Estimation and comparison of integral dose to target and organs at risk in three-dimensional computed tomography image-based treatment planning of carcinoma uterine cervix with two high-dose-rate brachytherapy sources: 60Co and 192Ir.

BACKGROUND: Iridium-192 (192Ir) has been a widely accepted radioisotope for high-dose-rate (HDR) brachytherapy. Recently, Cobalt-60 (60Co) radioisotope with a longer half-life (5.26 years) has been gaining popularity due to economic and logistical reasons as compared with the traditional 192Ir. AIM: This study aimed to evaluate and compare the integral dose (ID) to the target and organs at risk (OARs) with two HDR brachytherapy sources in brachytherapy treatment of carcinoma uterine cervix to find appropriate HDR radioisotopes for clinical benefit. MATERIALS AND METHODS: This is a retrospective analysis of 52 computed tomography image-based brachytherapy plans of 52 patients who have received intracavitary treatment with 192Ir HDR source. For each patient plan, one additional set of plan was created using 60Co source in place of 192Ir source keeping the same dwell position, and again dose was optimized. The volume and mean dose for target, OARs, and volume structures of 400%, 200%, 150%, 100%, and 50% were recorded for the estimation and comparison of ID. RESULTS: The mean ID to high-risk clinical target volume was significantly higher by 5.84% in 60Co plan than that in 192Ir plan. For OARs, the mean ID to the rectum was significantly higher by 2.60% in 60Co plan as compared to 192Ir plan, whereas for bladder and sigmoid colon, it was lower in 60Co plan than that in 192Ir plan. The mean ID of central dose volume structures of 400%, 200%, 150%, 100%, and 50% was higher by 12.97%, 9.77%, 8.16%, 6.10%, and 3.22%, respectively, in 60Co plan than that of 192Ir plan. CONCLUSION: The results of our study concluded that 192Ir HDR radioisotope should be preferred for intracavitary brachytherapy due to its ideal physical characteristics for better clinical outcomes.

Bone metastases incidence and its correlation with hormonal and human epidermal growth factor receptor 2 neu receptors in breast cancer.

AIM: In this paper, we present a prospective observational study, which determines the incidence of bone metastases and its correlation with hormonal receptors (estrogen receptor [ER]/progesterone receptor [PR]) and human epidermal growth factor receptor 2 (HER2) in breast cancer. MATERIALS AND METHODS: From October of 2015 to July 2017, 262 patients were eligible for the study, of which 98 patients presented/developed bone metastases. ER/PR and HER2 receptor status were determined, and bone scintigraphy with a technetium-99 m was carried out on each patient during the study. RESULTS: The incidence rate of bone metastases as found in this study was 25.25%, and the mean and median age at diagnosis were 47.23 and 46, respectively (age range = 28-80). Bone metastases were more prevalent in ER-positive tumors (P = 0.043), tumors with lymph node positivity (P = 0.002), and lower grade tumors (P = 0.002), whereas visceral metastases were more common with ER-tumors (P = 0.005), tumors with higher grade (P = 0.012), and tumors with lymph node positivity (P = 0.034). In this study cohort, the spine and pelvis were the most commonly involved subsites of bone metastases (P < 0.001). CONCLUSION: This study demonstrates that the metastatic patterns in breast cancer strongly correlate with various breast cancer subtypes, mainly designated by ER, PR, and HER2. Hormone receptor-positive tumors show a predilection for bones as the first site of relapse compared to hormone-receptor-negative tumors which have a proclivity to develop as visceral metastases.

Role of serum prostate-specific antigen as predictor for bone metastases in newly diagnosed prostate cancer.

