|Year : 2018 | Volume
| Issue : 11 | Page : 853-870
|Date of Web Publication||29-Nov-2018|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Gynaec-Oncology. J Can Res Ther 2018;14, Suppl S4:853-70
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High dose rate intracavitary brachytherapy (postexternal beam radiotherapy) for carcinoma of cervix – Comparision of two different fractionation regimens for clinical response and complication in organs at risk
Sheikh Owais Ahmad, Piyush Kumar, Arivind Kumar, J. Nigam
Aims/Objectives: (1) To analyze clinical response and complications in organs at risk (Rectal, Bladder and small intestine) in Group-A receiving (6 Gy per fraction X 4 applications). (2) To analyze clinical response and complications in organs at risk (Rectal, Bladder and small intestine) in Group-B receiving (7 Gy per fraction X 3 applications). (3) Compare Group-A and Group-B. Materials and Methods: Inclusion Criteria: (1) Biopsy proven cancer cervix, (2) Age >18 years, (3) Karnofsky performance scale above 70, (5) Stage IB1 to IIIB (6) No history of previous malignancy, (7) Hepatic, Renal, and Cardiopulmonary functions are adequate. Exclusion Criteria: (1) Carcinoma of the cervix FIGO stage IV patients, (2) Metastatic disease, (3) Any previous pelvic surgery, radiotherapy or chemotherapy. Prospective study. Fifty patients of cancer cervix were enrolled into this study. In this study, the treatment outcomes and complications were assessed in each arm and compared with each other. The local control of the disease and complications were assessed clinically up to six months post treatment in each group. Objective tumor response was made according to WHO criterion. Radiation toxicity was assessed by RTOG acute and late morbidity scoring criteria. Results: A BED in group A was 98.40 Gy and group B 95.91 Gy. Total rectal BED mean in group A 116.77 Gy and in group B 114.09 Gy and the total bladder BED mean in group A was 107.63Gy and in group B 112.09 Gy. There was one patient reported with Grade I reaction in Group A rest all patient in Group A had no any significant early genito-urinary symptoms. In group B one patients presented with a Grade II reactions and no any genito-urinary symptoms noted in Group B. The p-value was one which is not significant. There were three patient reported with Grade I reaction in Group A rest all patient in Group A had no any significant early small intestinal symptoms. In group B no patients presented with any reactions. The p-value was 0.740 which is not significant. In analyzing late lower gastrointestinal symptoms we observed that six patient with grade I rectal reactions in Group A and in Group B no patient was reported with any reactions. The p-value was 0.0090 which was significant. In Group A there were one patient of Grade II genitourinary symptoms. In Group B there were no patients of any genitourinary symptoms. The p-value was one which was not significant. In Group A there were one patient of Grade I small intestinal reaction. In Group B there were no patients of any small intestinal reaction. The p-value was one which was not significant. Conclusion: In our study, dose escalation at point A was and in a follow up of 6 months we did not find any significant difference in toxicities of rectum and bladder.
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Correlation between volume of bone marrow irradiated and haematological toxicity in definitive chemoradiotherapy: A prospective study in cervical cancer
Febin Antony, C. Jomon Raphael, K. Mathew Varghese, Paul Gopu, K. Venkatesan
Department of Radiation Oncology, Amala Institute of Medical Sciences, Thrissur, Kerala, India
Objectives: Primary objective is to analyze the volume of bone marrow (BM) irradiated and evaluate the haematological toxicity (HT) in cervical cancer patients receiving definitive chemoradiotherapy (CRT). Consequently, to formulate bone marrow dose volume constrains with the available data. Materials and Methods: Patients receiving definitive radiotherapy along with concurrent chemotherapy using weekly doses of cisplatin (40mg/m2/w) were included. After completing pelvic radiotherapy all the patients received high dose rate brachytherapy, thus a total of 85Gy to point A was delivered. On a CT based plan, target volumes and organs at risk (OAR) were delineated according to consensus guidelines. Total BM was contoured from the L4 vertebral body to the ischial tuberosities, including the pelvis, L4-L5 and sacrum. An IMRT plan was generated to obtain a full coverage of the PTV with the 95% isodose curve and to achieve dose constraints to OAR. The volume of BM obtaining 5, 10, 20, 40, 50 Gy (V5, V10, V20, V40, V50, respectively) were computed. Weekly blood investigations were done to evaluate the HT and was graded according to Common Terminology Criteria for Adverse Events, version 4.0. The correlation between volume of BM irradiated and HT was investigated. Results: A total of twenty-nine patients were studied. Overall, 13 patients (44.8%) experienced acute Grade 1–2 neutropenia. On multiple regression and correlation analysis using Pearson, Kendall's Tau b and Spearman's rho coefficients; increased BM- V5, V10, V20, V40, V50, were significantly associated with decreased WBC nadirs and increased neutropenia. When V5 >939.21cc, V10 > 868.69cc, V20 >761.52cc, V40 >381.41cc, V50 >140.14cc, grade 1 neutropenia was observed. Similarly, when V5 >963.30cc, V10 >882.85cc, V20 >774.63cc, V40 >393.82cc, V50 >148.74cc, grade 2 neutropenia was observed. Conclusions: This study supports the hypothesis that the volume of bone marrow getting irradiated is associated with an increased neutropenia during CRT in cervical cancer. With the available data we could conclude that neutropenia was observed more with increasing the volume of V5, V20 and V40.
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High risk human papillomavirus genotypes for risk stratification in cervical cancer screening
Salini, Lalitha Subramanian, U. Insuvai
Thoothukudi Medical College, Thoothukudi, Tamil Nadu, India
Introduction: Cervical cancer is one of the leading causes of cancer mortality in India with 67,477 deaths annually. Investments in cancer control in the form of prevention, early detection is needed in the low and middle income countries. Prevention of HPV related cervical cancer can be potential cancer control intervention as it helps in early detection and prevention with vaccination. The guidelines from WHO, 2013 recommends cervical cancer screening by HPV testing in screening programs as it is more sensitive than Pap smear. In the current study, we have studied the prevalence of high risk HPV testing by real time PCR and correlated the findings with Pap test and VIA-VILLI. Objective: To evaluate the prevalence of HPV along with genotyping. To study the correlation between HPV testing, Pap testing and VIA VILI. Materials and Methods: Women aged between 21 to 70 years attending the NCD clinic in Thoothukudi Medical College were sampled for high-risk HPV and Pap test. HPV testing was done using real-time PCR (Biorad, Inc). Only women who are both high-risk HPV positive with abnormal cytology were further tested by colposcopy. High-risk HPV positive women with normal cytology will be screened for HPV in subsequent years. Women negative for both HPV and Pap can be assured of free of the risk of cervical cancer for 5 years and can be offered screening after 5 years. Results: A total of 156 women aged between 21-65 years participated in our study. The median age of the women was 41.5 years. More than 50% of women were in the age group 31-50 years. Around 75% of them were premenopausal and multiparous women. The most frequent presenting symptoms were leucorrhea followed by lower abdominal pain. The presence of high risk HPV was seen 23% (36/156). Our studies showed that 24/36 (66.6%) harboured more than one genotype, remaining 12/36 (33.33%) had single HPV infection. We found a statistically significant correlation (p=0.000, chi square = 67.497) between biopsy proven CIN and multiple high risk HPV infection. Out of the 24 patients having multiple HPV infections, 17 patients (70.8%) were histopathologically CINII or above compared to 5/115 (4.2%) being positive for CIN II or above among the women negative for high risk HPV. HPV 16 was common subtype followed by HPV 31. The sensitivity of VIA VILI and Pap smear are 41.18% and 35.29% respectively. Conclusion: HPV genotyping helps in risk stratification of women likely to harbor CIN on colposcopy and biopsy. HPV testing as a primary screening is useful to identify the women who should be taken up for further intervention. Combined testing using Pap smear and HPV testing will identify high-risk women, and early identification will thus reduce the disease burden. This high burden of HPV infection prevalent in our population can be reduced by HPV vaccination in the adolescent age group.
