Role of preoperative MR volumetry in patients with renal cell carcinoma for prediction of postoperative renal function after radical nephrectomy and nephron sparing surgery

ABSTRACT Purpose Preoperative computed tomography or magnetic resonance (MR) imaging are commonly used for radiological evaluation of renal cell carcinoma (RCC) before radical nephrectomy or nephron sparing surgery(NSS). This study aimed to assess the role of MRI for predicting postoperative renal function by preoperative estimation of renal parenchymal volume and correlation with glomerular filtration rate (GFR). Materials and Methods A prospective observational study was conducted from February 2015 to October 2016 at a tertiary care hospital in northern India. MR imaging was done on 3 Tesla MR scanner (Signa Hdxt General Electrics, Milwaukee, USA). MR volumetry was used to estimate the renal parenchymal volume. GFR was measured in all patients using Tc99m Diethyl-triamine-penta-acetic acid using Russell's algorithm. Such measurement was done preoperatively, and postoperatively 3 months after surgery. Results 30 patients with suspected RCC underwent NSS (n=10) and radical nephrectomy (n=20). Median tumour volume was 175.7cc (range: 4.8 to 631.8cc). The median volume of the residual parenchyma on the affected side was 84.25±41.97cc while that on the unaffected side was 112.25±26.35cc. There was good correlation among the unaffected kidney volume and postoperative GFR for the radical nephrectomy group (r=0.83) as well as unaffected kidney volume, total residual kidney volume and residual volume of affected kidney with postoperative GFR for the NSS group (r=0.71, r=0.73, r=0.79 respectively; P <0.05). Conclusion Preoperative residual parenchymal volume on MR renal volumetry correlates well with postoperative GFR in patients with RCC undergoing radical nephrectomy or NSS.

A comparative study for surface dose evaluation in conventional treatment of carcinoma breast patients irradiated with Co-60 and 6 MV radiation beam

Aim: In the present study, surface doses within the target area and contralateral breast (CLB) received during conventional treatment of carcinoma breast are evaluate and compared for treatment on two different beam energies, i.e., Co-60 γ-ray and 6 MV X-ray beams with thermoluminescent dosimeter, LiF:Mg, Ti (TLD-100). Materials and Methods: The study includes a group of 23 patients comprising 11 patients treated with Co-60 γ-ray beam and 12 patients by 6 MV X-ray beam. Results and Discussion: The treatment using Co-60 γ-ray and 6 MV X-ray beams contributes an average percentage dose of 8.15% ± 0.56% and 4.73% ± 0.94%, respectively, to CLB in mastectomy patients. The contribution of tangential fields (mastectomy) to the CLB doses ranges between 12.71 and 16.40 cGy (5.45%–7.03%) for treatment with Co-60 γ-ray beam and 6.33–10.95 cGy (1.86–4.69%) for treatment with 6 MV X-ray beam. The supraclavicular field (SCF) contributes 1.45%–1.93% and 1.02%–1.43% for treatment with Co-60 γ-ray and 6 MV X-ray beams, respectively. The average surface dose (normalized with breast dose) 89.1% ± 8.5% for Co-60 beam in the SCF region differs significantly from the 60.2% ± 13.0% value for 6 MV X-ray beam. Conclusion: The CLB doses for mastectomy patients are higher for Co-60 beam as compared to 6 MV X-ray beam, and better dose homogeneity is achieved within the irradiated breast from 6 MV X-ray beam. The CLB doses are slightly higher for patients treated with breast conservative radiotherapy or lumpectomy. The average surface dose to SCF decreases by ~30% of treated breast dose for treatment with 6 MV X-ray beam

Kilovoltage cone-beam computed tomography imaging dose estimation and optimization: Need of daily cone-beam computed tomography

Aim: The aim of the present study was to access the need of daily cone-beam computed tomography (CBCT) and the requirement of in-house protocols of image acquisition frequency to reduce unnecessary exposure to the patients undergoing radiotherapy treatment. Materials and Methods: The dose delivered during CBCT procedure (On-Board Imager, Trilogy, Varian medical system, Inc., Palo Alto, California) was assessed for pelvic and head and neck region. For dose estimation, cylindrical polymethyl methacrylate phantoms of 15 cm length, 16 cm, and 32 cm diameter were used to simulate the patient's head and neck and pelvic region thickness, respectively. More than 10 cm scatterer was added on either end of this phantom. Calibrated Ionization chamber DCT10 LEMO SN 1685 iba, dosimetry, Germany (10 cm active length) was used to measure the dose Index. The doses known as cone-beam dose index (CBDI100) were estimated for all the scanning protocols (kV and mAs setting) available on the machine. In this study, image acquisition frequency to correct the setup error was optimized. In-house protocol for image acquisition frequency during treatment has been suggested to reduce the dose. It was based on the principle of as low as reasonable achievable. Results: Optimized dose protocol observed was the “standard dose head” for which the CBDI100 was 2.43 mGy. Whereas for pelvic imaging, single protocol of 125 kV, 80 mA was available by which a dose of 7.61 mGy is likely to be received by the patient during scan. Maximum shift of 6 mm in lateral direction was observed to the patient of Pelvis region and 5 mm was observed in the longitudinal direction for the H and N patients. Angular shift measured in patient position was 3.8° and 3.1° for H and N and pelvic region, respectively. Conclusion: Three consecutive-day CBCT-imaging at the beginning of the treatment followed by once weekly CBCT and two-dimensional (2D) imaging in remaining days of treatment can be an optimized way of imaging for the patient having malignancy in the region of pelvic and abdomen. For H and N, once in a week, CBCT with standard dose head protocol, followed by 2D-imaging in remaining days can be an optimized way of imaging.

