for histologically proven squamous cell carcinoma (SCC) at RCC.17 patients had T1 and 3 had T2 tumours. None had clinically significant regional lymphadenopathy. Histology was well differentiated SCC in 10,moderately differentiated in 5,poorly differentiated in 1,verrucous in 2 and not graded in 2 patients. Treatment was given using cylindrical mould using preloaded sources. Dose was prescribed at surface of penis and ranged from 55-65 Gy over 6 days (median 60 Gy).

Results: One patient (T2) had residual disease at 3 months and was advised amputation. Four patients recurred of which one had local recurrence after 6 months and had amputation, and one had locoregional recurrence and had total penectomy with bilateral block dissection. The other two patients had isolated inguinal node metastasis at 6 and 12 months and had block dissection .15 patients (all had T1 disease) remained well without any evidence of disease with median follow up of 31 months (range 6-72 months).

Conclusion: Mould brachytherapy is useful for patients with early lesions of penis, who would like to preserve the organ.

A Rare Case of Second Malignancy in Oesophagus after Primary Thyroid Malignancy-A Case Report

A 60 yr old male patient reported with second malignancy in oesophagus 13 years after treatment of medullary thyroid cancer. Second malignancy in oesophagus is common after head&neck, breast &lung cancer but is rare after thyroid cancer due to poor treatment outcome. Hence here we present a rare case of second oesophageal malignancy after first thyroid malignancy.

Benefit Of Respiration-Gated Radiotherapy versus Expenditure of Working Time and Technologically Preparation

Purpose: To weigh up the benefit of respiration-gated radiotherapy (RT) e.g. reduction of treatment margins and sparing of normal tissues and additional expenditure e.g. increasing working time for oncologists, physicists and technologists and more technologically preparation.

Methods and Materials: We used a multislice CT (Light Speed, General Electric) and the Varian gating Real-time Position management (RPM) system connected to the Acuity simulator with a-Silicon panel, gated images and fluoroscopic capability. In order to evaluate the benefit of a respiration-gated RT we compare the planning target volume (PTV) and mean lung dose (MLD) of a non-gated and gated treatment plan for non small cell lung cancer. The several steps of the concept developed in Dortmund to conduct respiration-gated RT were analysed regarding to the additional working time of the staff and the technological preparation. The Dortmund concept includes, (1) recording the external respiratory waveform at the simulator, (2) performing two planning CT’s during inhale and exhale and a free breathing single slice CT sequence of one minute, (3) using the in-house developed software ORAT to determine the amplitudes of target movement in all three space directions and the optimal gating parameters, (4) assessing the patient-individual internal margin (5) verification of the treatment plan at the simulator with gating conditions, (6) preparation of the gating treatment at the accelerator (7) supervision of the respiration gated RT cource analyzing a portal imaging video.

Results and Conclusions: With the gated RT technique we were able to reduce the PTV up to 22% and the MLD up to 16%. The average additional working time for the oncologist including step (1), (2), (3) and (5) is 90 minutes. For the physicists we take into account 30 minutes for step (3) and (4). The technologists need additional 15 minutes for (2) and every day 3 to 4 minutes for (6). The treatment time is usually prolonged by nearly three beam-on times. For every portal imaging video control with ORAT the oncologist needs another 30 minutes. After step (1) it is important to make the decision whether there is enough benefit of a respiration-gated RT for the patient to justify the additional efforts.

Evaluation of Portal images for 3D conformal radiation therapy of prostate generated with Amorphous Silicon Electonic Portal imaging Device

Dinesh.M, Geeta.S, Br.Sunil , Asha Arjun, Richard F. Cohen, Narayanan.S, ,Jijy Jacob Jackarias Doraiswamy, Sathish Prasad, Bhaskaran Pillai.K , Padmanabhan T.K

Department of Radiation Oncology, Amrita Institute of Medical Sciences & Research Center, Kochi, Kerala.

