An experience with simultaneous integrated boost-volumetric-modulated arc therapy in the definitive treatment of head and neck cancer: An Indian data.

Background: There are very few prospective studies comparing simultaneous integrated boost versus sequential boost in the setting of definitive treatment modality of head and neck squamous cell cancer (HNSCC), especially in the Indian scenario. Materials and Methods: We prospectively randomized 50 patients with biopsy-proven squamous cell carcinoma of the oropharynx, hypopharynx, and larynx malignancies, stage T1-3, enlarged node measuring ≤3 cm that are planned for definitive radiotherapy with chemotherapy into either hypo-fractionated simultaneous integrated (Hypo-SIB VMAT) boost arm or conventional (Conv-VMAT) boost arm. Results: Most of the patients were men and aged less than 50 years. Patients with nodal involvement were 76% in Hypo-SIB VMAT and 80% in Conv-VMAT arm. The overall stage group distribution of II, III, and IVA were 16%, 44%, 40%, and 12%, 56%, and 32%, respectively, in both arms. All patients completed the intended treatment in both arms. Overall survival at the end of 2 years was 84% in Hypo-SIB VMAT arm and 80% in the Conv-VMAT arm (P = 0.25); disease-free survival (DFS) was 88% and 72%, respectively (P = 0.12); and locoregional recurrence-free survival (LRFS) was 92% and 84%, respectively (P = 0.38). All the acute and chronic toxicities in both the arms were comparable with no significant difference in any of the toxicities. The average overall treatment time (OTT) in Hypo-SIB VMAT arm is 39.4 days and in Conv-VMAT arm is 50.2 days (P = 0.00001) which is statistically significant. Conclusions: Accelerated Hypo-SIB VMAT has similar response and toxicities as compared to Conv-VMAT in the setting of definitive concurrent chemoradiation of HNSCC patients with the advantage of less OTT, faster treatment delivery, and patient compliance.

Evaluation and evolution of apparent diffusion coefficient (ADC) in image-guided adaptive brachytherapy (IGABT) for cervical cancer.

PURPOSE: Image-guided adaptive brachytherapy (IGABT) recently has shown excellent clinical outcomes with superior local control and less toxicity. For IGABT, T2W (T2-weighted) MRI is the gold standard. However, studies have shown that target delineation with the same results in uncertainties, poor interobserver variabilities, and low conformity indices for high-risk clinical target volume contours. In this study, we investigate the role of diffusion-weighted imaging-derived apparent diffusion coefficient (ADC) maps to aid in IGABT. We also evaluated ADC from the baseline to brachytherapy. METHODS AND MATERIALS: Thirty selected patients were enrolled for this study, and two MRIs were taken at diagnosis and before brachytherapy. Patients were divided into two groups, Group 1 being patients with parametrial involvement before external beam radiotherapy and no parametrial involvement before brachytherapy. Group 2 included patients with parametrial involvement before external beam radiotherapy and persistent parametrial involvement before brachytherapy. ADC was measured at the center, edge, and 1 cm from the edge. RESULTS: The measured ADC increased from diagnosis to brachytherapy, and this increase was more for the patients in Group 1 than in Group 2. The mean TDadc (diagnosis ADC, center), TEadc (tumor edge ADC diagnosis), and T1cmDadc (1 cm from edge at diagnosis) were 0.884, 1.45, and 1.9 × 10-3 mm2/s, respectively. The TBadc (ADC at brachytherapy, center), TEBadc (tumor edge ADC at brachytherapy), and TE1cmBadc (1 cm from edge brachytherapy) were 1.2, 1.8, and 2.3 × 10-3 mm2/s, respectively, p-value <0.00001. No abnormal ADC was present outside the high-risk clinical target volume contours. CONCLUSION: MRI-based IGABT using T2W imaging essentially covers all functionally abnormal zones at brachytherapy. Diffusion-weighted imaging, along with ADC maps, should only be used as a supplement for target delineation.

A prospective comparative dosimetric study between diffusion weighted MRI (DWI) & T2-weighted MRI (T2W) for target delineation and planning in cervical cancer brachytherapy.

AIM: To evaluate the difference between GTVBT (Gross Tumor Volume at Brachytherapy) and HR CTV (High Risk Clinical Tumor Volume) delineated with DWI and T2W MRI. To evaluate doses to organs at risk and targets from plans generated using T2W and DWI. BACKGROUND: Functional imaging with DWI can improve cervical tumor distinction as it is more sensitive than T2W MRI even in detecting parametrial invasion. This study does a dosimetric comparison between a T2W and DWI based plan. METHODS: Fifty carcinoma cervix patients were subjected to MRI based brachytherapy. T2W and a diffusion weighted sequence were acquired. Target delineation and brachytherapy planning was done on both T2W and DWI. Standard DVH parameters were recorded and the treatment was given using the plan generated from T2W images. RESULTS: GTVBT and HRCTV contours on DWI were different when compared with T2W. Mean GTVBT volume on T2W and DWI was 5.25 and 5.23, respectively (p value 0.8). Mean HRCTV on T2W and DWI was 28.3 and 27 cc, respectively (p value 0.003). Planning on the above volumes resulted in a superior coverage in terms of HRCTV D90 and D100 for DWI based plan, HRCTV D90 - 735.1 and 741 cGy for T2W and DWI, respectively (p value 0.006), HRCTV D100 - 441.05 and 444.5 for T2W and DWI plans, respectively (p value = 0.006). Doses to the OAR were not significantly increased. CONCLUSION: GEC ESTRO based contouring guidelines cover all the functionally abnormal areas on DWI. DWI should only be used as a supplement to T2W for contouring target volumes.

