Interstitial brachytherapy in soft tissue sarcoma: a 5 years institutional experience with Cobalt 60-based high-dose-rate brachytherapy system.

PURPOSE: Soft tissue sarcoma (STS) is rare but aggressive neoplasm. Interstitial brachytherapy (ISBT) alone or combined with external beam radiotherapy (EBRT) as post-operative treatment improves loco-regional (LRC) and distant control. MATERIAL AND METHODS: Out of twenty-nine non-metastatic STS (lower limb 64%) patients (median age 37 yrs), treated with surgery and post-operative ISBT during February 2011 - December 2016, 27 patients with > 6 months follow-up were analyzed. Spindle cell sarcoma was the commonest (24%) histology. Eleven patients (44%) received EBRT (45-50 Gy), where ISBT was used as boost (16-20 Gy). Fourteen patients (56%) received ISBT alone (4 Gy per fractio). Treatment was done with a 60 Cobalt (60Co) source high-dose-rate system. RESULTS: With a median follow-up of 20 months (17-51 months), LRC rate was 85.7% (with EBRT 90.5% and ISBT 83.2% alone). Median disease-free survival (DFS) was 39.7 ±3.9 months (32-47.2 months). Median loco-regional failure-free survival (LRRFS) was 43.8 ±3.6 months (36.8-50.9 months). Distant failure-free survival (DFFS) was 18 months (15.5-26.6 months). Overall survival was 42.4 ±3.4 months (35.7-48.1 months). Tumor grade was a significant factor for DFFS. Total radiation dose (including EBRT) has significant influence on DFS and LRRFS. 14.8% patients developed ≥ grade 2 late toxicity (skin atrophy, hypo-pigmentation, and telangiectasia). CONCLUSIONS: Combination of surgery and ISBT with/out EBRT improves local and distant control with acceptable late toxicities. 60Co-based ISBT is safe and gives a good outcome.

Rectal separation using hydroxypropyl methylcellulose in intracavitary brachytherapy of cervical cancer: an innovative approach.

PURPOSE: This study was initiated to prove feasibility of hydrogel application in recto-vaginal space in intracavitary brachytherapy (ICBT) of cervical cancer in order to reduce rectal toxicity. MATERIAL AND METHODS: In a case of stage IIB cervical cancer, after external beam radiotherapy (EBRT), we planned ICBT 7 Gy × 3 fractions. In 1st fraction (Plan 1), due to narrow separation between rectum and cervix (0.18 cm), only 5 Gy was delivered at point A (with high-risk clinical target volume [HR-CTV] D90 5.94 Gy, intermediate risk clinical target volume [IR-CTV] D90 4.54 Gy, rectum D2cc 5.72 Gy, bladder D2cc 5.52 Gy, and sigmoid colon 5.82 Gy). In 2nd fraction (Plan 2), interstitial brachytherapy (ISBT) was attempted. For the prescription of 5 Gy, we get dose levels almost similar to the 1st insertion: HR-CTV D90 (6.7 Gy), IR-CTV D90 (3.06 Gy), bladder D2cc (5.7 Gy), rectum D2cc (4.8 Gy), sigmoid colon D2cc (1.3 Gy) (separation = 0.23 cm). During 3rd fraction (Plan 3), prior doing interstitial insertion, we instilled 50 cc of hydroxypropyl methylcellulose (Viscomet®) up to the tip of recto-vaginal septum. A repeat computed tomography (CT) scan was done 4 hours after Plan 3 treatment and it was re-planned (Plan 4) to find out migration of hydrogel if any and its dosimetric impact. RESULTS: 9 Gy was delivered to point A with a separation of 1.1 cm in Plan 3 (with HR-CTV D90 16.4 Gy, IR-CTV D90 11.3 Gy, rectum D2cc 3.6 Gy, bladder D2cc 6.9 Gy, and sigmoid colon 2.2 Gy). We achieved an optimum cumulative EQD2 dose (HR-CTV D90 98.4 Gy, IR-CTV D90 76.1 Gy, rectum D2cc 67.7 Gy, bladder D2cc 73.2 Gy, and sigmoid colon 59.3 Gy). Hydrogel volume was decreased in Plan 4 without a major dosimetric changes. CONCLUSIONS: Hydrogel instillation is a useful tool for recto-vaginal separation during cervical cancer brachytherapy. It increases therapeutic ratio without any adverse event.

Effect of bladder distension on dosimetry of organs at risk in computer tomography based planning of high-dose-rate intracavitary brachytherapy for cervical cancer.