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Observational study of late complications in carcinoma cervix patients treated with curative radiotherapy
G. Kiron, Venkatarmana, Krishna Sharan, Anshul Singh
Department of Radiotherapy and Oncology, Shirdi Sai Baba Cancer Hospital and Research Centre, KMC, Manipal, Karnataka, India
Aims/Objectives: To estimate the proportion and severity of late complications (Proctitis, Cystitis and Vaginal stenosis in carcinoma cervix patients treated with curative radiotherapy and to find relationship between dose received by rectum and bladder to the severity of the toxicity. Materials and Methods: This was a retrospective observational study done in the Department of Radiotherapy and Oncology, Shirdi Sai baba cancer hospital and research Centre, KMC Manipal during October 2015 - June 2017 of Histopathological proven carcinoma cervix patients treated with radical external beam radiotherapy to a dose of 46-50 Gray and HDR brachytherapy with tandem ovoid applicator with point A based planning to a dose of 7-8 Gray per fraction in 3 fractions/2 fractions with or without concurrent cisplatin based chemotherapy who had at least 6 months of follow up are evaluated and data is collected regarding demographic and disease parameters like age, histology, stage at initial presentation, performance status, dosimetry parameters like, ICRU bladder and rectum point dose, late reactions appearing after six months of completion of RT like cystitis, proctitis and vaginal stenosis. Results: A total of 143 patients were included into the study based on the inclusion and exclusion criteria. The mean age of the patients at presentation was 53 years (range: 33-81 years). Stage IIB predominated in the study with 67%, followed by stage IIIB 35%. Percentage of patient with IIA was 5%. Only three patients had stage IB2 at the time of presentation. The mean dose of rectum during ICR procedure was 3.79 Gy, and that to bladder was 3.34 Gy. The proportion of Proctitis was nearly 56%, that of cystitis was 43%, and that of vaginal stenosis was 43%. The mean duration to time of onset of GI toxicity was 16 months (range 8-24 months). Conclusion: Of the total of 80 (56%) patients who reported symptoms suggestive of radiation proctitis on follow up, Nearly 67% (53 patients) had ≤ grade 2 proctitis, while 3% (5 patients) had grade 4 proctitis. A spearman rank correlation was run to determine the relationship between grades of toxicity in GI and EQD2 dose to rectum. There was a moderately strong positive correlation with a ρ value of 0.61 (p=0.001). Of the total of 62 (43%) patients presented with symptoms suggestive of cyctitis, majority had ≤ grade 2 cystitis (50 patients; 80%). Grade 4 cystitis was noted in only one patient. BySpearman rank correlation, there was a weak positive correlation between grades of genitourinary toxicity and EQD2 dose to bladder with a ρ value 0.49 (p= 0.001). Among the 143-patient's vaginal toxicity is encountered in 43% of patients (n=62) 17% patients (n=25) experienced mild vaginal stenosis. Grade III vaginal stenosis was noted in 26% of the study patients (n=37).
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Uncommon uterine malignancies
K. E. Greeshma, Nabeel Yahia, M. K. Advaith, M. Geetha, Joneetha Jones, Shoaib Navaz, Arun P. Narendran
Department of Radiation Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
Aim: A retrospective analysis of incidence and outcome of patients with rare uterine malignancies reported at a tertiary cancer centre in North Kerala. Objectives of the Study: To analyse the incidence of patients with rare uterine malignancies who reported to Malabar Cancer Centre, the treatment received by them, their disease outcome and whether the recent advances in the treatment protocol has made any impact on the disease outcome. Materials and Methods: All patients registered at Malabar Cancer Centre with a diagnosis of rare uterine malignancy between January 2011 and December 2016 were included in the study. The date of diagnosis of the uterine malignancy, the treatment received including the mode of surgery, the chemotherapy schedules and the adjuvant radiotherapy including EBRT and brachytherapy were recorded. Disease free interval (DFS) is defined as the interval between the date of diagnosis and the date of first recurrence.. Overall Survival (OS) is defined as the interval between the date of diagnosis and the last date of follow up or the date of death. Results: Of the 317 patients reported with uterine corpus malignancies between 2011 and 2016, 70 patients (22%) had rare uterine histology (55.7% epithelial and 44.3% nonepithelial). Median age at presentation was 53y. Majority (78.6%) presented with early stage disease except serous carcinoma where 40% had advanced disease at presentation. Mixed serous and endometrial carcinomas also showed similar pattern of advanced stage at presentation. In spite of the early stage at presentation, 58.6% had recurrence. Among the nonepithelial tumours, LMS had significantly higher recurrence rate compared to ESS (80% vs 28.%, p 0.007). Majority (75%) of LMS recurrence were local. Adjuvant pelvic radiotherapy was not considered for these patients as they presented with stage 1 disease. Among the epithelial tumours, 90% of carcinosarcomas recurred, with 70% of them failing systemically. Sixty percent of serous carcinomas recurred, of which 78% failed either in the lymph nodes or distally. There was no difference in the recurrence pattern depending on whether the patient received local therapy alone, systemic therapy alone or both. The DFS rate was 23.2% at 5 y with a median DFS of 20 months (95% CI 10.8 - 29.2 months). DFS rate was significantly lower for LMS compared to ESS (8.6% vs 67.3%, p 0.001). For serous carcinomas the DFS rate was 36.7% at 5 y. The median was DFS of 20 months for serous carcinomas and carcinosarcomas. The OS rate was 39.4% at 5y with a median OS of 37 months (95% CI 17.8 - 56.2 months). OS rate was 16.2% and 66.8% for LMS and ESS respectively (p 0.002). For serous carcinomas the survival rate was 65% at 5y. The mean OS of 30.2 months for serous carcinomas and carcinosarcomas. Conclusions: Except for ESS, the overall prognosis of rare uterine malignancies remains poor, irrespective of the adjuvant treatment they receive. Adjuvant local radiotherapy needs to be strongly considered for LMS even in stage 1 disease.
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Impact of volumetric imaging (cone beam computed tomography) in defining PTV margins in the treatment of carcinoma cervix
Shailley, Anil Kumar Anand, Anirudh Punnakal, R. K. Munjal, A. K. Bansal, Gaurav Kumar, Abhishek Gulia
Aim: To quantify organ motion and set up errors in our set of patients of carcinoma cervix treated with Volumetric arc therapy (VMAT) which in turn will help us individualize PTV margins. Materials and Methods: From December, 2014 to 30 June, 2015 seven patients of Carcinoma cervix who opted for treatment with Image Guided Radiotherapy were taken for interfraction set up errors and organ motion quantification. Strict bladder protocol was followed. Cone beam CT scans were acquired on first 3 days of treatment and twice weekly thereafter and totally 10 pre treatment CBCT scans were evaluated per patient. Values for inter-fraction set up was registered for three principal axes, in left-right(x), supero-inferior (y) and antero posterior (z) axes. We have evaluated movement in mid-rectum in anterior, posterior, right and left direction and taken antero-posterior and transverse diameter and compared mean CBCT diameters with Planning CT scan diameters. Interfraction motion was assessed by the differences in bladder volume and translation of the bladder wall in three dimensions in comparison to the baseline PCT. Results: Mean (standard deviation) bone shifts noted were 0.32± 0.24 cm, 0.29± 0.21 cm and 0.13 ± 0.12cm in x, y and z axis respectively. Mean movement of mid-rectum was maximum in anterior direction in our cases. Mean CBCT AP and transverse diameter was 2.61 ± 0.83 cm and 3.10 ± 0.42 cm respectively and mean PCT AP and transverse diameter was 2.49 ± 0.72 cm and 3.01 ± 0.54 cm respectively. Maximum movements were seen along anterior followed by superior bladder wall and minimum movements were seen along right bladder wall. Conclusion: Set up errors and organ motions are within our prescribed PTV margins, however exceptional errors in set up need to be addressed on time. Adaptive strategies based on first and second week CBCTs should be undertaken. Patient follow up during treatment is must and should be frequent to assess patients' dietary, bowel and bladder habits and weight loss during treatment. Daily CBCT may be required for patients with altered bowel and bladder habits. We require further studies to quantify the effect of organ motion on adjacent organs.