We recently brought into clinical use an Elekta Precise Linac with iViewGT EPID. The iViewGT portal imaging system consists of an amorphous silicon detector (a-Si EPID),along with its arm movement assembly and the application software. A-Si EPIDs exhibit a linear response to absorbed dose and they have the potential to produce a two-dimensional pixel map of dose and/or energy fluence within a given therapeutic field. The portal image is compared with the treatment field in the digitally reconstructed radiograph image acquired from the CT simulation plan, to see the accuracy of treatment set up. Template matching and image approval is done using the software application.The portal images are repeated for every patient on a weekly basis to ensure accuracy.

Analysis of port films in prostate patients undergoing 3D conformal radiation therapy is undertaken to estimate the shifts before initiating treatment and during the treatment period. Interobserver variation in portal film template matching are estimated to evolve an off-line correction protocol to even out systematic and random set up uncertainities.

Dosimetric comparative studies of two inverse planning systems for Static and Dynamic Intensity Modulated Radiotherapy in Nasopharyngeal Carcinoma

V Subramani, S Chander, RC Joshi, T Ganesh, N Gopi Shankar,
SK Das Majumdar, GK Rath.

Department of Radiation oncology, All India institute of Medical Sciences,
New Delhi.

Purpose: To evaluate and compare two inverse treatment planning systems for static and dynamic intensity modulated radiotherapy techniques in Nasopharyngeal Carcinoma.

Materials and Methods: The Planning study was conducted for 10 Nasopharyngeal Carcinoma of primary tumors using two inverse planning systems (ITP) of Eclipse-Helios and Plato-ITP lightning. CT slice thickness of 2.5mm were obtained and transferred to eclipse planning system, where CTV, PTV and normal structures were drawn and transferred through dicom-RT to Plato ITP. Plans were generated for static and dynamic IMRT in Helios ITP and also for step and shoot IMRT in Plato ITP for a given target volume. The number of beams, number of intensity levels, dose volume constraints were same for both systems. The dosimetric parameters such as PTV coverage, conformity and uniformity indices, organs at risk and Irradiated volume of 50% dose (IV50) and also for delivery efficiency of beam on-time and number of segments were compared.

Results and Conclusion: PTV coverage was defined as isodose coverage that encompasses atleast 95% of PTV in both systems. In PTV coverage, the average percentage difference between Plato ITP static versus Helios static and Plato ITP static versus Helios dynamic IMRT techniques were found to be 9.7% and 10.1% respectively. The difference in uniformity index was about 10.9% and 11.9% and in conformity Index was about 15.4% and 16.8%. Helios static and dynamic IMRT techniques provide always better conformity and uniformity indices than Plato ITP static technique. Conversely, in organs at risk dose, Plato ITP showed about 5% less compared to Eclipse Helios and its variation may be due to the different configurations and beamlet size used in both systems. The difference in IV50 was within + 2%. In terms of delivery efficiency, the number of segments in Helios-static IMRT was 3.1 times of Plato ITP. The difference in beam-on time between two static IMRT and static versus dynamic technique was about 20% and 40% more in Helios ITP than in Plato ITP.

In a clinical set-up, having two different accelerators and two different ITP systems, when patients are being treated by IMRT technique in one machine, if that goes of malfunction and it happens to shift the patient from one system to other, there will be a difference in dosimetric parameters between ITP systems and techniques and its implication are to be known when situation arises. The optimization and leaf sequencing algorithms of both systems will be discussed in detail during the presentation.

Nowadays a large variety of isotopes are available for brachytherapy. Over the years three isotopes became very popular, I-125 for permanent seed implantation, Cs-137 for the temporary low dose rate intracavitary brachytherapy and Ir-192 for interstitial low dose rate applications. High dose rate brachytherapy has been initially developed using Co-60 sources. However, the sources where very large and could only be used for intracavitary applications. With the introduction of the single stepping source technology for remote controlled afterloading devices, the Co-60 sources have been replaced subsequently by miniaturised high activity Ir-192 sources. However, along with the short half life time of Ir-192 of 74 days, the sources needed to be replaced 3 to 4 times per year resulting in high after sales costs for such a device. For developing countries the import of the sources with the short half life might be even more cumbersome as the import of radioactive products is undergoing restrict and sometimes lengthy customs procedures.

