Tumour bleeding: Efficacy and outcome of haemostatic radiotherapy.

Background: Management of tumour bleeding remains a challenge in oncology. With a number of methods available, radiotherapy still holds a crucial place. There are no standard guidelines for dose fractionation of haemostatic radiotherapy (HRT), and it varies from case to case. We aimed to study the effectiveness of HRT. Methods: We retrospectively analysed the effectiveness of HRT in 70 patients in terms of control of bleeding and overall survival, who presented to us with advanced cancers from July 2014 to June 2017. Results: The median age was 48 (range 23-76) years, and male to female ratio was 2.18:1. The most common malignancy encountered was lung and gynaecological (both 17.1%). Stage IV was the most common stage (48.6%) of the primary tumour. The site of bleeding was the primary tumour in 50 (71.4%) patients, whereas fungating regional nodes were the cause in the remaining. The median duration between initial diagnosis and HRT was 5 (range 0-19) months. Seventeen patients (24.3%) had a history of prior radiotherapy. Fifty-one patients (72.8%) required at least 1 unit of blood transfusion. Hypofractionated HRT schedules were used in all patients with the most common being 30 Gy in 10 daily fractions for 5 days a week (18, 25.7%). At the end of HRT, bleeding was effectively controlled in 53 patients (75.7%). The median survival was 13 (range 1-26) months. The 1- and 2-year survival rates were 55.7% and 4.3%, respectively. Conclusions: HRT is safe and effective in achieving haemostasis in advanced tumours presenting with bleeding from either the primary or the regional lymph nodes. Although optimal dose fractionation has not yet established, hypofractionated radiotherapy is preferred, with the total dose depending on several factors. However, the overall prognosis remains poor.

Palliation of Brain Metastases: Analysis of Prognostic Factors Affecting Overall Survival.

CONTEXT: Brain metastasis is one of the most feared complications of cancer that poses significant mortality and morbidity in patients with advanced cancer. The incidence is rising because of greater use of magnetic resonance imaging and spectroscopy; and increased survival from recent advances in immunotherapy and modern radiotherapy techniques. Despite all, the prognosis remains poor. AIMS: This study aimed to analyze prognostic factors and overall survival in patients with brain metastases. SUBJECTS AND METHODS: A total of 145 patients were analyzed from July 2014 to June 2015 for various prognostic factors prospectively. Survival analysis was done using Kaplan-Meier curve. RESULTS: The median overall survival was 6 months, while 1- and 2-year survival rates were 8.3% and 1.4%, respectively. Median survival was highest with surgery followed by radiotherapy (11 months). Whole-brain radiotherapy (WBRT) significantly improved the survival (P = 0.006). The most common primary was lung cancer (58%) and the most common histology was adenocarcinoma (36%). Most patients (38%) were diagnosed upfront with brain metastases. Most of the lesions were multiple (80%) and located in cerebrum (58%). Survival was significantly improved with female gender (P = 0.003), Eastern Cooperative Oncology Group performance status (PS) 0-2 (P = 0.006), breast primary (P = 0.004), time lag of >6 months (P < 0.001), solitary lesion (P = 0.002), and controlled primary (P = 0.017). CONCLUSIONS: WBRT remains the cornerstone of the management of brain metastases. The present study concludes that the survival of patients with brain metastases is significantly improved with female gender, good PS, primary breast cancer, time lag of >6 months between diagnosis of the primary tumor and development of brain metastases, solitary lesion, and controlled primary tumor.

Dosimetric comparison of IMRT versus 3DCRT for post-mastectomy chest wall irradiation.