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A prospective evaluation of interfraction change in dosimetric parameters in patients of localy advanced carcinoma cervix undergoing intracavitary brachytherapy
Upasana Mukherjee, Anis Bandopadhyay, Sandip Ghosh, Mousumi Das, Poulami Basu, Praloy Basu, Arnab Adhikary, Arunima Gupta, S. K. Sarkar
Medical College, Kolkata, West Bengal, India
Background: Recent advances in technology have allowed the use of volumetric imaging in gynecological brachytherapy planning. Evaluation of interfraction organ deformation and its association with dose distribution are essential to analyze the risk of acute and late adverse events on Organs at risk. Data from some of the recent series have highlighted the problem of interfraction dose variation in HDR brachytherapy using volumetric imaging modalities. Purpose: Keeping these previous works in the background, the aim of this study is evaluation of interfraction change in dosimetric parameters by CT guided imaging of Target volumes and organs at risk along with its comparative analysis during the course of Intracavitary brachytherapy. Methods: Following the completion of External beam radiotherapy, image (CT) guided High Dose Rate Intracavitory brachytherapy was with a strict bladder protocol. To analyse the interfraction change in detail, every applicator insertion was imaged to obtain dose volume histogram parameters. The GTV, IRCTV, HRCTV & OARs were contoured on the CT images based on the prebrachytherapy MR image and clinical findings as well as the present CT findings. Treatment of all the patients was provided by the GammaMedplus HDR afterloader machine using Iridium192. All the contours were compared with the initial reference CT images. Results: For a sample size of 32 patients, the systematic dosimetric variations for all organs at risk, i.e. mean variations of D2cm3, were found to be minor (<5%), while random variations, i.e. standard deviations were found to be high due to large variations in individual cases. The D2cm3 variations (mean ± 1SD) were 0.7 ± 17.6% and 3.4 ± 23.1% for the bladder and rectum. For HR CTV, the variations of D 90 were found to be −1.3 ± 14.2% for the whole sample. No statistically significant differences between the two groups were detected in dosimetric variations for the HR CTV. Conclusion: Substantial variations occur in fractionated cervix cancer ICBT but the treatment approach has to balance uncertainties for individual cases by maintaining Institution based protocol against the use of repetitive imaging, adaptive planning and dose delivery.
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Cross-sectional analysis of quality of life in long-term survivors of carcinoma cervix treated with chemoradiation /neo-adjuvant chemotherapy followed by surgery'
Prachi Sawant, Reena Engineer, Sudeep Gupta1, Umesh Mahantshetty, Supriya Sastri, Rajendra Kerkar2, Amita Maheshwari2, T. S. Shylasree2
Departments of Radiation Oncology,1 Medical Oncology, and2 Gynec-Oncology, TMH, Mumbai, Maharashtra, India
Aims and Objectives: In cervical cancer patients, for stage 1B2 and IIB, although chemoradiation is the recommended treatment, in early stages surgeons prefer surgery over CTRT due to a common perception that CTRT leads to deterioration in QOL especially sexual functions as compared to surgery. Although there have been several quality of life studies in cervical cancer survivors, most of them have a heterogeneous cohort of patients, with advanced cases receiving radiation as compared to those undergoing surgery. Our study aims to evaluate QOL in cancer survivors treated with chemoradiation Vs Neo-adjuvant chemotherapy followed by surgery in early stage disease. The particularity of our series is that, it mostly comprises of a homogenous patient base from a previously randomised controlled study with uniformity in type of surgery, radiation dose and technique. Also QOL has not been previously studied in patients receiving Neo adjuvant chemotherapy followed by surgery before. Materials and Methods: In a cross-sectional descriptive study design, 100 cervical cancer survivors completed EORTC questionnaires assessing QOL during routine follow up. Results: Overall 100 participants were enrolled from the NACT Ca Cervix randomized study from the two arms of NACT Ca Cervix trial (CTRT arm –N=55, NACT –Surgery arm-N=45). Mean duration of follow up was 5years. The mean age across all treatment subgroups remained between 53-55 years. Global QOL, function and symptom scales were comparable across both arms of the study, NACT f/b surgery arm and chemoradiation. The most reported symptom was fatigue, sleep disturbances, pain and dyspnoea. About 53% of the total enrolled patients were sexually active during the study. Sexual activity was more in chemoradiation arm as compared to NACT followed by surgery arm.(Mean scores - 45 vs 25, p-0.012). However, overall vaginal dysfunction and sexual anxiety scores were comparable in both arms. As per analysis of as treated population, sexual activity was more in chemoradiation as compared to NACT followed by surgery followed by adjuvant therapy(Mean scores 45 vs 19, p-0.039). Other symptom scales and function scales showed no significant difference in sub group analysis. Body image was consistently high across the cohort (Average score of 90). Conclusion: In view of the recent results of the 14 year old randomised NACT Ca Cervix trial, chemoradiation continues to be proven as the standard for stage IB2 –IIB Carcinoma Cervix. It will therefore, be helpful to know that quality of life in long term survivors is not at all compromised in those receiving chemoradiation as compared to those who have had surgery, especially sexual quality of life in long term survivors of early cervical cancer.
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Objective evaluation of asymmetric set-up margin (clinical target volume to planning target volume) and internal margin (clinical target volume to internal target volume) expansions in cervical cancer image-guided radiation therapy
C. H. Pushpa Naga, Umesh Mahantshetty, Ankita Nachankar, Supriya Sastri, Lavanya Gurram, Yogesh Ghadi, Libin Scaria, A. Dheera, Dandapani Epili
Department of Radiation Oncology, Tata Memorial Hospital, HBNI, Mumbai, Maharashtra, India
Aims/Objectives: Although the concept of clinical target volume (CTV) to planning target volume (PTV) expansions is described to account for patient movement, positioning uncertainties, and organ motion, it is unable to adequately address complex utero-cervical movements during cervical cancer radiotherapy. This prospective, observational study aimed to define set-up margin (CTV to PTV) for pelvic nodal CTV and internal margin (CTV to ITV) expansions for utero-cervical movements during cervical cancer image-guided radiation therapy. Materials and Methods: A total of 70 patients with locally advanced cervical cancer of FIGO Stage IIB-IIIB undergoing definitive pelvic radio (chemo) therapy were accrued prospectively between April 2011 and April. Daily pre-treatment kilo-voltage, cone-beam computed tomography (CBCT) of pelvic region was acquired at every fractions for all patients. Initially co-registration of daily CBCT with the planning CT images was done to match pelvic vessels/CTV pelvic nodal region after initial rigid alignment based on bony anatomy to define CTV to PTV margins. Subsequently, soft-tissue matching was done at the levels of mid-cervical canal and uterine fundus separately to record the residual errors to assess organ motion CTV to ITV expansions for cervix and uterine region, respectively. Mean displacements, systematic, and random errors of the study population for CTV pelvic nodal and utero-cervical matching were calculated. Set-up margin (CTV to PTV) for pelvic nodal CTV and additional internal margin (CTV to ITV) were derived separately using published margin recipes. Results: Data acquired from 1380 CBCT scans belonging to final 67 patients was analysed. The recorded mean (±SD) displacements, systematic error (Σ), random error (σ) distribution along the six directions in millimetre for pelvic nodal CTV region, mid-cervix, and uterine fundal matching is shown in [Table 1]. The calculated CTV to PTV set-up margin recipe for 95% pelvic nodal CTV coverage were 7.0 & 8.9 (bilaterally), 10.3 & 7.2 (antero-posteriorly) and 8.5 & 9.8 (supero-inferiorly), respectively. The additional internal margin (CTV to ITV) expansions for mid-cervix is 7.3 & 7.7, 8.5 & 6.7 and 9.5 & 8.5, respectively. Similarly, for uterine region, 7.3 & 7.6, 10.2 & 10.4 and 20.9 & 12.6, respectively. Conclusion: Our study suggests set-up margins (CTV to PTV) to account for daily set-up uncertainties and an additional internal margin (CTV to ITV) for the cervical and uterine regions to account for utero-cervical motion during cervical cancer radiotherapy to prevent geographical miss. Further research is warranted to evaluate to adopt these margins in various adaptive strategies for cervical cancer radiotherapy.