In the present paper an alternative to the Ir-192 high activity source is presented with a miniaturised high activity Co-60 source. The source has been specially developed to fit into a capsule attached to a source cable. The active pellet size of only 0.6mm diameter and 3.5mm length is equivalent in size to a conventional high dose rate afterloader source. The dosimetry of the new source will be presented and in addition the cost efficiency compared with Ir-192 sources.

Vijay Anand P. Reddy, Santosh G. Honavar, Milind N. Naik, Kalpesh Shah, Debraj Shome.

Aim: To report our initial experience with Ruthenium (Ru-109) plaque brachytherapy in the management of ocular surface, uveal & retinal tumors.

Methods: Nineteen eyes of 19 consecutive patients with ocular tumors treated with Ru-109 radioactive plaque brachytherapy between Jan 2002 & December 2004 were included. Indications for treatment, radiation dose & exposure time were studied. Outcome measures assessed were tumor regression, eye salvage, vision salvage & resolution of subretinal fluid as appropriate for a specific tumor type & location. Treatment complications were analyzed.

Results: The treated tumors included ocular surface squamous neoplasia (1), conjunctival lymphoma (1), uveal melanoma (8), choroidal hemangioma (6), choroidal metastasis (1), & retinoblastoma (2). Of 19 eyes treated, tumor regression was seen in 18 (94.7%). None had systemic metastases. 18 (94.7%) eyes were salvaged & 1(5.3%) was enucleated. Vision improved in 10 eyes (52.6%), was stable in 4 (21%) & deteriorated in 4 (21%). Subretinal fluid resolved following treatment in all eyes with choroidal hemangioma. Complications included radiation cataract & radiation retinopathy in 1 eye each.

Conclusions: Plaque brachytherapy is a useful therapeutic tool in the management of a various ocular surface & intraocular tumors.

Evaluation of Degree of Reproducibility of Various Head & Neck Immobilization Devices from Two Different Manufacturers

*Dept of Radiation Oncology and #Dept of Medical Physics, Tata Memorial Hospital.

Background and Objectives: Reproducible set up of the radiation portals improves treatment accuracy. Immobilization devices are most useful in the head and neck (H&N) region, which is unique in the range of movements. The cost and availability of H&N immobilization devices has prevented their widespread use in developing countries. This IAEA sponsored study was designed to compare various H&N immobilization devices of two manufacturers in terms of degree of reproducibility on repeated set-ups and other technical aspects.

Materials and Methods: Various H&N immobilization devices (Thermoplastic mask, Nasion, Chin or Mouth bite restraints) of two manufacturers- MedTec (MT) and Arplay (AR) were compared with each other and with simple positioning on a neck rest (SNR) without immobilization. Five Head and Neck cancer patients were included in our study. Steel markers on the forehead and nose in midline and right and left malar prominence were used and these along with bony landmarks on the skull and upper jaw were marked on the MT and AR thermoplastic mask simulator films. Patients were evaluated with 5 set ups and 5 anterior + 5 lateral simulator films for each of the 9 immobilization methods. In the final comparative study, there were 450 simulator films in five evaluable patients. The deviation of each of the 4 markers in the x, y and z-axes was calculated and the values were pooled for comparison.

Results: Without immobilization, repositional variability was noted in all the three axes, but was significantly less in the cranio-caudal direction (mean 2.9mm SD +/-2.6) compared to the right to left (mean 3.8mm SD +/-2.6) or anterior-posterior direction. (mean 4.8mm SD +/-4). Repositional variability in all the axes and rotation were significantly reduced with all immobilization methods except the chin restraints of either manufacturer. When similar restraining devices of the two manufacturers were compared on various parameters, MedTec Mouth bite (mean 1.6mm SD +/-1.4) and Arplay Thermoplastic mask (mean 1.3mm SD +/-1.1) restraints were significantly better than similar devices of the other manufacturer.