PURPOSE: Distension and shape of urinary bladder may vary during intracavitary brachytherapy (ICBT) for cervical cancer, significantly affecting doses to bladder, rectum, sigmoid colon and small intestine and consequently late radiation toxicities. This study is to evaluate the effects of different fixed volume bladder distention on dosimetry, assessed by three dimensional image based planning, in different organs at risk during the treatment of cervical cancer with ICBT. MATERIAL AND METHODS: Forty seven cervical cancer patients (stage IB to IVA) were qualified for ICBT following external beam radiotherapy. Urinary bladder was distended with different volumes of normal saline instilled by a Foley's catheter. Planning CT scans were performed after insertion of applicators and three dimensional treatment planning was done on Brachyvision(®) treatment planning system (Varian Medical Systems, Palo Alto, CA). Dose volume histograms were analyzed. Bladder, rectum, sigmoid colon and small intestine doses were collected for individual plans and compared, based on the amount of bladder filling. RESULTS: Mean dose to the bladder significantly decreased with increased bladder filling. However, doses to the small volumes (0.1 cc, 1 cc, 2 cc) which are relevant for brachytherapy, did not change significantly with bladder filling for bladder, rectum or sigmoid colon. Nevertheless, all dose values of small intestine are decreased significantly with bladder filling. CONCLUSIONS: Bladder distension has no significant effect on doses received during brachytherapy by relevant volumes of bladder, rectum and sigmoid colon except intestine where values are decreased with bladder distension. A larger study with clinical correlation of late toxicities is essential for proper evaluation of this strategy.

Metastatic melanoma from an unknown primary site presenting as skin-colored nodules and multiple visceral involvement.

A 55-year-old man presented with multiple gradually progressing asymptomatic swellings on his body for the preceding 6 months. He had no personal or family history of any skin disease. There was no systemic symptom apart from occasional constipation. Examination revealed multiple discrete, firm, nontender, skin-colored nodules of varying sizes, fixed to the skin but free from the underlying structures on his chest, abdomen, and back. The overlying skin of the nodules was erythematous at places (Figure 1). A solitary depigmented, nonanesthetic patch (measuring 3 cm x 3 cm) was noted around a central gray macule (4 mm x 4 mm) on his left shin (Figure 2). The surface of this lesion was otherwise normal. Wood's lamp examination of this area showed attenuation of pigmentation in the central area and total depigmentation surrounding it. No dyspigmented area was noted on Wood's lamp examination of the other areas. There was no abnormality of the orogenital mucosae. General examination revealed mild pallor and multiple discrete, nontender, firm lymph nodes, measuring 3 cm x 3 cm, attached to the skin in the left inguinal region. The overlying skin was normal. Ocular examination (including direct and indirect ophthalmoscopy) and otolaryngologic evaluation were normal. Proctoscopic examination revealed a reddish-black indurated mass at the right lateral wall of the lower third of the rectum. Examination of the other system was noncontributory. Complete hemogram showed mild anemia (hemoglobin % = 10 gm%) and raised ESR, (80 mm in the first hour; Westergren's method). Biochemistry panel was normal apart from raised levels of aspertate transaminase (78 U/L), alanine transaminase (68 U/L), alkaline phosphatase (386 U/L), and lactate dehydrogenase (692 U/L). Chest x-ray showed a rounded opacity in the left apical area suggestive of cannon-ball metastasis (Figure 3). Ultrasonography and computed tomography of the abdomen revealed multiple liver nodules suggestive of hepatic metastasis. Findings from omputed tomography of the brain and upper gastrointestinal endoscopy were normal. Colonoscopic examination did not reveal any colonic lesion. Fine needle aspiration cytology of the enlarged inguinal lymph node was suggestive of malignant melanoma (MM). Histopathologic examination of the excision biopsy specimen of a skin nodule showed a tumor mass in the dermis composed of nests of oval to polygonal cells with vesicular nuclei and large prominent nucleoli (Figure 4). Extensive areas of necrosis were also seen. The tumor cells contained brownish pigment that stained positively with Masson Fontana stain. Pearl's stain was negative. Excision biopsy of the depigmented patch on the left shin showed mild hyperkeratosis, proliferation of capillary-sized blood vessels in the dermis, and thick-walled blood vessels in the subcutaneous tissue (Figure 5). No cellular atypia or any other evidence of malignancy was noted in this specimen. Biopsy from the rectal growth was suggestive of MM. Tumor cells were positive for S100 and human melanin black 45. Based on the clinical presentation, histopathology, and laboratory investigations, a diagnosis of metastatic MM (stage IV: T(x)N(3)M(1c)) with unknown primary site was made. Treatment was started with injection dacarbazine 250 mg/m2 intravenous infusion daily for 5 days intended to be given every 3 weeks for palliation. The patient died 2 week after the first treatment with chemotherapy.