|Table 1: The mean, standard deviation of target-motion along with systematic error (Σ), random error (σ) distribution and calculated margin (mm) recipe for 95% coverage for pelvic nodal clinical target volume region, mid-cervix, and uterine fundal matching|
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Factors determining the bladder and rectal dose in patients undergoing intracavitory brachytherapy-high dose rate in carcinoma cervix
Vezokhoto Phesao, Khaleel, Gowtham, Poornachandra Tejaswi, Anup Hegde, Shija Merrin, Fareena Taj, H. B. Govardhan
Aims/Objectives: To assess the various factors such as volume and shape of bladder, size of uterus; which will affect the bladder and rectal dose in patients undergoing ICBT-HDR in carcinoma cervix. Methods: A total of 21 patients with carcinoma cervix post external beam radiation therapy (EBRT) undergoing ICBT-HDR was prospectively recruited for this study. ICBT application was done as per institutional protocol. CT simulation was taken with empty bladder, 100ml, 200ml, and 300ml bladder filling with normal saline. A total of 84 scans were obtained. For all the 84 scans bladder and rectum were contoured and brachytherapy planning was done with Eclipse treatment planning system. Uterus size were measured at level of point A for both “x” and “y” axis in transverse section view. Shape of the bladder either flat/ellipsoid/horse-shoe/globular were documented. Prescribed dose was 7 Gy to point A. Thus D0.1 and D2 were calculated for both bladder and rectum. The dose to bladder and rectum was correlated with different volume & shape of the bladder and size of the uterus. Appropriate statistical test were used for analysis. Results: On measurement the mean dose to point A was 7.1 Gy (L) and 6.9 Gy (R). Mean volume of bladder for 0 cc, 100 cc, 200 cc & 300 cc were 71.9 cc, 171.3 cc, 261.9 cc & 360.6 cc respectively. Mean D 0.1 was 10.1 Gy, 10 Gy, 12 Gy, 12.9 Gy and D2 cc was 7.1 Gy, 7.5 Gy, 8.8 Gy, 9.3 Gy for 0 cc, 100 cc, 200 cc, 300 cc respectively. With reference to shape of bladder 15.4% were flat, 21.4% were ellipsoid, 32.1% were horse-shoe and 30.9% were globular shape. Mean D0.1 cc was 10.6 Gy, 12.4 Gy, 11.2 Gy, 10.7 Gy and D2 cc was 7.2 Gy, 8.0 Gy, 8.5 Gy, 8 Gy for flat, ellipsoid, horse-shoe and globular bladder respectively. Rectal mean for D 0.1 was 7.3 Gy, 8.8 Gy, 8.3 Gy, 7.9 Gy and D2 was 5.4 Gy, 6.04 Gy, 5.9 Gy, 5.7 Gy for 0 cc, 100 cc, 200 cc, 300 cc respectively. Rectal dose seen for 0cc bladder, the mean D0.1 cc was 8.7 Gy, 6.9 Gy, 5 Gy and D2 cc was 6.4 Gy, 5.07 Gy, 3.76 Gy for uterus size of y(AP) <3, 3-4, >4 cm respectively. Mean size of uterus at level of point A was x = 4.4 cm and y = 3.3 cm. For bladder volume 0cc, mean D0.1cc was 10.6 Gy, 9.8 Gy, 9.6 Gy and D2cc was 7.6 Gy, 6.7 Gy, 6.4 Gy for uterus size of y(AP) <3, 3-4, >4 cm respectively. Conclusion: Bladder volume of Less than 100 cc, flat and globular shaped baldder and uterus size of >4 cm (antero-posterior) at point A level showed a significant lower dose to rectum and bladder in patient undergoing ICBT in carcinoma cervix.
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Trends of carcinoma of uterine cervix at a tertiary cancer centre in Jharkhand
Anup Kumar, Tannu Kumari, Susanta Kumar Sahoo, Payal Raina, Kumar Satyam, Ashish Kumar Sukla
Objective: Reports on incidence and trends of various cancers in India come from data compiled by National Cancer Registry Program (NCRP) through 29 population based (PBCR) and 29 hospital based cancer registry (HBCR). Despite this, several states in India including Jharkhand does not have either HBCR or PBCR and information regarding incidence and trends of various cancers including cervical cancers is lacking. In the absence of an established cancer registry, data from our institute which is the largest tertiary cancer center of Jharkhand may be important to understand the demographics of cancer in this part of country. Methods: We did this retrospective study to examine the incidence and trends of carcinoma of uterine cervix at our institute Among 520 patients of cancer identified from 2014 till date, carcinoma of uterine cervix comprised of 30.57% of all cancer cases. Result: 41.6% of patients belonged to age group of 41-50 years. Majority of patients (33.58%) belonged to stage IIIB (FIGO 2009) followed by stage IVA (24.82%). Highest number of cases (32.85%) were reported from Ranchi district followed by Giridih district of the state. As per the results of our study, cervical cancer comprises approximately one third of all cancers at our institute and mostly present in advanced stage. Conclusion: The data may help in formulation of the health care policy as well as design of well-designed cancer control measures in this part of the country.