Role of stereotactic body radiation therapy in liver metastasis: A pilot study from tertiary cancer institute in India

Purpose: This trial studies the feasibility and potential utility of stereotactic body radiation therapy in patients with unresectable liver metastasis. Aims: (1) The aim of this study is to assess the local response of the liver lesions poststereotactic body radiation therapy regarding number and size of lesions and (2) to evaluate the toxicity to organ (s) at risk. Materials and Methods: A total of 15 patients were enrolled in this study from November 2014 to October 2015. The inclusion criteria for this study were patients having 1–3 liver metastasis from any solid tumor except germ cell tumor or lymphoma with no evidence of progressive disease (PD) outside the liver. A planning four dimensional-computed tomography (CT) scan was taken. Planning target volume was generated by giving margin of 5 mm. Dose prescribed was 36 Gy in 3#. Response was defined by CT abdomen done at 3 and 6 months poststereotactic body radiation therapy as per RECIST guideline (v1.1). Results: At 3 months poststereotactic body radiation therapy, five patients had partial response, five patients had stable disease, and five patients had PD as per RECIST criteria. Out of 20 assessable lesions, 16 were controlled at 3 months poststereotactic body radiation therapy. The actuarial local control rate was 86% at 3 months and 77% at 6 months poststereotactic body radiation therapy. The median progression free survival was 7 months. Two patients experienced Grade 2 gastric toxicity and one patient experienced Grade 2 small bowel toxicity. No cases of radiation-induced liver disease were observed. Conclusions: This trial examines the feasibility of stereotactic body radiotherapy to liver metastasis in the Indian scenario. It shows excellent tolerability and is a safe therapeutic option for inoperable patients, showing good local control

Renal cell carcinoma in India demonstrates early age of onset & a late stage of presentation.

Background & objectives: Clinical spectrum of most of the diseases in developing countries is different from the west. Similarly whether renal cell carcinomas (RCC) in a developing country like India is seen in the same spectrum in relation to the age at presentation as in the west is not described in the literature. This study was carried out to investigate the spectrum of RCC in India with regards to age of onset, stage at presentation and survival. Methods: Patients with renal tumour, treated between January 2000 to December 2012 in a tertiary care hospital in north India, were analyzed for age at presentation, clinical features and histopathological characteristics. Clinical diagnosis was made by contrast enhanced computerized tomography (CECT) scans and/or magnetic resonance imaging (MRI). Renal masses diagnosed as angiomyolipoma, infective masses and hydatid cysts were excluded from the analysis. Impact of various age groups on gender, tumour size, TNM stage, Fuhrman grade, histopathological subtypes, lymph node, inferior vena cava (IVC) involvement and survival was analyzed. Patients were grouped in five age groups i.e. ≤39, 40-49, 50-59, 60-69 and more than 70 yr of age. Results: Of the total 617 patients with 617 renal tumours (2 patients had bilateral tumours but only the larger tumour was considered) clinically suspected as RCC, 586 had epithelial cell tumour and the remaining 31 had non epithelial cell tumour. The mean tumour size was 8.08±3.5 cm (median 7, range 1-25 cm). Tumour of less than 4 cm size was present in only 10.4 per cent patients. The mean age at diagnosis was 55.15±13.34 (median 56, range 14-91 yr) years. A total of 30.03 per cent of renal tumours presented in patients younger than 50 yr of age. Though there was no difference in stage, Fuhrman’s grade, IVC involvement and lymph nodal spread among various age groups, younger patients had higher proportion of non clear cell RCC and only 48.59 per cent of them presented with conventional RCC. Mean survival was lower in patients younger than 39 yr with HR of 1.7 (0.8-3.2). Interpretation & conclusion: Our results showed that renal cell carcinoma was more frequent in younger people in India. One third of the patients were less than 50 yr of age and only 10.4 per cent patients had tumour of less than 4 cm (T1a). Younger patients of <39 yr of age had relatively lower survival rates.

Polymorphisms in base-excision & nucleotide-excision repair genes & prostate cancer risk in north Indian population.