The promise of image-guided brachytherapy of better clinical outcomes in treatment of cervical cancer: Does it deliver? An Indian scenario.

PURPOSE: The purpose of this series is to study the effectiveness of MRI based image-guided brachytherapy (IGBT) in Indian patients with cervical cancer who mostly present in later stages with bulky diseases. PATIENTS AND METHODS: 151 cervical cancer patients treated at our institution in last four years, with definitive chemoradiation followed by MRI-based brachytherapy were reviewed. With median follow up of 26 months, Kaplan Meier estimates at two years were calculated for local control (LC), pelvic control (PC), disease-free survival (DFS) and overall survival (OS). Also, severe late sequelae were reported. RESULTS: The patients predominantly presented with locally advanced cervical cancer in FIGO stages IIB (53.6%) and IIIB (23.2%). Tumour dimensions at diagnosis were ≥5 cm in 56.3% and pelvic nodal involvement was found in 38.4% of the patients. 94% of the patients received curative chemoradiation. Mean HRCTV volume at the time of brachytherapy was 42.2 ±â€¯19 cm3 and mean cumulative dose to HRCTV was 78.9 ±â€¯5.6 Gy. Overall LC, PC, DFS and OS at 2 years were 88.7%, 88.1%, 82.2% and 94% respectively. The predictors for local failure were FIGO stage (p = 0.002) and tumour size at diagnosis (p = 0.009). Late grade 3-4 bladder and bowel toxicities were observed in 3.8% of the patients. CONCLUSION: Our review demonstrates that IGBT is an effective strategy to improve locoregional control with limited long-term sequelae in patients with locally advanced extensive cervical cancer in the setting of a developing country.

Gastric cancer-a clinicopathological study in a tertiary care centre of North-eastern India.

BACKGROUND: The incidence of gastric cancer varies in different parts of the world and among various ethnic groups. It remains the fifth most common cancer among males and seventh most common cancer among females in India. MATERIALS AND METHODS: We conducted a retrospective study using the data base of 158 patients of primary gastric cancer diagnosed in the Department of Surgery at Regional Cancer Centre, RIMS, Manipur, India from July 2009 to June 2013. RESULTS: Our study revealed a male to female ratio of 2.16(:)1, distribution of age varied from 28 to 91 years. Majority of the men were in the age group of more than 60 years (45.37%) and majority of females were of 51-60 years (44%). Nearly 7.6% patients had a positive family history. Dietary history of intake salted, fermented fish was present in 67.7% of patients, whereas history of consumption of smoked meat was found in 77.8% of patients. Only 27.8% of patients in our study had history of regular consumption of fresh fruits. About 35.4% of the patients had poor drinking water source. Nearly, 67.6% of males and 44% of females had smoking history. Combined consumption of alcohol and smoking was present in 33.5% of patients. Vague abdominal discomfort was the most common presenting symptom in 61.4% of patients. The most common site of gastric cancer in our study was antrum (50.6%) followed by cardia (17.1%). The most common histological type was adenocarcinoma (95.6%). Most of our patients presented in locally advanced stage (62.7%). CONCLUSIONS: Our analysis suggests that poor dietary habits such as smoked mead, dried fish and excessive use of tobacco are associated with high occurrence of gastric cancer in this part of the India. Increasing the awareness regarding the aetiology and varied clinical presentation among general population and health providers is needed for prevention and early detection.

Clinico-pathology of lung cancer in a regional cancer center in Northeastern India.

BACKGROUND: Globally, there have been important changes in trends amongst gender, histology and smoking patterns of lung cancer cases. MATERIALS AND METHODS: This retrospective study was conducted on 466 patients with lung cancer who were registered in Regional Cancer Center, Regional Institute of Medical Sciences, Manipur from January 2008 to December 2012. RESULTS: Most were more than 60 years of age (67.8%) with a male: female ratio of 1.09:1. Some 78.8% of patients were chronic smokers with male smoker to female smoker ratio of 1.43:1. Consumption of alcohol was found in 29.4%, both smoking and alcohol in 27.5%, betel nut chewing in 37.9% and tobacco chewing in 25.3%. A history of tuberculosis was present in 16.3% of patients. The most frequent symptom was coughing (36.6%) and most common radiological presentation was a mass lesion (70%). Most of the patients had primary lung cancer in the right lung (60.3%). The most common histological subtype was squamous cell carcinoma (49.1%), also in the 40-60 year age group (45.9%), more than 60 year age group (51.6%), males (58.1%) and females (41.8%). As many as 91.9% of squamous cell carcinoma patients had a history of smoking. About 32.5% of patients had distant metastasis at presentation with brain (23.8%) and positive malignant cells in pleural effusions (23.1%) as common sites. The majority of patients were in stage III (34.4%), stage IV (32.5%) and stage II (30.2%). CONCLUSIONS: Our analysis suggests that the gender gap has been narrowed such that about half of the patients diagnosed with lung cancer are women in this part of India. This alarming rise in female incidence is mainly attributed to an increased smoking pattern. Squamous cell carcinoma still remains the commonest histological subtype. Most of the patients were elderly aged and presented at locally or distantly advanced stages.