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Comparison of international commission on radiation unit and GEC-ESTRO organ at risk doses in intracavitary brachytherapy for carcinoma cervix
N. V. Vinin, Joneetha Jones, M. Geetha, Resmi K. Bharathan, P. Shimjith
Malabar Cancer Centre, Thalassery, Kerala, India
Background: In intracavitary brachytherapy (ICBT) for cervical cancer doses to bladder and rectum were traditionally estimated using the International Commission on Radiation Units and Measurements (ICRU) reference points. With the availability of CT scanner and treatment planning software for 3D brachytherapy in recent years, we have moved forward towards volumetric assessment of Organ at risk (OAR) doses. With this study we want to know whether there is concordance between ICRU and GEC ESTRO recommended OAR doses. Aim: To compare International Commission on Radiation Units and Measurements (ICRU) bladder and rectum reference points doses with volumetric OAR doses in intracavitary brachytherapy (ICBT) for cervical cancer. Objectives: To compare International Commission on Radiation Units and Measurements (ICRU) bladder and rectum reference points doses with GYN GEC ESTRO recommended OAR doses in 3D CT based intracavitary brachytherapy (ICBT) for cervical cancer. To assess the EQD2 doses to OAR structures. To assess point A dose on right and left side and EQD2 dose to point A. Materials and Methods: This was a retrospective study, done in Department of Radiation Oncology Malabar Cancer Centre. ICBT done in Carcinoma Cervix patients with a dosage schedule 7 Gy for 3 fractions were included. During the period January 2017 to December 2017 were analysed. CT based ICBT plan was be analysed from Oncentra Treatment Planning System. From the DVH parameters OAR doses like D 0.1cc, D1cc & D2cc will be noted. ICRU rectal point and bladder point doses were also noted from corresponding CT images. Point A doses on right and left side were noted. EQD2 doses for point A and OAR were calculated. Results: 165 ICBT details were analysed. Mean ICRU rectal point dose was 4.43 Gy and mean ICRU bladder point was 3.83 Gy. D2cc dose to Rectum, Bladder & Sigmoid was 3.51 Gy, 5.23 Gy and 4.72 Gy respectively. Mean comparison between Rectal ICRU point & D2cc of Rectum showed p value of <0.0001 and was extremely significant. Mean comparison between Bladder ICRU point & D2cc of bladder showed a p value of <0.0001 and was extremely significant. Mean Point A dose on right and left side were 6.87 Gy & 6.91 Gy respectively. Mean EQD2 dose to point A on right and left side were 78.5 Gy & 78.8 Gy respectively. Mean OAR doses combining EBRT & ICBT with ICRU point doses were for Rectum & Bladder 68.1 Gy & 64.1 Gy respectively. Mean OAR doses combining EBRT & ICBT with GEC ESTRO D2cc doses were for Rectum, Bladder & Sigmoid 62.1 Gy, 74.2 Gy & 70.2 Gy respectively. Conclusion: As per our study there is no concordance between ICRU rectal & bladder point doses to GEC-ESTRO recommended OAR doses. Hence we recommend wherever feasible for a CT based ICBT planning with documentation of GEC-ESTRO recommended OAR doses for proper documentation of OAR doses.
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Association between bone marrow dosimetric parameters and acute hematologic toxicity in cervical cancer patients undergoing concurrent chemoradiotherapy: A comparison of three-dimensional conformal radiotherapy and intensity-modulated radiation therapy
Siba Sankar Mahapatra, N. Panda, L. Pattanayak, S. Padhi, S. N. Senapati
Department of Radiotherapy, AHRCC, SCB MCH, Cuttack, Odisha, India
Introduction: More than 50% of active bone marrow is located in the pelvic region which receives varying degree of exposure during pelvic radiotherapy for cervical cancer resulting in acute haematological toxicity. Adverse reactions like acute hematologic toxicity results in delayed treatment in carcinoma cervix patients undergoing concurrent chemoradiotherapy, which adversely impacts the prognosis. It is possible to reduce the incidence of acute hematologic toxicity by reducing the volume of bone marrow to different dose of irradiation. Aims and Objectives: To compare different doses of radiation received by bone marrow in concurrent chemoradiotherapy for cervical cancer by 3DCRT and IMRT techniques and to analyse the incidence of acute hematological toxicity in both the patient cohorts. Materials and Methods: A prospective observational Study was done by taking 15 patients of carcinoma cervix in each arm 3DCRT and IMRT with weekly concurrent cisplatin (40 mg/m2/) in our institute. All pelvic bones were contoured as a surrogate of bone marrow on planning CT image. V10, V20, V30, V40, and V50 of Bone marrow respectively were calculated in Monaco® 5.11 for IMRT and ONCENTRA 4.2 for 3DCRT. Haematological toxicity according to RTOG toxicity criteria were analyzed on weekly basis during concurrent chemoradiation and the data was analyzed on spss version 24. Results: V10, V20, V30, V40, and V50 in the IMRT arm were 94.91±3.5%, 86.56±7.5%, 54.08±10.01%, 33.78±.8.5%, and 3.99±1.8% respectively and in the 3DCRT arm 94.73±14.5%, 87.7.±24.3%, 70.68.±19.98.%, 45.84±13.9%, and 9.26±4.3%. The percentage of patients with grade 1 and grade 2 anemia was 53.3% (8/15) and 26.6% (4/15) in the IMRT group, whereas it was 80% (12/15) and 13.3% (2/15) in the 3DCRT group. The percentage of patients with grade 1 and grade 2 leucopenia was 33% (5/15) and 6.6%(1/15) in IMRT arm where as in 3DCRT arm grade 1 leucopenia was 40% (6/15). The percentage of patients with grade 1 Neutropenia was 6% (1/15) and grade 1 Thrombocytopenia was 6% (1/15) in IMRT arm whereas in 3DCRT arm percentage of patients with grade1 Neutropenia was 15% (2/15). No thrombocytopenia was observed in any of the patients in 3DCRT arms. Conclusion: As compared to 3DCRT, in IMRT less volume of bone marrow was irradiated in V30, V40 and V50. The incidence of acute hematological toxicity was comparatively less in IMRT arm with similar target coverage as 3D conformal radiotherapy. But there is no significant difference in response with respect to locoregional control. Further prospective studies with larger sample size is required to validate the results of this study.
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Dosimetric analysis of bone marrow sparing IMRT and four field conformal technique for the treatment of locally advanced cervical carcinoma - A randomised prospective single institutional study
Ghritashee Bora, Apurba Kumar Kalita, Mouchumee Bhattacharyya, Moirangthem Nara Singh, Partha Pratim Medhi, Shashi Bhushan Sharma, Shashank Bansal
Aims and Objectives: Dosimetric comparison of Bone Marrow Sparing IMRT versus 4 field 3DCRT in locally advanced Cervical Cancer in terms of doses to OARs. Materials and Methods: This is a hospital based prospective randomised study conducted in the period from June 2017 to May 2018. Histologically proven Cervical Carcinoma patients with FIGO stage II A to IV A (locally advanced) were selected for the study. A total of 30 patients were randomly allocated to one of the two treatment arms: A) Bone- Marrow sparing IMRT; B)Four field conformal technique.EBRT was delivered to a dose of 50Gy/25# followed by 21Gy/3 # of weekly HDR Brachytherapy. The target volumes and the OARs (Bladder, Rectum, Bowel and Bone Marrow) were delineated as per contouring guidelines. The Bone Marrow comprised of Pelvic Bone Marrow (PBM); Lumbo-sacral Bone Marrow (LSBM); Ilium Bone Marrow (IBM) and Ischium, Pubis and Pelvic femora together constituting Lower Pelvis Bone Marrow (LPBM). The CT regimen used was Cisplatin at a dose of 40mg/m2 weekly. Results: BMS-IMRT was found to be superior to the four-field conformal technique in reducing the dose to the PBM, small bowel, rectum, and bladder. On comparison of the Bone marrow DVH in the various subsites, it is seen that the p value is significant (BMS IMRT vs Four field conformal technique) in the higher dose range (30 and 40 Gy) for the IBM, LPBM and Whole Pelvis BM. But the low dose irradiation (10 and 20 Gy) although reduced, the difference is not statistically significant. Also it is seen that in the LSBM region, BMS IMRT is superior at all dose levels but the p value is not significant (p value> 0.05). Conclusion: Thus Bone Marrow Sparing IMRT (BMS IMRT) results in significant reduction of dose to the Pelvic Bone Marrow. This can further help in reducing the hematologic toxicities associated with Pelvic Radiation. The main limitation is less patient data and need of clinical follow up. More prospective data to further validate the subject is essential.
