Routine use of ultrasound guided tandem placement in intracavitary brachytherapy for the treatment of cervical cancer - a South Indian institutional experience.

PURPOSE: Intracavitary brachytherapy necessitates the insertion of a tandem applicator through the cervical os into the uterine cavity. Blind insertion of the tandem may result in suboptimal tandem placement. This decreases the control of the tumor locally and may result in uterine perforation. Although routine real time ultrasound guided tandem placement has shown better results, it is seldom practised. The aim of this work is to evaluate the role of routine real-time intraoperative trans-abdominal ultrasound guided tandem placement in intracavitary brachytherapy for the treatment of cervical cancer. MATERIAL AND METHODS: This is a prospective single institutional study conducted from April 2013 to May 2015. A total of 96 patients of locally advanced cervical cancer were treated with routine ultrasound guided brachytherapy amounting to a total of 282 intracavitary applications. RESULTS: In 78 of the study patients, the cervical os could be easily identified visually, which was then confirmed with ultrasound guidance. In another 12 patients, though the os could be identified visually, uterine sounding was only possible under ultrasound guidance. In another 4 patients, the cervical os could not be identified visually as the cervix was flushed with vagina and ultrasound guidance was necessary for accurate os identification. In 2 of the study patients, intraoperative ultrasound helped in identifying the patients suitable for interstitial brachytherapy rather than intracavitary brachytherapy. Out of the 96 study patients, the length of the uterine canal changed in 15 patients during the subsequent brachytherapy application. CONCLUSIONS: This procedure is strongly advocated for proper placement of the tandem applicator and to avoid perforations. It is an accurate, fast, easily available, and cost-effective method. Hence, it can be incorporated in intracavitary applications for cervical cancers even in the developing countries where cost, accessibility, and time are important issues.

Chemoradiotherapy in a Case of Malignant Syringocystadenocarcinoma Papilliferum of Vulva with Locoregional Failure.

Introduction. Syringocystadenocarcinoma papilliferum (SCACP) is an extremely rare malignant adnexal tumor, which arises from syringocystadenoma papilliferum. To date, less than 30 cases of malignant SCACP have been reported, of which locoregional metastases were found in only four cases. Case Report. A 57-year-old female patient who presented to our Oncology Department with a recurrent malignant SCACP of the left labia along with right inguinal lymphadenopathy. Pathological examination confirmed the diagnosis of malignant SCACP with right inguinal lymph node metastases. Due to the fixity of the right inguinal nodes, neoadjuvant chemotherapy was administered with Cisplatin and 5-Fluorouracil for four cycles, following which the primary tumor and the contralateral inguinal nodes regressed completely. Then definitive chemoradiation was delivered with five cycles of weekly Cisplatin and external beam pelvic irradiation up to a dose of 59.4 Gy. Patient is disease-free 11 months after treatment. Discussion. We here report the fifth case of malignant SCACP with locoregional metastases. This is the first case of malignant SCACP which has been treated with neoadjuvant chemotherapy followed by concurrent chemoradiation. Although surgery has been used most commonly, chemoradiation may also have a role in the treatment of malignant SCACP, especially in cases of locoregional metastases.

High Dose Rate Brachytherapy in Two 9 Gy Fractions in the Treatment of Locally Advanced Cervical Cancer - a South Indian Institutional Experience.

BACKGROUND: Although 3D image based brachytherapy is currently the standard of treatment in cervical cancer, most of the centres in developing countries still practice orthogonal intracavitary brachytherapy due to financial constraints. The quest for optimum dose and fractionation schedule in high dose rate (HDR) intracavitary brachytherapy (ICBT) is still ongoing. While the American Brachytherapy Society recommends four to eight fractions of each less than 7.5 Gy, there are some studies demonstrating similar efficacy and comparable toxicity with higher doses per fraction. OBJECTIVE: To assess the treatment efficacy and late complications of HDR ICBT with 9 Gy per fraction in two fractions. MATERIALS AND METHODS: This is a prospective institutional study in Southern India carried on from 1st June 2012 to 31st July 2014. In this period, 76 patients of cervical cancer satisfying our inclusion criteria were treated with concurrent chemo-radiation following ICBT with 9 Gy per fraction in two fractions, five to seven days apart. RESULTS: The median follow-up period in the study was 24 months (range 10.6 - 31.2 months). The 2 year actuarial local control rate, disease-free survival and overall survival were 88.1%, 84.2% and 81.8% respectively. Although 38.2% patients suffered from late toxicity, only 3 patients had grade III late toxicity. CONCLUSIONS: In our experience, HDR brachytherapy with 9 Gy per fraction in two fractions is an effective dose fractionation for the treatment of cervical cancer with acceptable toxicity.

Osseous Metastases in Gynaecological Epithelial Malignancies: A Retrospective Institutional Study and Review of Literature.

INTRODUCTION: Osseous metastasis in gynaecological epithelial tumours is an extremely rare phenomenon occurring in less than 1% of these cancers. AIM: To analyse the clinical characteristics and prognosis in patients with gynaecological epithelial cancers with bone metastases. MATERIALS AND METHODS: This was a single institutional retrospective study done with the data available from January 2008 to January 2015. Out of 1686 patients with epithelial gynaecological malignancies there were a total 18 (1.07%) patients with osseous metastasis. Clinico-pathologic characteristics were tabulated in Microsoft Excel 2013 and data were analysed using SPSS software Version 21. A p-value< 0.05 was taken to be statistically significant. Survival analysis was done by using Kaplan-Meier method and log-rank test was used to find out the difference in survivals. RESULTS: Out of the 18 gynaecological epithelial cancer patients with bone metastases, 12 had cervical cancer, three had ovarian cancer, two had endometrial carcinoma and one patient had vulvar malignancy. Twelve patients had squamous cell histology, while the rest had adenocarcinoma. The mean interval from primary diagnosis of cancer to the detection of bone metastases was 31.9 months (range, 1 - 60 months). Solitary bone lesion was present in seven patients. The most common site of bone metastasis was lumbar vertebra. Extra-osseous metastasis was present in 12 patients. The mean follow-up period was 8.3 months. During the follow-up period 12 out of the 18 patients died. There was significant difference in survival (p = 0.005) between patients with solitary bone metastasis and patients with multiple osseous metastases. Near significant survival difference (p = 0.056) was also noted in patients with extra-osseous metastases when compared to the patients without. Improved survival was also found in patients with controlled local disease (p = 0.003) when compared to patients with local failure. CONCLUSION: Bone metastasis in gynaecological epithelial malignancies is a rare phenomenon, but with grave prognosis. Multiple sites of bone involvement, recurrence at the primary tumour site and presence of other non-osseous metastases are poor prognostic indicators. Treatment in these patients should be tailored according to the patient's need.