Conclusion: This study confirms the utility of various H&N immobilization devices in reducing the set up errors. Without immobilization >5mm variation was noted in 25% set-ups. More economical devices such as nasion or mouth bite restraints provides reproducibility as good as thermoplastic mask but does not provide a surface for marking the portals. Devices of both manufacturers provided comparable accuracy but Arplay devices were more complex to use. Reproducibility error associated with a particular device, its cost and intent of treatment should be taken in to account in selecting an immobilization device. More cost effective and versatile immobilization devices are required, especially for the head & neck region to allow their widespread use in the developing countries.

S.Dayananda, Ritu Raj Upreti, C.M.Tambe, Reena Phurailatpam†, Deshpande Sudesh, D D Deshpande, S K Shrivastava#, K A Dinshaw#

Departments of Medical Physics & #Radiation Oncology,
Tata Memorial Hospital, † CRC, ACTREC

Purpose: Increase of monitoring unit (MU) per target dose in sliding window intensity-modulated radiotherapy (IMRT) may yield increase in peripheral dose (PD) and risk of radiation induced secondary malignancy. The purpose of this study was to measure PD from uniform dynamic multileaf collimation (DMLC) fields and validation of the measured data for patient specific fluence treated for head and neck cancer with sliding window IMRT.

Material and Methods: Uniform DMLC fields having fixed sweeping-gap width of 0.5, 1.0, 1.5, and 2.0 cm are created using 26 pairs of MLC to give an effective field size of 6 ? 6, 10 ? 10 and 14 ? 14 cm2. PD from these uniform DMLC fields was measure for 6 MV X-ray on Clinac 2100 C/D linear accelerator using a 0.6 cc ionization chamber inserted at 5 cm depth in a 35 ? 35 ? 105 cm3 solid virtual water phantom. Five patients treated for head and neck cancer employing sliding window IMRT was selected for in-vitro and in-vivo measurement of PD using thermoluminescent (TL) phosphor powder. The average MU per 200 cGy target dose increases to 1272 (range 997-1807) in IMRT compared to 225 of conventional and 348 of conformal therapy with wedge. The cGy/MU measured at different out-of-field distance from uniform DMLC fields was compared with in-vivo and in-vitro measured PD from clinically used fluence.

Result: PD resulting from uniform DMLC fields manifests two distinct regions showing crest and trough within 30 cm from the field edge and steady exponential fall beyond 30 cm. For 6 ? 6 cm2 field size, DMLC with 0.5 and 2 cm sweeping gap width deliver a maximum of 8 and 2 times higher PD than that of static open field at around 55 cm from the field edge. The corresponding factor for 14 ? 14 cm2 field size is 15 and 6 respectively. cGy/MU derived at different out-of-field distance from the PD data of uniform DMLC fields was found to be in agreement with in-vitro measured data from patient specific intensity fluence. In-vivo measured extra-target dose shows good agreement with in-vitro data. The average sternal dose in our study was 876 mSV for a prescribed dose of 60 Gy at tumour.

Conclusion: Our PD data expressed as cGy/MU from uniform DMLC fields can be used as a good approximation to derived dose at any critical organ or whole body in patients treated with sliding window IMRT. This data can help in estimating risk of radiation induced secondary malignancies in patient treated with this state –of –art technique.

Delays from Symptom Onset to Treatment in Malignant Spinal Cord Compression: Quantification and Effect on Pre-Treatment Neurological Status

Gunita Mitera B.Sc., MRT (T), D. Andrew Loblaw B.Sc, MD, MSc, FRCPC, CIP

Canada

Background: Malignant spinal cord compression (MSCC) is a devastating complication of advanced malignancy. Any delay in initiation of radiation treatment may result in a deterioration of pre-treatment neurological function; hence, a poorer prognosis of post treatment outcome and quality of life. A British study documented significant delays in patients with MSCC, the majority losing neurological function as a result. The objective of this study was to prospectively document patterns of care from symptom onset of MSCC until initiation of radiation treatment at our centre, and investigate potential affects on pre-treatment neurological status.

