Clinical significance of geographic miss when using conventional four field radiotherapy technique in treatment of locally advanced carcinoma cervix.

BACKGROUND: Although conventional four‑ field radiotherapy based on bony landmarks has been traditionally used, areas of geographical miss due to individual variation in pelvic anatomy have been identified with advanced imaging techniques. AIMS: The primary aim of this study is to evaluate the geographical miss in patientswhen using the conventional four‑field planningplanning and to find out the impact of 3‑D conformal CT based in patients with locally advanced carcinoma cervix. MATERIALS AND METHODS: In 50 patients, target volume delineation was done on planning computed tomography (CT) scans, according to guidelines by Taylor et al. Patients were treated with modified four field plan, except for the superior, where field border was kept at L4‑L5 interspace A dosimetric comparison was done between the conventional four‑field based on bony landmarks and the target volume delineated on computed tomography. The disease free survival, pelvic and para aortic nodal free survival, distant failures free survival were calculated using Kaplan Meir Product Limit Method. RESULTS: Patients were followed‑up for a median period of 11 months. The median V95 for conventional and modified extended four field plans were 89.4% and 91.3% respectively. Patients with V95 for modified extended pelvic fields less than 91.3% had a trend toward inferior disease free survival (mean DFS 9.8 vs. 13.9 months) though the difference was not statistically significant log rank test. CONCLUSIONS: Our preliminary data shows trend toward lower DFS in patients with inadequate target volume coverage. We recommend routine use of CT based planning for four field technique.

Dosimetric evaluation and clinical outcome in post-operative patients of carcinoma vulva treated with intensity-modulated radiotherapy.

BACKGROUND: To compare dosimetric parameters of intensity‑modulated radiation therapy (IMRT) with 3D conformal radiotherapy (3DCRT) in post‑operative patients of vulvar cancer and to assess clinical outcome and toxicity with IMRT. MATERIALS AND METHODS: A total of 8 post‑operative patients of vulvar cancer were treated with IMRT. All patients were also planned by 3DCRT for comparison with IMRT. The two plans were compared in terms of conformity index, homogeneity index, tumor control probability (TCP) and normal tissue complication probability (NTCP) for the planning target volume and organs at risk (OAR). RESULTS: IMRT resulted in significantly lesser doses to rectum, bladder, bowel and femoral head as compared with 3DCRT plans. Mean conformity and homogeneity indices were better and within range with IMRT. The TCP was comparable between the two treatment plans and NTCP for rectum, bladder, bowel and femoral head was significantly less with IMRT as compared with 3DCRT. Treatment was well‑tolerated and none of the patients developed Grade 3 or higher toxicity. CONCLUSION: IMRT yielded superior plans with respect to target coverage, homogeneity and conformality while lowering dose to adjacent OAR as compared with 3DCRT. Thus, IMRT offers a reduction in NTCP while maintaining TCP.

Radiation Schedules for Palliation in Carcinoma Esophagus.

This study was undertaken to compare the three different radiation schedules for their efficacy in symptom relief, dysphagia free survival and radiation morbidity (if any), in carcinoma oesophagus. A total of 116 inoperable patients were prospectively randomized to three different arms of radiation. Arm-A received external beam radiation (EBRT) to a dose of 30Gy/10 #/2 weeks along with two sessions of intraluminal brachytherapy (ILBT), 600cGy each, one week apart, after a gap of two weeks from EBRT. Arm-B received only EBRT to a dose of 30Gy/10 #/2 weeks. Arm-C received EBRT to a dose of 20Gy/5#/1week without brachytherapy. The age of the patients ranged from 30 - 70 years. Improvement in dysphagia was seen in 76% of patients in Arm-A, 56% in Arm-B & 54% in Arm-C at 1 month. The dysphagia progression free survival was 10.6+0.6 months in Arm-A, 9.8+0.8 months in Arm-B and 9.9+0.6 months in Arm-C respectively. Grade 1 & 2 acute radiation toxicity was seen in 50% of patients in Arm-A, 55% patients in Arm-B & 30% patients in Arm-C. It is concluded that all the three radiation schedules achieved good palliation with similar dysphagia free survival.

Results of letrozole in postmenopausal women after tamoxifen treatment for advanced breast cancer.