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Outcomes and toxicity in locally advanced carcinoma cervix treated with hypofractionated radiotherapy and concurrent cisplatin versus conventional radiotherapy and concurrent cisplatin: A comparative study
Barnini Ghosh, Bodhisattwa Dutta, Rumeli Roy, Debasis Das, Snigdha Hazra, Asit Ranjan Deb
Aims/Objectives: To evaluate local control with hypofractionated radiotherapy and concurrent cisplatin versus conventional radiotherapy and concurrent cisplatin. To compare the early and late toxicities between the two groups with a mean follow up of 2 years. Conventionally fractionated radiotherapy with concurrent cisplatin followed by Intracavitary brachytherapy is the standard practice for locally advanced carcinoma cervix, where local tumour control decreases by 0.5% per day when the overall treatment time exceeds 49 days. Hypofractionation involves giving larger dose per fraction, reducing the total number of fractions and the overall treatment time. In institutions with huge patient load and long waiting time for initiating treatment, reducing the overall treatment time for each patient by hypofractionation, can be helpful. Materials and Methods: A single institution longitudinal study was done comprising of 62 patients of locally advanced carcinoma cervix (stages IIB-IVA), who first attended the Radiotherapy Department between the years 2015-2016. In one arm, 33 patients were evaluated who had received pelvic EBRT of 50 Gy in 25 fractions over 5 weeks (conventional fractionation) with concurrent cisplatin. In another arm, 29 patients were evaluated who had received pelvic EBRT of 45 Gy in 20 fractions over 4 weeks (hypofractionation) with concurrent cisplatin. All 62 patients received 3 fractions of Intracavitary HDR brachytherapy, 7 Gy per fraction, following EBRT. The age group, histology, clinical stage, response to treatment and side effects were noted from the case record files of patients and analyzed by descriptive statistics. Results: The commonest presentation was in the 5th decade, IIIB being the commonest stage. 6 wks post-treatment, 83.3% and 16.7% patients in the hypofractionated arm showed CR and PR respectively, while 76.7%, 20% and 3% patients in the conventionally fractionated arm showed CR, PR and no response respectively (p=0.556). The mean DFS for the hypofractionated arm and conventionally fractionated arm were 19.6 months and 18.2 months respectively (p=0.433). The hypofractionated arm had higher rates of Grade 2 anaemia, acute skin toxicity, acute upper GI toxicity, acute lower GI toxicity and acute genitourinary toxicity, [p<0.05]. Development of vaginal stenosis was more in the conventionally fractionated arm, [p=0.559]. Occurrence of proctitis (36.7% vs 23.3%), cystitis (23.3% vs 13.3%) and late skin toxicities were more in the hypofractionated arm [p<0.05]. Conclusions: Patients in both the arms showed comparable response in terms of loco-regional control and toxicity (both acute and chronic). Hence, in institutions with huge patient load, hypofractionation can be tried as an alternative to reduce the long waiting periods for radiotherapy by reducing the overall treatment time, leading to better patient compliance, shorter hospital stays. It may also have an advantage of reducing tumour re-population during treatment. However, further studies are required to derive more conclusive evidence regarding this matter.
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Dosimetric predictors of acute bone marrow toxicity in carcinoma cervix
Rohith Singareddy, Harjot Kaur Bajwa, Krishnam Raju Alluri
Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Aim: To determine the dose volume parameters predicting acute haematological toxicity in carcinoma cervix patients undergoing concurrent chemoradiotherapy. Materials and Methods: All patients that presented to the hospital between Jan 2017 till Dec 2017 were prospectively analysed. Patients diagnosed to have Carcinoma Cervix and planned for concurrent chemoradiation by volumetric modulated arc therapy (VMAT) were included for analysis. Patients were assessed at baseline and every week during treatment for acute haematological toxicities. Dose volume parameters from treatment plans were correlated with RTOG grade of haematological toxicities. Results: A total of 34 patients diagnosed to have squamous cell carcinoma of cervix were treated by radical radiotherapy by VMAT technique and concurrent chemotherapy (weekly cisplatin 40 mg/m2). Median age of presentation was 54 years (39-73 years). The most common stage of presentation was stage IIB (61.7%). 29 patients (85.2%) completed five cycles of weekly cisplatin whereas four patients received four cycles and one patient received three cycles of chemotherapy. Statistical analysis for sensitivity and specificity of dosimetric parameters was performed using ROC curve. The probability of developing bone marrow toxicity was analyzed using T test. Mean dose to the bone marrow more than 28.5Gy was significantly associated with bone marrow toxicity (sensitivity – 82.4%, specificity- 70.6%). On analyzing different dose volume parameters, volume of bone marrow receiving 20 Gy and 30 Gy (V20 and V30) more than 71.75%, and 49.75% was significantly associated with increased bone marrow toxicity (p value <0.05). Conclusions: Our study concludes that the mean dose to bone marrow exceeding 28.5 Gy has high sensitivity and specificity for predicting bone marrow toxicity. Volume of bone marrow receiving 20 Gy and 30 Gy significantly correlated with acute haematological toxicity.
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Adjuvant concurrent chemoradiation followed by chemotherapy for high risk non-metastatic endometrial cancer
Beena Kunheri, Thushar Tatineni, Rajasree Rajan
Department of Radiation Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
Background: Although women with endometrial cancer generally have a favourable prognosis, those with high risk disease features are at increased risk of recurrence. Adjuvant chemotherapy and radiation was found to be effective, but the optimal time sequence remains unknown. The PORTEC-3 trial was initiated to investigate the benefits of Adjuvant Chemotherapy during and after Radiotherapy versus standalone Pelvic Radiotherapy for women with high risk endometrial cancer. The acute toxicities and tolerance of concurrent CTRT have been analysed in our setting. Aim: To assess the toxicity and tolerance of Adjuvant Concurrent Chemoradiation (“CTRT”) followed by Chemotherapy for High Risk Non Metastatic Endometrial Cancer (“HREC”)”. Materials and Methods: The tolerance and toxicity of Adjuvant CTRT followed by Adjuvant Chemotherapy in high risk endometrial cancer were prospectively evaluated from December 2016 to September 2018. The patients were treated with Radiotherapy to a dose of 48.6Gy in 1.8Gy/Fraction in 5 days per week. Chemotherapy during radiation was administered through two cycles of Cisplatin 50mg/m2, followed by 4 cycles of outback Chemotherapy – Carboplatin AUC 5 & Paclitaxel 175mg/m2. Radiotherapy techniques used were either VMAT or Helical Tomotherapy for marrow and bowel sparing. The primary endpoint being Toxicity Analysis (determine the frequency, degree and nature of toxicity). Results: 15 patients were enrolled during the period of study, 9 patients from them have completed the treatment and were evaluable for toxicity and response. Treatment is ongoing in the remaining 6 patients. Acute Toxicity Analysis of the 9 patients showed that all the patients developed Grade 1 & 2 toxicity during various cycles of Chemotherapy, and half of the patients developed Grade 3 toxicity. All the Grade 3 toxicities were haematological in nature [anaemia]. In addition, 7 of the patients developed grade 1 & 2 Gastrointestinal toxicity during CTRT. The most common concern was loose stools but acute toxicities were self-limiting and all of them completed the planned CTRT followed by Adjuvant Chemotherapy. Long term follow up of these patients will throw light on the efficiency of this regimen and long term morbidity. Conclusion: Concurrent CTRT followed by Adjuvant Chemotherapy is tolerated in our patients, however with self-limiting acute toxicity. The advantage of this regimen is the shorter duration of treatment, compared to sequential regimen of 6 cycles of Chemotherapy followed by RT. Early introduction of Radiation might improve the local control. Long term follow up with sufficient number of patients is required for definitive conclusions.
