Retrospective analysis of role of interstitial brachytherapy using template (MUPIT) in locally advanced gynecological malignancies.

AIM: The aim of this retrospective study was to assess treatment outcomes for patients with locally advanced gynecological malignancies being treated with interstitial brachytherapy using Martinez universal perineal interstitial template (MUPIT) and to study the acute and late sequelae and survival after treatment by this technique. MATERIALS AND METHODS: Ninety seven patients untreated with histopathological confirmation of carcinoma of cervix (37) vault (40) and vagina (20) were treated by combination of external beam RT (EBRT) using megavoltage irradiation to pelvis to dose of 4000-5000 cGy followed by interstitial brachytherapy using MUPIT between September 2001 to March 2005. Median age was 46 years. Only those patients who were found unsuitable for conventional brachytherapy or in whom intracavitatory radiotherapy was found to be unlikely to encompass a proper dose distribution were treated by interstitial template brachytherapy using MUPIT application and were enrolled in this study. The dose of MUPIT was 1600-2400 cGy in 4-6# with 400 cGy/# and two fractions a day with minimum gap of six hours in between two fractions on micro-HDR. Criteria for inclusion of patients were as follows: Hb minimum 10 gm/dl, performance status--70% or more (Karnofsy scale), histopathological confirmation FIGO stage IIB-IIIB (excluding frozen pelvis). RESULTS: Among the 97 patients studied, 12 patients lost to follow-up and hence they were excluded from the study. Follow-up of rest of the patients was then done up to September 2006. The duration of follow-up was in the range of 20-60 months. Parameters studied were local control rate, complication rate, mortality rate and number of patients developing systemic metastasis. Local control was achieved in 56/85 (64.7%) and complication rate was 15/85 (17.6%). Local control was better for nonbulky tumors compared bulky tumors irrespective of stage of disease. Local control was better in patients with good regression of disease after external beam radiotherapy. Time of gap between EBRT and implant also had an impact on the outcome. CONCLUSION: Interstitial template brachytherapy by MUPIT is a good alternative to deliver high dose radiation in locally advanced gynecological malignancies where conventional brachytherapy application is either not feasible or likely to give optimal dose distribution. Loco regional control obtained is definitely better than EBRT alone and within the accepted range of complications.

Inoperable non-small cell lung cancer: palliative radiotherapy with two weekly fractions.

Thirty seven cases (30 males; 7 females) of advanced non-small cell lung cancer were treated with short course of palliative radiotherapy. All the patients were inoperable. Their main symptoms were related to primary intrathoracic disease and poor performance status. Radiotherapy was delivered to a total dose of 17 Gy in two fractions one week apart. Ninety percent of the patients had cough, 50% complained of haemoptysis, 45% chest pain and 30% breathlessness. Palliation of main symptoms was achieved in majority of the patients, more than 90% in haemoptysis, 60% in cough, 70% in chest pain and 50% in breathlessness. Mean duration of palliation was four months and performance status improved in 60% of the patients. Short course radiotherapy of 17 Gy in two weekly fractions is recommended in patients with advanced non-small cell lung cancer (NSCLC) having poor performance status.

Plasmacytoma of scalp.

An interesting case of plasmacytoma of the scalp is described. Extramedullary plasmocytoma of scalp is rarely reported. This patient was treated with external radiotherapy dose of which was 40 Gy/20 fraction. Disease responded very well to radiotherapy.

Post orchiectomy management in stage II testicular seminoma.

Twenty eight patients with stage II A and twenty patients with stage II B testicular seminoma were treated at this institute between January 1982 and December 1988. The three year crude survival observed in this retrospective analysis was 82% and 75% respectively. Post orchiectomy infradiaphragmatic radiotherapy was the mainstay of the treatment. In stage II A 4 patients were administered adjuvant chemotherapy as well. Prophylactic Mediastinal Irradiation (PMI) was not employed as a routine in this subgroup. Eight patients (28%) relapsed (Mediastinal Nodes--4, Pulmonary--3, Scrotal--1). In stage II B twelve patients were treated with primary abdominal radiotherapy and of them 4 were delivered PMI as well. Induction chemotherapy was administered in remaining 8 patients. Seven patients (35%) relapsed (Pulmonary-4, Mediastinal Nodes-3). Mediastinal recurrence was noted only in those who were treated with abdominal radiotherapy alone. Though salvage chemotherapy proved successful in 5 of the seven patients (70%) with nodal relapse, none of the patients with extranodal relapse responded to subsequent chemotherapy. For stage II A we recommend abdominal radiotherapy alone and for stage II B Induction chemotherapy is advised keeping radiotherapy reserved for residual mass. We do not advocate PMI as a routine in stage II testicular seminoma as no survival benefit is observed.

Leiomyosarcoma of the ovary.

A diagnosis of leiomyosarcoma of ovary was made in a 60 year old female presenting with generalised weakness and abdominal lump. On clinical examination, a hard, big mass with some cystic areas was found occupying the pelvic cavity. Chest X-ray revealed presence of metastases. Deranged renal function and structure due to extrinsic pressure were evident on pyelography and USG. USG also suggested the ovarian origin of the mass. Fine needle aspiration biopsy was suggestive of leiomyosarcoma. Laparotomy was carried out for excision of tumor along with bilateral salpingo-oophorectomy and hysterectomy. Post-operatively renal functions normalized. A course of radiotherapy was given. At 6 months' follow-up, abdomino-pelvic sonography was normal but lung metastases were found to be enlarged. The patient was asked to follow up for chemotherapy but did not come. She died 18 months after treatment, as revealed through correspondence.

Carcinoma of the oesophagus: correlation of radiological appearance with response to radiotherapy.

In order to predict possibility of local control in carcinoma of the oesophagus by radiotherapy, the relationship between the x-ray findings before and after radiotherapy were analyzed in 55 irradiated cases. In the superficial or proliferative type on x-ray before treatment, local control was observed in 87% cases with dose of 40 Gy, whereas in the ulcerative or infiltrative type it was observed in 20% cases. Radiation response is remarkably good in proliferative and superficial lesions seen in oesophagogram.