Methods: A standardized data collection form was used to document demographics, tumor and functional information; and centre and referring doctors’ charts were used to augment patient history. Chi-squared analysis and Person’s r correlation determined statistical significance. Thirty patients identified from Jan/03-Dec/03 were accrued. Three subgroups were formed based on time from symptom onset until RT treatment: 0-7 days, 8-14 days, and >14 days.

Results: A median delay of 16 days from symptom onset till RT treatment was experienced, of which 90% resulted from symptom onset to initiation of medical attention. When patients perceived symptoms to be related to their previous cancer the median time delay was 6 days, compared to 7 days when patients related symptoms to other co-morbidities.

Conclusions: Deterioration of symptoms was strongly correlated with time delay in patients with MSCC at our centre, thereby supporting prevention and educational strategies to help reduce the impact of this complication on patients with advanced cancer.

Reasons for Emergency Weekend Radiation Treatment in the Radiation Therapy Department at the Toronto-Sunnybrook Regional Cancer Centre (TSRCC) – a Retrospective Review

Gunita Mitera B.Sc., MRT (T), Meagan Doyle B.Sc (C),
Emily Sinclair B.Sc., MRT (T), Edward Chow MBBS, M.Sc., FRCPC,
Dr. Shun Wong MD, FRCPC, Dr. Cyril Danjoux MD, DMRT, FRCPC,
Ms. Sheila Robson MRT (T), ACT, B.Sc.

Canada

Introduction: Patients deemed to be an "oncologic emergency," in accordance with department policy at TSRCC, can be treated on Saturday and Sunday of each week.

Objective: The primary objective of this retrospective study was to examine the number of patients treated and the nature and rationale for their treatment over the 108 weekends from September 1, 2002 to August 31, 2004.

Methods: The patient hospital files number and OPIS scheduling system were used to chart relevant data.

Results: 161 patients were treated as emergency cases. The median age was 67 and 62% were male. 33% of the population had lung cancer as their primary, 20% had prostate cancer and 18% had breast cancer. 70% of cases were treated with radiation to their spinal cord, of which 82% were spinal cord compressions. 20% of cases were brain metastases, and 11% were superior vena cava obstructions. Other reasons for emergency weekend treatment included pelvic/GI bleeding, bone/skull/orbit metastasis, spinal fracture, pain control, nerve root compression, impending cord compression, bowel obstruction, lung mass, and leptomeningeal disease. 70% of cases were treated as out-patients. 94% of patients were treated with 2000cGy in 5 fractions.

Conclusion: The extracted information will contribute to an enhanced understanding of patterns of practice for weekend treatments at a large Toronto Cancer Centre.

Informed Consent for Radiotherapy in The Great Poland Cancer Centre in Poznan, Poland.

Introduction: Informing patients about their health conditions, the treatment plan, shearing the process of decision making by the physician and the patient as well as the informed consent for the proposed treatment is the key to the realization of patients’ rights and their fundamental freedoms.

Purpose: The aim of this work was to design the procedure and the informed consent form for radiotherapy given by the patients in The Great Poland Cancer Centre.

Materials & Methods: The Polish acts of law, The European Convention on Bioethics, the guidelines of The Polish, Physician’s Code of Ethics and the standards of The Accreditation Program for Hospitals were compared in terms of their similarities and compatibility referring to the informed consent. Subsequently based on the related contents of the above documents, the informed consent form for radiotherapy was designed.

Results & Discussion: As a result the informed consent form for radiotherapy and the procedure of obtaining the form were designed. It has become undeniable that the consent of the patient is a prerequisite to radiotherapy. The patient has to know the advantages and disadvantages (risks, potential complications) of the proposed therapy. When obtaining the consent the patient should be informed on details of diagnosis and prognosis with or without the proposed medical intervention and the uncertainties and questions should be explained and answered. Therefore the informed consent form for radiotherapy is not only a document proving that the patient agreed to perform the treatment but also a tool that allows the patient to comprehend the purpose, benefits and risks of the proposed therapy and to participate in the decision making process.