INTRODUCTION: Prostate cancer is most frequently diagnosed cancer of men and bone is the most common site of metastasis. There is a lack of consensus for the selection criteria for bone scan in low-risk patients. Western guidelines do not recommend use of bone scan in asymptomatic patients and in low prostate-specific antigen (PSA) values. We try to correlate the PSA value with bone metastases through bone scan in the Indian population. MATERIALS AND METHODS: A total of 68 histologically newly diagnosed prostate cancer subjected to bone scan were retrospectively analyzed. The patients were stratified into four groups according to their PSA level: The first group of patients had PSA level ranging from 0 to 10 ng/ml (n = 4), the second group had PSA level ranging from 10.1 to 20 ng/ml (n = 13), the third group had PSA levels 20.1-100 ng/ml (n = 23), and the fourth group has PSA >100 (n = 28). RESULTS: The incidence of osseous metastases proven by bone scan was found to be zero (0 out of 4) for PSA level 0-10 ng/ml; 38.46% (5 out of 13) for PSA level 10.1-20, 60.87% (14 out of 23) for PSA level 20.1-100 ng/ml, and 100% for PSA >100 (P < 0.005) (95% confidence interval 1.01-1.1). For cut-off value of PSA ≤10 ng/ml, sensitivity and specificity were 100% and 19.05%, respectively, with positive predictive value of 73.44%. CONCLUSION: The correlation between PSA value and presence of metastases confirms the usefulness of bone scan scintigraphy in prostate cancer staging. The screening bone scan at initial diagnosis should be included for all patients with PSA >10 ng/ml in Indian setting.

Interfraction physical dose variations in high-dose-rate brachytherapy for carcinoma cervix based on computed tomography image dataset to find the compatibility of the first fraction plan to treat successive fractions.

CONTEXT: Due to limited resources and/or affordability by majority of the patients, many centers in low- and middle-income countries are still not able to adapt three-dimensional image-based brachytherapy planning in their routine practice. AIM: The aim of the study was to see the feasibility of using computed tomography (CT)-based plan of the first fraction to treat successive fractions of intracavitary brachytherapy based on the estimation of the physical dosimetric differences between successive applications. MATERIALS AND METHODS: CT image-based brachytherapy plans of 38 patients who received three insertions of intracavitary application with high-dose-rate brachytherapy have been analyzed. Revised plans for the second and third insertions were generated by adapting dwell time and dwell position of the first insertion plan. The dose to point "A" and maximum doses to 2, 1, and 0.1 cc volumes of the rectum and bladder have been used for dosimetric comparison. RESULTS: The statistical differences of mean point "A" doses were observed insignificant except between original and revised plans for the second insertions. The dosimetric differences between consecutive original and revised plans for the bladder and rectum have not shown any significance except minimum dose to 0.1 cc volume of the rectum for the third insertions. CONCLUSIONS: Dosimetric deviation for tumor and organs at risk is within acceptable limit while using CT image-based brachytherapy plan of the first fraction for treating successive fractions.

Effect of postoperative time for adjuvant radiotherapy in malignant phyllodes tumor: An institutional experience.

INTRODUCTION: Cystosarcoma phyllodes of the breast, an uncommon sarcoma found primarily in women of the age group of 35-55 years, constitutes <1% of all breast neoplasms. These tumors are resistant to chemotherapy and hormonal therapies and often recur aggressively after initial surgery. Limited research is available about the role and effectiveness of adjuvant radiotherapy in reducing recurrences. OBJECTIVES: Surgery has been the primary treatment modality to date but with high recurrence rates. The purpose of this retrospective study is to highlight the role of postoperative time for adjuvant radiotherapy in aggressive borderline and malignant phyllodes tumor (PT). MATERIALS AND METHODS: This retrospective study reviewed 13 histopathologically proven borderline and malignant PT, treated with radiation therapy to the dose of 50 Gray by external beam radiotherapy (EBRT) after primary surgical management. RESULTS: The mean age at presentation was 33 years. Right laterality was more common (60% cases). Although all patients presented with lump, those who had pain as an added symptom turned out to be histopathologically malignant later on. Histopathologically, 66.6% patients were malignant, 20% borderline, and 13.3% benign. High mitotic index and stromal activity were observed in younger patients. Patients who received EBRT within a month of surgery had no local recurrence, whereas those who received EBRT after a month developed local recurrence (P = 0.012). CONCLUSION: Adjuvant radiotherapy is appropriate treatment for aggressive borderline and malignant PT. This study revealed that time interval between surgery to initiation of EBRT plays a significant role in the prevention of recurrence.

Five versus ten fractions per week radiotherapy in locally advanced head and neck cancer.