Background & objectives: Genetic variation in the DNA repair genes might be associated with altered DNA repair capacities (DRC). Reduced DRC due to inherited polymorphisms may increase the susceptibility to cancers. Base excision and nucleotide excision are the two major repair pathways. We investigated the association between two base excision repair (BER) genes (APE1 exon 5, OGG1 exon 7) and two nucleotide excision repair (NER) genes (XPC PAT, XPC exon 15) with risk of prostate cancer (PCa). Methods: The study was designed with 192 histopathologically confirmed PCa patients and 224 age matched healthy controls of similar ethnicity. Genotypes were determined by amplification refractory mutation specific (ARMS) and PCR-restriction fragment length polymorphism (RFLP) methods. Results: Overall, a significant association in NER gene, XPC PAT Ins/Ins (I/I) genotype with PCa risk was observed (Adjusted OR- 2.55, 95%CI-1.22-5.33, P=0.012). XPC exon 15 variant CC genotypes presented statistically significant risk of PCa (Adjusted OR- 2.15, 95% CI-1.09-4.23, P=0.026). However, no association was observed for polymorphism with BER genes. Diplotype analysis of XPC PAT and exon 15 revealed that the frequency of the D-C and I-A diplotype was statistically significant in PCa. The variant genotypes of NER genes were also associated with high Gleason grade. Interpretation & conclusions: The results indicated that there was a significant modifying effect on the association between genotype XPC PAT and exon 15 polymorphism and PCa risk which was further confirmed by diplotype analysis of XPC PAT and exon 15 in north Indian population.

Primary Extradural Non-Hodgkin's Lymphom

A 28 years old male presented to our institute with 3 months history of paraparesis with decreased sensation over left foot and loss of bladder and bowel control .The diagnostic work up revealed an extradural mass at spinal level L3 L4.Had laminectomy and the tumour was sub totally resected. Histological examination revealed non hodgkin's lymphoma. The patient was worked up for disease anywhere else and was confirmed to have primary extra-dural non-hodgkin's lympoma(PENHL). Patient was treated with corticosteroides, adjuvant radiotherapy and chemotherapy. The residual tumour completely disappeared and patient is living normal healthy life and is walking without support after 9 years of follow-up.

Rhabdomyosarcoma of Head and Neck -A Ten Year Review

Rhabdomyosarcoma is an aggressive malignant skeletal neoplasm arising from embryonal mesenchyme. It accounts for over 50% of all paediatric soft tissue tumours. It may OCCur in any site of tile body but the most common sites of tumor occurrence are orbit (12%) and head and neck (16%). Use of multimodality approach to treatment, including multidrug chemotherapy, radiotherapy has resulted in a dramatIc improvement in the outlook of affected children. Orbit has long been recognized as a favourable site as compared to other head and neck sites due to paucity of lymphatics and high response rates seen with radiation therapy and chemotherapy. A ten year relrosprvyibr analysis of 31 patients of Rhabdomyosarcomas of head and neck was done. The main outcome measures were age, gender, histopathologic type, treatment received ,follow up period. and eventual outcome. Most of our patients presented with an advanced stage. A complete response of 91.6% and 28.2% was seen in orbit and other non orbital head and neck sites respectively. The 5- year disease free survival in patients of orbital rhabdomyosarcoma was 83.3%

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.

Comparative Evaluation of Concurrent Chemotherapy & Hyperfractionated radiotherapy Versus Conventional Radiotherapy alone in the Treatment of Locally Advanced Carcinoma Cervix-A Prospective Randomised Study

The aim of this study was to determine whether the addition of concurrent cisplalin and hyperfractionation in external pelvic radiotherapy improves local control and survival in patients with locally advanced carcinoma cervix as compared to treatment with conventional radiptjerapy alone. The morbidity of two treatment protocols was also compared. Sixty patients of newly diagnosed squamous cell carcinoma cervix, FIGO stage 118 and III were randomised into the following two treatment protocols: Group A (study group): Cisplatin30 mg/m2 weekly x 5 courses and external beam pelvic radiotherapy 50 Gy/33#4.5 weeks with hyperfractionation in first and following weeks. Group B (control group) : External beam pelvic radiotherapy 46 Gy/23#/4.5 weeks. Patients in both the group were then treated with intracavitary brachytherapy by LDR/MDR Selectron and a dose of 28 Gy was delivered to point A. The patients who were not suitable for intracavitary treatment were treated by supplementary external beam pelvic radiotherapy 20 Gy/ 10#/2" ceks. The actuarial local control at 4 years was 60% in group A and 42% in Group 8 9p<0.05). The a Cluarial disease free survival at 4 years was 52% in Group A and 35% in Group 8 (p<0.05). Only grade I acute and delayed haematological toxicity and grade I nausea and vomiting as acute toxicity "ere significantl) higher for Group A patients as compared to Group 8. Concomitant chemotherapy with hyperfraclionated radiotherapy is well tolerated and seems to offer potential benefit for imprOl ing the locoregional control in locally advanced carcinoma of cervix.

Cutaneous Metastasis :A rare Clinical Entity.

An interesting and rare case of cutaneous metastasis in xiphisternal region is being reported. The patient presented with a fungating nodule in xiphisternal region of 3 months duration. The biopsy showed metastatic carcinomatous deposits (Keratin ising Squamous cell carcinoma). Primary lesion was later localised in the right lung.