One Fraction Hemibody Irradiation – A Simple and Effective Palliation for Painful Skeletal Dissemination

1Radiotherapy Department, M. Sklodowska-Curie Cancer Center, Institute of Oncology, branch Gliwice, Poland 2The God Compassion Hospice, Gliwice, Poland

Material and Method: 61 patients with multiple, painful bone dissemination treated by HBI between 2001-2004. Primary malignancies were: breast, prostate, renal, lung, skin rectal, larynx and bladder cancer. In 6 cases origin was unknown. 21 patients had UHBI and 40 LHBI. When metastases in skull and distal parts of limbs were absent, these regions were not irradiated. 6 Gy for UHBI and 8 Gy for LHBI was delivered, from two opposite fields, using 6 MV photons. Pain intensity in 11 degrees scale, pain frequency in 4 degrees scale and kind of used analgesics were evaluated. Patients were examined in HBI day, 2 weeks later and next, every month. Dependencies between pain before HBI and pain relief 2 and 6 weeks later were checked. Pain 2 and 6 weeks after U and LHBI, and pain relief in this time for breast and prostate patients were compared.

Results: Pain intensity mean in HBI day was 6.3 and decreased to 3.0 after 2 weeks. Next values were 4.0, 3.0, 3.0, 4.5, 2.0 and 3.4 six months later. Pain frequency mean in HBI day was 3.1 and did not change significantly (from 2.8 to 3.0). In HBI day 3.4% of patients did not use analgesics, 31% used NSAID, 8.6% tramadol, 10.3% opioids, 10.3% NSAID+tramadol and 36.2% NSAID+opioids, so 46.5% used opioids. Patients percentage without analgesics increased to 37.5% and percentage using opioids decreased to 25% 3.5 months later. Dependency between pain before HBI and pain relief 2 weeks later was found. Pain relief 2 and 6 weeks after HBI was higher for breast than for prostate patients. No difference between U and LHBI effectiveness was found.

Conclusion: HBI is an effective and simple treatment modality for patients with multiple, painful skeletal dissemination allowing to decrease an analgesics intake.

Dvorak J., Vesely P., Petera J., Melichar B., Zoul Z., Vosmik M., Vaculikova M., Dolezel M.

Department of Oncology and Radiotherapy, Charles University Hospital, Hradec Kralove, Czech Republic

Purpose: The aim of the present retrospective study was to evaluate the efficacy of radiotherapy in the treatment of brain metastases (mts) from renal cell carcinoma.

Patients and Methods: Between June 1994 and October 2003, 13 patients (pts), 11 males and 2 females, mean age 62 (range 27-77) years, with brain mts from renal cell carcinoma were irradiated at our department. TNM stage of the primary renal cell carcinoma at the date of diagnosis was as follows: 2 pts stage I, 3 pts stage II, 2 pts stage III and 6 pts stage IV. In 2 pts 1 brain mt was treated, in 3 pts 2 brain mts and in 9 pts more than 2 brain mts. Five pts had surgery before start of radiotherapy. All pts were treated with whole brain radiotherapy. Two pts received dose 40 Gy in 20 fractions (2 Gy daily), 2 pts 30 Gy in 15 fractions (2 Gy daily), 7 pts 30 Gy in 10 fractions (3 Gy daily), 1 pt 20 Gy in 5 fractions (4 Gy daily) and 1 pt 10 Gy in 1 fraction. All pts received concomittant steroid therapy, usually dexamethasone.

Results: The median interval between diagnosis of the primary tumour and brain mts was 473 days (95% CI: 127-487 days). The median of survival from the time of brain mts was 188 days (95% CI: 96-224 days). One-year survival from the time of brain mts was 15.4% (95% CI: 0-35.0%) At the date of evaluation (December 31th, 2004) all pts died.

Conclusion: The prognosis of patients with renal cell carcinoma brain metastases is poor. Radiotherapy has only short-term palliative effect.