PURPOSE: To compare the dose distribution of three-dimensional conformal radiation therapy (3DCRT) with intensity-modulated radiation therapy (IMRT) for post-mastectomy radiotherapy (PMRT) to left chest wall. MATERIALS AND METHODS: One hundred and seven patients were randomised for PMRT in 3DCRT group (n = 64) and IMRT group (n = 43). All patients received 50 Gy in 25 fractions. Planning target volume (PTV) parameters-Dnear-max (D2), Dnear-min (D98), Dmean, V95, and V107-homogeneity index (HI), and conformity index (CI) were compared. The mean doses of lung and heart, percentage volume of ipsilateral lung receiving 5 Gy (V5), 20 Gy (V20), and 55 Gy (V55) and that of heart receiving 5 Gy (V5), 25 Gy (V25), and 45 Gy (V45) were extracted from dose-volume histograms and compared. RESULTS: PTV parameters were comparable between the two groups. CI was significantly improved with IMRT (1.127 vs. 1.254, p < 0.001) but HI was similar (0.094 vs. 0.096, p = 0.83) compared to 3DCRT. IMRT in comparison to 3DCRT significantly reduced the high-dose volumes of lung (V20, 22.09% vs. 30.16%; V55, 5.16% vs. 10.27%; p < 0.001) and heart (V25, 4.59% vs. 9.19%; V45, 1.85% vs. 7.09%; p < 0.001); mean dose of lung and heart (11.39 vs. 14.22 Gy and 4.57 vs. 8.96 Gy, respectively; p < 0.001) but not the low-dose volume (V5 lung, 61.48% vs. 51.05%; V5 heart, 31.02% vs. 23.27%; p < 0.001). CONCLUSIONS: For left sided breast cancer, IMRT significantly improves the conformity of plan and reduce the mean dose and high-dose volumes of ipsilateral lung and heart compared to 3DCRT, but 3DCRT is superior in terms of low-dose volume.

A Comparative Study of Hypofractionated and Conventional Radiotherapy in Postmastectomy Breast Cancer Patients.

OBJECTIVE: The aim of this study was to compare toxicity and locoregional control of short duration hypofractionated (HF) radiotherapy (RT) with conventional RT in breast cancer patients. METHODS: A total of 100 postmastectomy breast cancer patients were randomized for adjuvant RT in control group (comprising fifty patients who received the standard conventional dose of 50 Gy in 25 fractions with 2 Gy per fraction) and study group (comprising fifty patients who received HF RT with dose of 42.72 Gy in 16 fractions with 2.67 Gy per fraction). All patients were treated on linear accelerator with 3-dimensional conformal RT technique. Outcome was analyzed in terms of toxicity, tolerability, and locoregional control. RESULTS: In the present study, at a median follow-up of 20 months, almost similar results were seen in both the groups in terms of toxicity, tolerability, and locoregional control. Adjuvant postmastectomy HF RT was found to be well tolerated with mild-to-moderate side effects that neither reached statistical significance nor warranted any treatment interruption/hospitalization. CONCLUSIONS: HF postmastectomy RT is comparable to conventional RT without evidence of higher adverse effects or inferior locoregional tumor control and has an added advantage of increased compliance because of short duration; hence, it can help in accommodating more breast cancer patients in a calendar year, ultimately resulting in decreased waiting list, increased turnover, and reduced cost of treatment.

Compliance to radiotherapy: A tertiary care center experience.

CONTEXT: The most commonly prescribed conventional fractionation radiotherapy uses 1.8-2.2 Gy per fraction for five fractions in a week. Many times, unwanted interruptions are encountered, which ultimately affect the local control and overall survival. AIMS: The present retrospective study was carried out to study the compliance to radiotherapy at our institute and to determine various factors related to it. PATIENTS AND METHODS: The present retrospective study was carried out at the department of Radiotherapy, SMS Medical College and attached group of hospitals, Jaipur; in patients who were treated with curative intent with conventional fractionation radiotherapy over telecobalt machine from January 2017 to April 2017. Noncompliance was studied for association with various factors such as age, sex, site of primary disease, stage of tumor, distance patients had to travel to receive treatment, administration of concurrent chemotherapy, and financial burden of the treatment. RESULTS: Of 203 patients, 138 were of head-and-neck cancer, 42 of cervical cancer, and 23 of breast cancer. The cumulative incidence of noncompliance was 12.8% (15.9% for head-and-neck cancer, 7.2% for cervical cancer, and 4.4% for breast cancer). Statistically significant association was found between noncompliance and higher age of the patients (P = 0.07), male gender (P = 0.002), advanced stage (P = 0.004), administration of concurrent chemoradiotherapy (CCRT) (P < 0.001), and greater distance patients had to travel for radiotherapy (P = 0.03). CONCLUSIONS: The factors with which noncompliance is significantly associated in the present study are higher age, male gender, advanced stage of tumor, administration of CCRT, and greater distance patients had to travel to avail radiotherapy.