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Compare treatment response of cervical carcinoma patients infected with HPV 16 and HPV 18 treated with chemo radiation
D. Esther Praisy, Geeta S. Narayan
Department of Radiation Oncology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
Background: Persistent infection with human papillomavirus (HPV) is the major etiological factor for development of cervical cancer. Although the standard treatment of locally advanced cervical cancer includes chemo radiation, little is known about the impact of HPV on the response to chemo radiation and on the patients' clinical outcome. Aims and Objectives: Primary objective was to compare treatment response of cervical carcinoma patients infected with HPV 16 and HPV 18 who are treated with chemo radiation. Materials and Methods: Ninety six patients of carcinoma cervix were included for the study. Inclusion criteria were patients with biopsy proven and considered suitable for curative treatment with definitive radio-chemotherapy with Performance Status 0-2 (ECOG) and FIGO Stage IB2 to IIIB. HPV testing was carried out with. All the patients received External Beam Radiation therapy (EBRT) on linear accelerator with 3 dimensional conformal technique to a dose of 4600cGy in 23 fractions, 5 fractions per week. High-dose rate intracavitary radiotherapy was delivered once a week with a fraction dose of 7 Gy at point A for 3 times. InjCisplatin 40 mg/m2 was administered weekly during EBRT. Results: Of the 96 patients, 79 (82.3%) patients were positive for HPV DNA. Seventy three patients showed HPV genotype 16 and 6 patients were positive for genotype 18. The response was correlated with HPV genotype. There was a significant increase in radiological complete response in HPV16 compared to HPV 18 and negative groups at 3 months, 80.8%, 50% and 52.9% resp. (χ2=36.5, p<0.001). There was also a significant increase in clinical response at 3 months in HPV 16 group compared to HPV 18 and negative groups, 87.5%, 50% and 50% resp. (χ2=29.9, p<0.001). The age, volume of the disease, overall treatment time, and average hemoglobin level and number of blood transfusions did not have any correlation. Conclusion: HPV genotype 16 positive show higher complete response in cervical carcinoma patients treated with definitive chemo radiation compared to HPV 18 genotype. Further HPV genotyping could potentially help to stratify cervical cancer patients for more effective therapeutic regimens.
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From bivalent to nonavalent human papilloma virus vaccine, resolving all controversies
Anil Kumar Dhull, Vivek Kaushal
Aims/Objectives: The current US estimate of new HPV infections is over 6.2 million cases each year. Certain viral serotypes have been implicated in causing cervical and penile carcinomas as well as anogenital, vulvar, vaginal, and oropharyngeal carcinomas. There are more than 150 documented HPV viruses with about 40 having potential transmission through sexual contact. Materials and Methods: PubMed and Google Scholar search engines were explored related to clinical studies on HPV viruses and their oncogenic subtypes responsible for carcinoma cervix. Different vaccination types were explored for the pros, cons and CDC recommendations. Results: PROS: The oncogenic viral types (HPV-16 and -18) and wart-causing viral types (HPV-6 and -11) are the targets for the quadrivalent vaccine. HPV vaccine produces higher levels of antibodies that fight HPV infection in preteens than it does in young adults. The CDC recommends that the vaccine be administered to children between 11 and 12-years of age. To date, none of the deaths that occurred after vaccine administration have been directly linked to the vaccine. CONS: More than 67 million doses were administered nationally since the HPV vaccine was licensed in June 2006 until March 2014. There were 25,176 reports to VAERS (Vaccine Adverse Event Reporting System). About 92.4% of the adverse events were not serious. Adverse events are considered serious if it is life threatening, or results in death, permanent disability, and abnormal conditions at birth, hospitalization or prolonged administration. The most common events reported were syncope; local reactions at the site of immunization; dizziness; nausea & headache. In the first report, there were 12,424 reports of adverse events, 772 (6% of all reports) described serious adverse events including 32 reports of death. Upon further screening of the reported deaths, there were no common patterns to the deaths that would suggest that they were caused by the vaccine. There was increased reporting of syncope and pulmonary emboli compared to other vaccines given to females of the same age. The VAERS reports cannot prove the vaccine caused the adverse event in women with these risk factors. Nonavalent (9-valent) HPV vaccine: Studied in more than 15,000 males and females and Licensed in Dec. 2014. Nonavalent HPV vaccine protects against nine types of HPV (HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58). Nonavalent vaccine protect against total 81% of cervical cancers. Three-dose schedule at 0, 2, and 6 months have shown better efficacy as compared to 2-dose schedule. Conclusions: HPV infection remains one of the most commonly sexually transmitted infections in both females and males. The evidence favors administration of the vaccine to prevent the precancerous and malignant disease conditions caused by HPV infection. There is room for more education and counseling to improve the acceptance of the vaccine series. Despite the ethical concerns raised, the benefits of vaccination with regard to cancer prevention outweigh the risks and potential side effects related to the HPV vaccine.
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Expression of biomarkers Bcl-2 and survivin in patients of cancer cervix undergoing chemo-radiotherapy
Sanjog Pal, Gopeshwar Narayan1, Satyajit Pradhan, Amrita Ghosh Kar2, TB Singh3, Vinita Kumari, Chandra Bhusan Prasad1, L. M. Aggarwal, Ritika Ranjan
Departments of Radiotherapy and Radiation Medicine and2 Pathology, Institute of Medical Sciences,3 Division of Biostatistics, Institute of Medical Sciences,1 Department of Molecular and Human Genetics, Banaras Hindu University, Varanasi, Uttar Pradesh, India
Aim: Genes associated with apoptosis, angiogenesis and cell growth are known to be involved in tumorigenesis and tumor progression. Besides clinicopathological factors, cellular biological markers act as indicators of survival and/or response to chemoradiation in cancer cervix patients. Bcl-2 is one of the biologically relevant classes of apoptosis-regulatory gene products while Survivin is a new member of inhibitors of apoptosis proteins (IAP). Aim of the present study was: (1) explore expression of apoptotic markers Bcl-2 and Survivin, (2) correlate expression of the markers with response to treatment, in patients of carcinoma cervix receiving concurrent chemoradiation. Materials and Methods: The prospective study involving 36 patients of carcinoma cervix (Stages Ib1-IVa) was undertaken during the period March 2017 to June 2018. After detailed work up, investigation and staging, a tissue biopsy was done in all patients for histopathological and immunohistochemistry examination before these patients were taken up for concurrent chemo-radiotherapy. Expression of Bcl-2 and Survivin in the tissue samples were detected by Immunohistochemistry (reagents from Biogenex, USA). Pre-treatment expression of these markers were correlated with patient characteristics such as stage of disease, age of patients, histology, grade of tumour, tumour size, parametrial invasion, vaginal wall involvement, lymph nodal metastasis, response to initial therapy(external radiotherapy+chemotherapy) and response at first follow up. Results: With regard to expression of Bcl-2 and Survivin in the pretreatment samples, 33 of 36 (91.7%) were positive for Bcl-2 and 34 of 36 (94.4%) were positive for Survivin. Strong (2+ & 3+) positivity for Bcl-2 and Survivin were seen in 41.7% and 38.9% patients, respectively. The strong immunopositivity (2+ & 3+) of both Bcl-2 and Survivin was significantly related with advanced stage and histology of tumour (p<0.05 for each). Stronger Bcl-2 immunopositivity was significantly expressed in older age group, i.e. 50-65 years (p<0.05). Significantly stronger expression of Survivin was seen with higher grade of tumour (p<0.05). There was no statistically significant correlation of pre-treatment expression of Bcl-2 and Survivin with tumour size, parametrial invasion, vaginal wall involvement, lymph nodal positivity. Although statistically insignificant, response to initial therapy and at first follow up was better in patients with lower expression of Bcl-2 and Survivin. Conclusions: While stronger pre-treatment expression of Bcl-2 and Survivin was seen in patients having (a) Advanced stage of disease, (b) Squamous cell Histology, stronger expression of Bcl-2 was seen in age group more than 50 years and that of Survivin in patients with high grade of tumour. As the majority of the patients who had low positivity of both Bcl-2 and Survivin had better response to radiation, a low expression of these markers in tumor samples could be a possible marker for response to radiation and overall treatment outcome.