Placental Umbilical Cord Blood Transfusion in Cases of Advanced Cancer with Anemia and Emaciation: An Experience of Five Years

N Bhattacharya, M.K. Chettri, K.L. Mukherjee, M Bhattacharya, S Bhattacharya , A Das

Bijoygarh State Hospital, S.S.K.M.Hospital, Ramkrishnamission Seva Pratisthan, Jadavpur University, National Medical College, Calcutta.

In case of advanced malignancy the patient develops progressive anemia due spread of the disease or treatment or both. These cases should be treated with RBC transfusion or erythropoietin Problems of erythropoietin use includes cost, inconvenience of frequent injections limitation of efficacy, bone marrow refraction, and other indication restrictions. Another unresolved issue of erythropoietin use is the potentiality to trigger thromboembolic manifestations Certain cancer chemotherapy is notorious for triggering anemia through its bone marrow suppression effect. Radiation and rapid tumor progression can also trigger anemia through marrow suppression and or infiltration or refraction. Under normal circumstances the antitumor effect of radiation is mediated through interaction with oxygen to form labile free radicals ,intratumoral oxygen level has also a direct role on radiation induced tumor kill potential apart from the type of the tumor cell and its constituents’ composition. If not corrected before initiation of radiation anemia and subsequent tumor cell hypoxia can reduce the tumorocidal effect of radiation , in general apart from the negative effect of anemia on the quality of life of the cancer victims with progressive and worsening fatigue and depression Patients with malignant diseases often require transfusion for relief of the symptoms of anemia In most of the cases marrow function may be severely depressed by chemotherapy, radiotherapy. Infections and thrombocytopenic bleeding may be present and the recovery of the marrow is delayed due to combination of drug ,malignant infiltration or poor nutrition hysiological adjustment to chronic and acute anemia have a limit and particularly in elderly patients with myocardial and vascular disease anemia is poorly tolerated .The physician must decide when the patient is approaching this limit.

In India more than 20 million babies are born each year. We collected aseptically, fetal hemoglobin rich placental umbilical cord whole blood from the discarded placenta after the birth of the healthy baby, (which has the potentiality to carry more oxygen to the tissue Vol/Vol than adult blood because of its fetal hemoglobin component), at or near term, and used the same as an emergency substitute for adult whole blood after taking permission from the donor and recipient and passing through the Institutional Ethical Committee protocol. This project was submitted to the Dept. of cience and Technology, Govt. of West Bengal, Salt Lake, and Calcutta in January 1999. The project was subsequently sanctioned vide order No 495/ST/P/S& T9G-1099 dated 25/3/1999.We have transfused 213 units of placental umbilical cord blood in 72 consented volunteers. All the patients were suffering from advanced malignancy. We did not encounter a single case of immunological or non-immunological reactions so far.

Effectiveness of Fluoride Varnish Application in Patients Receiving Radical Doses of Head And Neck Radiotherapy.

Pranshu M*, Dinshaw K.A*, Agarwal J.P.*, Dholam K#, Prasad D.*, S.K. Shrivastava*, A.K.D'Cruz^

* Department of Radiation Oncology, # Dental Services, ^ Head and Neck Services, Tata Memorial Hospital, Mumbai

Aims and objectives: Dental complications are a significant morbidity of radical doses of head and neck radiotherapy, indirectly caused by ensuing xerostomia and also due to direct effect of radiation. The aim of current study was to test the effectiveness and compliance of intermittent fluoride varnish application (FVA) in avoiding dental problems post radical radiotherapy doses.

Materials and Methods: Randomly chosen 100 patients who have undergone external beam radiotherapy to a median dose of 60 Gy for Head and Neck cancers in the years 2001 and 2002 were analyzed for dental problems. DMFS index (Decay Missing Filled Sensitivity) was noted at presentation and all subsequent follow-ups with median follow up of 15 months. Existing decayed teeth were conserved or extracted if not salvageable. FVA was done 3-4 monthly at regular intervals with aim to prevent dental complications. We used slow release alcohol based topical dental fluoride (5% w/v)

Observation and Results: At presentation, 30 patients had dental decay. With FVA, 60% of these patients did not develop any further decay and 30% patients had only up to 3 teeth decay. In contrast amongst 70 patients with no decay at presentation, only 12% cases developed decay in at least one tooth, 5 of whom required extraction. It has been reported that daily fluoride gel application prevents occurrence of new lesions in 75% cases.Also it is much less than expected 31% decay without any preventive measures. None of our patients even with decayed teeth developed osteoradio-necrosis with maximum follow up of 31 months.