AIM: To analyze overall and progression-free survival after letrozole in postmenopausal women with advanced breast cancer who failed after tamoxifen therapy. MATERIALS AND METHODS: This is a retrospective analysis of 95 patients with breast cancer who were postmenopausal and had failed after tamoxifen therapy. Dose of letrozole was 2.5 mg daily until disease progressed. Patients had estrogen receptor- and/or progesterone receptor-positive tumors or both receptors were unknown. One complete course of (6 cycles) chemotherapy for metastatic disease was allowed. The primary end point was time to progression (TTP). Secondary end points included overall objective response rate (ORR), its duration, time to treatment failure (TTF), overall survival and tolerability. RESULTS: Median TTP was 10 months. ORR was 21% with complete response rate of 9%. Nine patients died of disease during treatment. Median overall survival was 36 months. Median time to response was three months and median duration of response was 13 months. Time to chemotherapy was 13.5 months and TTF was 9.3 months. Treatment failure was seen in 76% of patients. Disease progression was the main cause for treatment failure. Treatment was well-tolerated by all patients. CONCLUSION: This retrospective analysis shows that letrozole is quite effective as second line therapy in postmenopausal patients with advanced breast cancer who had failed after tamoxifen therapy.

Management and Outcome of Thymoma: A Retrospective Analysis

Thymoma is a rare disease. The treatment of invasive thymoma remains controversial. To evaluate the outcome of thymoma we reviewed aseven years [1996-2002] experience with 26 patients at PGIMER Chandigarh. It constituated about 16% of all mediastinal tumours in our institutions. All the patients had surgical intervention and diagnosis was made on pathologicalstudy. Post-operative staging was made on mordified Masoaka staging system. Out of 26 patients, six were with stage-1, 5 with stage- 2, 7 with stage-3 and 8 with stage 4. The pathological classification included 6 lymphocytic predominant,12 epitheloid and 8 mixed lymphoepitheloid histology. Myasthenia gravis was associated with 12 patients. Ten patients had complete surgical resection, 7 had incomplete surgery and 9 had only biopsy. All thepatients received external beam radiation with doses ranging from 3000 Cgy to 5000 Cgy in 3 to 5 weeks with a fraction size of 180-200 Cgy. Three patients received systemic chemotherapy with multidrug platinum based regimens. The median follow up was 26.2 months. Patients who received adjuvant external radition after complete surgery did better than who had incomplete surgery or only biopsy. Overall five years survival was 56.85. Post operative radiotherapy improved locoregional controls, however clinical stage and type of surgery were the two most important prognostic factors. Role of chemotherapy needs to be further assessed.

Local control of high-grade gliomas with limited volume irradiation versus whole brain irradiation.

INTRODUCTION: To evaluate the role of limited field radiation therapy in the management of high-grade gliomas and glioblastoma multiforme (GBM). MATERIAL AND METHODS: From July '96 to January '98, 50 newly diagnosed patients of high-grade gliomas (Grade III and IV) and glioblastoma multiforme who underwent surgery in the form of partial, sub-total or near-total excision as the primary treatment were enrolled in this study. The patients were randomized to receive two different postoperative external radiation protocols, Study Group A: Localized field external radiotherapy 50 Gy/25#/5 wks followed by Boost 10 Gy/5#/1 wk, Control Group B: Whole brain external radiotherapy 40 Gy/20#/4 wks followed by Boost 20 Gy/10#/2 wks by localized field. RESULTS: 20/25 (80%) patients in the study group and 14/25 (56%) patients in the control group showed improvement in their Karnofsky Performance Status (KPS). Thus a significant difference in the performance status was noted in favor of limited field irradiation. No significant difference in the local response was seen between the two groups after radiotherapy. Six months progression-free survival of the study group was 44% as compared to 26% in the control group. Six months overall survival was 66.67% in the study group and 50.72% in the control group (P<0.01). Maximum recurrences were noticed within 2 cm of the original tumor margin in both the groups. CONCLUSIONS: Although local control and survival of the patient in both the groups were same, performance status definitely improved in patients treated with localized field irradiation only.

Testicular Choriocarcinoma Stage IV : Treated with Combination Chemotherapy

Choriocarinoma, a rare variety of testicular germ cell tumour, is associated with poor prognosis. A stage IV choriocarcinoma treated successfully with combination chemotherapy is being reported.