Breast cancer-related lymphedema in postmastectomy patients receiving adjuvant irradiation: A prospective study.

CONTEXT: In India, most breast cancer patients present with advanced stage requiring postmastectomy radiotherapy. Lymphedema is a long-term side effect that causes both physical and psychological distresses. AIMS: The present prospective study was carried out to study various factors affecting breast cancer-related lymphedema (BCRL). SUBJECTS AND METHODS: From January 2015 to March 2016, 100 postmastectomy patients who received adjuvant irradiation to chest wall were selected prospectively. Circumference of both arms was measured before surgery, at start, and at end of radiotherapy followed by 3 monthly intervals till last follow-up. Lymphedema was defined as a difference of ≥2 cm from the baseline in the arm circumference on the side of surgery. RESULTS: At a median follow-up of 24 months, the cumulative incidence of BCRL was 13%. On multivariate analysis, risk of BCRL was significantly associated with higher body mass index (BMI) (P = 0.004), greater number of lymph nodes (LNs) dissected (P = 0.005), higher nodal ratio (P = 0.006), and regional LN radiation (RLNR) (P = 0.048) but not with the type of fractionation (P = 0.094). CONCLUSIONS: Adjuvant RLNR, higher BMI, greater number of LNs dissected, and higher nodal ratio significantly increases the risk of development of BCRL. There was no significant difference in the lymphedema with the type of fractionation. Females receiving RLNR should be prospectively monitored for lymphedema to ensure early detection and possible intervention.

Hypofractionated Radiotherapy for Palliation in Locally Advanced Head and Neck Cancer.

CONTEXT: In India, a considerable proportion of patients with head and neck cancer present with locoregionally advanced disease. Symptom palliation becomes a major objective in these cases when they could not be considered for a curative approach. AIMS: The aim of this study is to assess the role of palliative radiotherapy for symptom control in patients with locally advanced head and neck cancer. SETTINGS AND DESIGN: This was a retrospective study. SUBJECTS AND METHODS: Between July 2015 and June 2016, 98 patients with stage IV head and neck cancer were treated with palliative radiotherapy 25 Gray (Gy)/4 fractions (fr)/1 fraction (6.25 Gy)/week. Presenting symptoms were noted. The primary end point was relief of symptoms in the 4th week after radiotherapy. Percentage symptom relief was quantified by the patient using a rupee scale. Treatment response was noted using the WHO criteria. Acute toxicity was graded as per the Radiation Therapy Oncology Group (RTOG) criteria. RESULTS: The most common presenting symptom was pain. At 4 weeks after radiotherapy completion, all patients had >50% pain relief. Dysphagia was improved in 82% of patients. Respiratory distress was improved in all the symptomatic patients. Tumor complete response (CR) was seen in 2 patients, partial response in 89, stable disease in 3, and progressive disease in 4. RTOG Grade 2 and 3 acute skin and mucosal toxicities were seen in 29% and 27% cases, respectively. No patient had Grade 4 adverse effect. CONCLUSIONS: Hypofractionated radiation could provide effective symptom palliation in advanced head and neck cancers. The weekly schedule was well tolerated and found convenient by the patients.