Conclusion: Effective prevention of dental decay was achieved in a large subset of patients with a good compliance for 3 - 4 monthly fluoride varnish applications. Thus in this subgroup of patients with poor dental hygiene and poor compliance, intermittent fluoride varnish application is a very effective & superior alternative to daily gel applications.

A Novel Method of Testing Radioprotective Effect of Ocimum Sanctum in Patients Undergoing Hemi Body Irradiation (HBI)

R Sarin, Prasad D, R Jalali, M A Muckaden, MS Ghadge, AS Raste, KA Dinshaw, P Uma Devi.

Tata Memorial Hospital, Parel, Mumbai, India. Project funded by Indian Council Medical Research.

Objectives: Flavinoids- Orientin and Vicenin from Ocimum sanctum (OS, Tulasi) extract have shown very promising radioprotector activity in animal experiments. We have developed a novel clinical model for testing these agents in vitro. The aim of the current study was to test the radioprotective (RP) effect of Tulasi. HBI provides a unique chance of testing the RP effects of single high dose RT on the two most radiosensitive organs (salivary glands & bone marrow) using objective laboratory endpoints which is not possible with fractionated RT to smaller areas of the body

Materials and Methods: In this double blind RCT, patients undergoing HBI for disseminated cancers are randomised to receive a placebo or an aqueous extract of OS. The patients were evaluated pre and post HBI for salivary amylase, Super oxide dysmutase (SOD), Glutathione reductase (GR) and glutathione peroxidase (GP) and haemogram.

Results: In this trial, 95 patients have been enrolled and biochemical data for 71 patients is available for analysis. The radiation salivary tissue injury manifested in marked increase in the serum salivary amylase levels, peaking 24 hours after upper HBI. The peak salivary amylase levels were significantly higher in the arm A (46 x base line) as compared to arm B (27 x base line) of the study (p=0.056). This indicates a possible radioprotective effect on the salivary glands by the Drug in arm B. No significant variations were noticed in the mean serum levels of the SOD, GR and GP or haematological parameters between the two arms of the study. None of the patients in the trial had any serious adverse event directly related to the investigational drug.

Conclusions: HBI is a good clinical model for evaluating the radioprotective effects of novel agents on the two most radiosensitive human organs, salivary gland and bone marrow. It is possible that the flavinoids in the Ocimum extract have radioprotective effect on the salivary tissue. We will have to wait for the completion of accrual and breaking the code to confirm that Tulasi has indeed radioprotective effect.

Ultrasonographic Changes In Malignant Neck Nodes during Radiotherapy in Head & Neck Cancers

Introduction: Limited information is available about the sonomorphological changes in metastatic neck nodes during a schedule of fractionated radiotherapy.

Aims: To evaluate the pattern of sonomorphological changes in metastatic neck nodes with radiotherapy.

Materials and Methods: The study population consisted of 16 consecutive patients planned for radical radiotherapy to the head and neck. All patients were subjected to four ultrasound examinations- before therapy, at 46 Gy, at conclusion of radiation and on first follow-up.

Results: A total of 59 ultrasound examinations were performed on 16 patients. The difference between the mean number of nodes detected per patient before (10.6) and after (7.8) radiation was significant (p=0.05). 16 nodes were categorized as malignant at first sonography, half of which reverted back to normal by sonomorphologic criteria by the conclusion of fractionated radiation.

Conclusion: Changes in the sonomorphology of malignant cervical lymph nodes occur with radiotherapy with more that half demonstrating reversion to normal pattern. Future studies correlating this with histopathology need to be considered.