A comparison of dose distribution from Manchester-style and Fletcher-style intracavitary brachytherapy applicator systems in cervical cancer.

PURPOSE: During intracavitary brachytherapy (ICBT) for cervical cancer, the choice of applicator system remains rather arbitrary. However, as the applicator geometry may play an important role in dose distribution, thereby improving the therapeutic ratio, this study was conducted to compare the Manchester-style and Fletcher-style applicator systems. MATERIAL AND METHODS: After completion of EBRT, 22 patients with cervical cancer (stage IIA-IIIB) underwent intracavitary brachytherapy. Two different types of applicators: Manchester-style and Fletcher-style were used for each patient for alternate insertions. The purpose was to compare the dose distribution obtained when two different applicators were applied to the same patient. CT based computerized treatment planning was done and dose was prescribed to point A. After optimization, height, width and thickness of the 100% isodose curve, as well as the 100% isodose volume were noted. Dose received by the urinary bladder and rectum were noted. RESULTS: The 100% isodose volume and its maximum width were significantly greater (P value < 0.0001 in both occasions) when Manchester-style applicator was used. However, the dose received by 0.1 cc, 1.0 cc and 2.0 cc of the urinary bladder were all significantly greater (P value < 0.0001) with the Manchester-style applicator. No significant difference was found in rectal doses. CONCLUSIONS: The larger 100% isodose volume, as well as the greater width achieved with the use of Manchester-style applicator can be helpful in circumstances where the tumour is large in size. However, this must be balanced against the increased dose received by the urinary bladder.

Letter: Docetaxel-induced supravenous serpentine dermatitis.

Serpentine erythematous or hyperpigmented streaks along the superficial venous network proximal to the site of injection may occur as a distinctive eruption after infusion of several chemotherapeutic agents. This morphological pattern has been described under various terms like, "persistent supravenous erythematous eruption," "persistent serpentine supravenous hyperpigmented eruption," or "persistent serpentine supravenous hyperpigmentation." These changes belong to the same clinical spectrum, which most often starts as erythematous serpentine streaks precisely located over the injected veins; the erythema is shortly replaced by hyperpigmentation. We report here a case of docetaxel-induced supravenous serpentine dermatitis with some interesting clinical and histological features.

Outcomes of high dose rate interstitial boost brachytherapy after external beam radiation therapy in head and neck cancer--an Indian (single institutional) learning experience.

PURPOSE: This study is to assess efficacy and toxicity associated with external beam radiation therapy (EBRT) and high dose rate (HDR) interstitial Iridium-192 ((192)Ir) brachytherapy for the treatment of squamous carcinoma of the oropharynx and oral cavity. METHODS AND MATERIALS: Between July 2004 and June 2006, 33 patients with oropharynx and oral cavity carcinomas were treated with (192)Ir interstitial implants after EBRT at Medical College Hospital, Kolkata. Fifteen patients had early stage disease (Stage I and II) and 18 had advanced stage disease (Stage III and IV). All received EBRT to a median dose of 50Gy (range, 46-66Gy) to the primary tumor and regional lymph nodes before brachytherapy. Node-positive patients with residual neck disease also underwent neck dissection. Brachytherapy dose (HDR) in combination with EBRT varied from 14 to 21Gy, 3-3.5Gy per fraction, two fractions daily. Locoregional control, freedom from disease, and complications were assessed. RESULTS: Followup duration was between 18 and 40 months. At the end of treatment with radiation, 79% achieved complete response (CR) (p<0.009), 21% achieved partial response (PR) and the ultimate control rate (including surgical salvage) was 100% and 78% for early and advanced disease, respectively (p<0.108). Three (9%) patients failed locally after CR. No distant metastasis was seen during followup. Grade 3 mucositis was seen in 12% cases. Transient hemorrhage occurred in 3 (9%) patients and local infection in 1 (3%) patient. Severe dysphagia was seen in 1 (3%) patient. 5/33 (15%) patients experienced xerostomia (Grade 3-4), but almost all patients had Grade 1-2 xerostomia. CONCLUSION: Oropharyngeal and oral cavity tumors can be effectively treated with (192)Ir implant boost after EBRT. Local control is excellent and complication rates are acceptable.