INTRODUCTION: Conventional fractionated radiotherapy (CFRT) is in use since a long time, but the invention of altered fractionation such as hyperfractionation has improved survival in head and neck squamous cell cancer (HNSCC). AIMS: Our aim of this prospective randomized study is to compare conventional 5 fractions per week (CFRT) with hyperfractionation 10 fractions per week (hyperfractionated radiotherapy [HFRT]) in locally advanced head and neck cancer. PATIENTS AND METHODS: The study period is from November 2013 to April 2015. Totally, 100 patients with proven head and neck cancer were submitted to radiotherapy on theratron 780 (cobalt 60) machine. Fifty patients in each CFRT group and HFRT group randomized to receive radiotherapy following induction chemotherapy. Patients in CFRT group have received 66-70 Gy/33-35 fractions Monday to Friday, while HFRT group have received 70.4 Gy/64 fractions Monday to Friday. RESULTS: Our results show manageable toxicity profile of a combined therapy consisting of cisplatin and paclitaxel, followed by concomitant chemoradiotherapy in the form of either CFRT or HFRT with cisplatin as a radiosensitizer in both treatment groups. The overall response at the completion of radiotherapy was 95.7% in HFRT versus 89.5% in CFRT with 76.6% complete response in HFRT versus 64.6% in CFRT. CONCLUSIONS: After induction chemotherapy, HFRT seems to be more efficacious than CFRT in locally advanced HNSCC, by increasing significantly the probability of progression-free survival and locoregional control.

Identifying the Factors Causing Delayed Presentation of Cancer Patients to a Government Medical College of Central India.

BACKGROUND: The incidence of cancer is increasing throughout the world. One of the prime aims of its management is early diagnosis and therapeutic intervention. Factors causing delay to either of these goals should be identified and rectified. AIM: To identify the factors causing delayed initial diagnosis and subsequent management in patients presenting to the Oncology department. MATERIALS AND METHODS: Three hundred proven cancer patients were prospectively evaluated for the pattern of presentation to the outpatient Department of Radiation Oncology of a Government Medical College (MC) in Central India. RESULTS: The mean age of presentation was 51.05 years (range 7 months-77 years). The number of male patients was 168 while females were 132. The duration of symptoms ranged from 20 days to 3 years. The number of patients with little/no education presented mainly in advanced stages as compared to their educated counterpart and this difference was statistically significant (p<0.001). The number of patients presenting directly to the department was 108, those diagnosed outside and referred to us was 84 while those diagnosed and received some form of oncologic treatment outside and referred thereafter was 108. The difference in the primary delay between patients presenting directly to the MC versus those diagnosed outside was significant (p=0.0126). The mean duration of starting definitive treatment after presentation to the outpatient was 4.68 days (range 0-22 days) and was very significantly (p< 0.001) less than the secondary delays caused to the other two subsets of patients. CONCLUSION: Factors causing delayed presentation are both patient and system related. It is imperative to educate the common people regarding the early signs and symptoms of cancer. At the same time, the system needs to overhaul its efficiency to avoid secondary delays that adversely affect the treatment outcome. An upgradation of the existing oncology facilities in the public sector can achieve this target efficiently.

Induction followed with concurrent chemo radiotherapy in advanced head & neck cancer.

BACKGROUND: The need for effective, well tolerated, and convenient therapies for inoperable Head and Neck cancer has led researchers to continually refine chemotherapeutic regimens with radiotherapy to balance efficacy with safety and tolerability in order to maintain or improve quality of life and chemotherapy either induction or concurrent with radiation have emerged as a viable alternative. AIM: This study was performed to analyze the efficacy and safety of induction chemotherapy with radiotherapy and concurrent radiotherapy on survival, functional and quality of life outcomes. MATERIAL AND METHOD: From Dec. 2001 to July 2003, hundred inoperable Head & Neck cancer patients were planned to be treated with methotrexate, Bleocin and cisplatin. On Completion of 3 cycles at 21 days interval, after 2 weeks of last cycles, fifty patients were planned to receive only radiotherapy (Group A) and rest 50 patients (Group B) were given cisplatin 50 mg weekly before Rt. on every Monday. All 100 patients received radiotherapy (66-70 cGy) to the locoregional sites by cobalt 60 units. RESULT: After completion of therapy in group A complete response was observed in 56% patients which was 68% in group B. After 2 years of follow up only 54% patient alive and 34% patients were disease free in group A where as in group B. 60% patient alive in which 42% were disease free. The survived patient enjoyed good quality of life. CONCLUSION: Patients responded better with induction chemotherapy can be treated with radiotherapy and those who failed to show satisfactory response may be treated with concurrent chemo radiotherapy to get additional benefit in term of survival with good organ preservation along with acceptable and manageable occurrence of schedule & dose related adverse events.