Role of Combined Approach with Radiotherapy and Metallic Stent in Palliation of Advanced Cases of Carcinoma Esophagus -APilot Study

Carcinoma esophagus presents with dysphagia and in 60% of patients, the aim of treatment is palliation. ThIs study was done to evaluate the feasibility and role of planned combined approach using radiotherapy with metallic stent in palliation of malignant dysphagia. Ten patients with histologically proven, locoregionally advanced esophageal carcinoma were selected. All patients underwent external radiotherapy followed by brachytherapy. The self-expanding metallic stent was placed under combined endoscopic and fluoroscopic guidance. A predetermined questionnaire to assess dysphagia, pain, reflux symptoms and quality of life was administered before the procedure, and thereafter at monthly intervals until death or last follow-up. 10/10 patients had grade III dysphagia at presentation. 4/10 patients underwent stent placement prior to any radiotherapy (group A), 4/1 0 patients had stent placement after external radiotherapy (group 8) and 2/1 0 had stent after completion of brachytherapy (group C). There was no difficulty in placing the stent despite the post-radiotherapy ulcerations and stricture in all the patients in group 8 and C. 8/8 patients in groups A and 8 had no difficulty in placing esophageal bougie for brachytherapy. The mean follow-up after stent placement was 9 months (4-24 months). There was complete disappearance of dysphagia in 4/4 patients in group A, 2/4 patients in group Band 0/2 patients in group C. The rest of patients had significant improvement in dysphagia score by atJeast two grades. For dysphagia grade. the mean progression free interval was recorded as 5 months for group A, 3 months for group Band 2 months for group C. Combining radiotherapy and metallic stent is a safe, simple and effective means to palliate malignant dysphagia. This raises an issue whether all patients with advanced carcinoma esophagus should preferably be pre planned for stent placement followed by radiotherapy for best results.

Primary Non-Hodgkin's Lymphoma ofWaldeyer's Ring-A Retrospective Analysis

Tweny -five newly diagnosed cases of primary Waldeye!'s Ring (WR) Non-Hodgkin's lymphoma (NHL) registered from 1989-99 were analysed. These comprised 5% of tota! NHL cases. The most common site was tonsil (44%). followed by nasopharynx (20%), base of tongue (20%). nasal cavity (12%) and palate (4%). All the patients were staged thoroughly according to Ann Arbor staging system and -40% patients were stage I. 36% patients stage II. 4% stage IIl and 20% stage IV. Eighty-eight per cent patients were high grade at presentation and 12% were intermediate grade. Three patients absconded without treatment. Patients were treated with radiotherapy alone (4/22 patients). chemotherapy with CHOP regimen alone (9/22 patients) or a combination of both (9/22 patients). On comparison. complete response was recorded in 4/4 patients treated with radiotherapy alone. 5/9 patients treated with chemotherapy alone and 7/9 patients treated with combination of radiation and chemotherapy (p>O.05). The range of Follow up period was 1-10 years with median 20 months. Overall 16/22 evaluable patients were with no evidence of disease on last follow up and the primary site was the most common site of first failure. A combined modality treatment except for stage Ia seems to be the treatment of choice for this relatively (Uncommon entity of Primary Waldeyer's Rjng NHL.

Plasmacytoma of the Mandible

We describe a patient with an extramedullary plasmacytoma (EMP) of the mandible. which presented a diagnostic and therapeutic challenge on several levels. We discuss herein the clinical presentation surgery and the role of radiotherapy in this rare case.

Primary gastrointestinal lymphoma--disease spectrum and management: a 15-year review from north India.

OBJECTIVE: To analyze retrospectively the disease spectrum and outcome of primary gastrointestinal lymphoma (PGIL) in a tertiary referral center in north India. MATERIAL: Seventy five patients presenting with PGIL between January 1971 and December 1985 were evaluated. RESULTS: The 49 males and 26 females were aged 3.5-69 years (mean 34) at presentation. Abdominal pain, weight loss and vomiting were cardinal symptoms at presentation; the stomach was the most common site of involvement. Histologically, a majority of patients were classified as having diffuse poorly-differentiated lymphocytic lymphoma (46.7%) and diffuse histiocytic type (30.7%). Twenty seven (36%) patients had stage I disease, 31 (40%) stage II, 11 (14.7%) stage III, and 6 (8%) stage IV. At laparotomy, primary resection and anastomosis was carried out in 66 patients, while only biopsies were taken in nine. Forty eight patients received adjuvant radiation with or without chemotherapy. The mean follow-up was 3.9 years (range 1-14). The 5-year actuarial survival was 34%, 25% and 16% for stages I, II, and higher-stage disease, respectively. The survival was significantly better (p < 0.01) for gastric location (44%) compared to other sites (24%). CONCLUSION: PGIL was more common in the 3rd and 4th decades of life, with the stomach being the predominant site of involvement. Survival was better among patients with stages I and II disease, and gastric location of lesion.