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Clinical outcomes of patients treated with vaginal brachytherapy alone using multi-channel vaginal brachytherapy applicator in operated early stage endometrial cancer
D. Savitha Mary, Karthik S. Rishi
Aims/Objectives: Carcinoma endometrium is found to have a rising trend, especially in urban India. The PORTEC- 2 trial established that vaginal brachytherapy alone is effective in early stage high-intermediate risk for local control. Materials and Methods: It is a single institution, retrospective, non-randomised study. All patients planned for vaginal brachytherapy from the period of May2013 to June2018 were included. Inclusion criteria were biopsy proven, operated (TAH+BSO) endometrial carcinoma patients in stages I and II of any histology. Patients who received External beam radiation or Neoadjuvant chemotherapy were excluded. Multi-Channel Vaginal Brachytherapy Applicator was used for all the patients. The applicator is CT-compatible and has22mm diameter applicator body with 6 channels positioned around the obturator. Application was done as outpatient procedure. For the first application, non-contrast simulation CT scan with the applicator in-situ was obtained. The images were transferred to the treatment planning system (Brachyvision, version 13.6). A dose of 5.5 Gy-6.5 Gy per fraction for 4 fractions was prescribed at 0.5 cm from the surface of applicator. In all patients a minimum of upper 3 cm was included in the treatment volume. The inferior extent of vaginal length was increased in patients having a sarcoma, or serous and clear cell histology. All patients were treated on Gamma-med Plus-iX remote afterloader with Ir-192 source. Subsequent applications were done similarly after 3-7 days. Patient did not undergo CT simulation for the remaining fractions and the same plan was executed. After completion of brachytherapy, patients were followed up at regular intervals. Treatment failures were classified as local recurrence, loco-regional recurrence or distant. Discussion: We demonstrated a 93% locoregional control with vaginal brachytherapy alone in patients which included both intermediate and high risk patients. We could not identify any particular histopathologic feature for relapse in the 2 patients who had local failure and 1 patient who failed in the pelvis. Successful salvage treatment was possible for local failures. There is no clear consensus as to which patients are defined as low and high intermediate risk group with varying criteria among the different studies. The multi-channel catheter is feasible in terms of dosimetry and ease which translates to clinical benefit. Conclusion: Vaginal brachytherapy alone should be considered for all Stage I and selected Stage II patients. Image guided brachytherapy allows for conformal dose distribution and the use of multi-channel applicator can potentially minimize the dose to the organs at risk.
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Overall treatment time in carcinoma cervix - Is there a need to be stringent?
Harshitha Jain, Mohan Kumar, Kirthi Koushik, M. G. Janaki, Arul Ponni, Ram C. Alva
Department of Radiation Oncology, Ramaiah Medical College Hospital, Bangalore, Karnataka, India
Objective: To correlate the overall treatment time with survival in patients with carcinoma cervix treated with radical chemoradation. Materials and Methods: A retrospective study that includes all the histologically proven patients with carcinoma cervix treated with radical intent with chemoradiation from 2015-2017 at Ramaiah Medical College Hospital, Bangalore. The sociodemographic data, tumor details, treatment details and follow up of these patients were reviewed. The primary endpoint of this study was disease specific death. Overall treatment time (OTT) was calculated from the day of start of EBRT to last fraction of brachytherapy. Using Spearman's Statistical test, the strength of correlation of OTT was analyzed with overall survival. Results: Total number of patients accrued was 176. The median OTT was found to be 49 days (IQR 47-55 days). OTT exceeded 56 days in 39 patients (22%) with a median extension of treatment by 7 days. Out of 176 patients, 21(12%) died and 5(2%) were found to have recurrence. Disease specific death was seen in 19 patients. A significant correlation was observed between the OTT & disease specific death (p=0.013). However, there was no correlation with the recurrence rate, histology and stage of the disease. Conclusion: Overall treatment time has an impact on the survival in patients with carcinoma. Hence, stringent measures should be taken to complete the treatment by 56 days.
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Profile of cervical cancer patients attending Tertiary Care Hospital of Banaras Hindu University, Uttar Pradesh: A 3 years retrospective study
Neelam Lader, A. K. Asthana, T.B. Singh1
Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Department of Community Medicine, Division of Biostatistics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
Objectives: To describe the socio-demographic characteristics and clinical profile of women presenting with cervical carcinoma and to identify factors associated with the timing of presentation and prognosis. Materials and Methods: Retrospective study carried out between January 2010 to December 2012 for patients attending every Monday OPD in Department of Radiotherapy and Radiation Medicine, institute of medical science, Banaras Hindu University, Uttar Pradesh. The collected data were entered and analyzed using SPSS version 16.0. Results: A total of 382 patients were included in the study. Mean age of diagnosis of cervical cancer was 51.5 years. Majority were diagnosed at locally advanced stage IIIB (51.57). Rural populations accounts for 96.6% of total patients. The mostly (73.56%) were postmenopausal at the time of diagnosis. Watery discharge per vagina was most common symptom (87%) followed by bleeding per vagina (85%). Squamous cell carcinoma was the most common reported histopathology (94%). Only 136 completed treatment among 382 patients. Among the 136 patients 109 (80.15) shows the complete response to therapy. The mean follow-up period for the study population was 17.39 months (S.D. ± 1.85). The mean overall survival was 47.14 months (S.D. ± 4.5). The OS at 12 months 99.5%, at 36 months 97.45% and at 60 months 97.45%. The DFS at 12 months, 36 months and 60 months were 74%, 53% and 36 % respectively. Conclusion: This study suggested that majority of the patient belongs to rural area and diagnosed with locally advanced disease. Cancer screening can significantly reduce the mortality and morbidity among the patients. Awareness and Availability of treatment will reduce the disease burden in population.
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Formation of institutional protocol for planning target volume margins in case of carcinoma cervix
Sarthak Moharir, Virendra Bhandari, K. L. Gupta, Om Prakash Gurjar, Priyusha Bagdare
Aim: To study different parameters for PTV margin formation in Carcinoma of Uterine cervix and draw up institutional guidelines. Objectives: Assess setup imaging and evaluation of interfractional movement. Analyse the total setup error (including setup and interfractional movement) and formation of guidelines for delineation of PTV margins. Materials and Methods: 50 patients undergoing pelvic RT for cancer cervix, using either or IMRT or IGRT technique were included in the study. Immobilization using a four clamp orfit and pelvic base plate, was done. Intravaginal fiducial marker was placed as per guidelines. Planning CECT was taken with 3mm thick slices. Contouring of GTV, PTV and relevant OARs was done as per RTOG guidelines. IMRT Treatment plans were generated by the medical physicist. 10 patients were treated by daily image guidance by kVCBCT. 40 patients were treated by weekly kV portal imaging. Translational shift (difference between planned and new coordinates) in all three directions recorded for each patient, separately for IMRT and IGRT groups. Mean and median shift and standard deviation in each direction, along with isodisplacement vector was calculated. Results: The mean movement in all the directions was calculated for all the patients over the course of the full treatment i.e. 25 scans per patient for IGRT and 6 OPI sessions per patient for IMRT. Longitudinal shift was the greatest. Mean Isodisplacement vector calculated for IGRT treatment technique is 0.7 cm and for IMRT treatment technique is 0.96 cm. The difference between the two is statistically significant (p-value=0.02). In our study, the standard deviation of shift in longitudinal direction was found to be 8 mm, 2.5 mm in the vertical direction and 3 mm in the lateral direction. PTV margin calculated using the Van-Herk Margin formula for IGRT and IMRT treatments was found to be 0.21 cms and 0.39 cms respectively (Taking into account only random errors and assuming zero systematic errors). (p- value: 0.01). Conclusions: Based on data collected from approximatepy 400 imaging sessions at our institute, for patients of carcinoma cervix being treated without image guidance, non-homogenous PTV margins should be given, atleast 5mm in Lateral and Vertical directions, and 10 mm in longitudinal direction. In patients being treated with image guidance, tighter margins may be taken with 4mm in lateral and vertical directions, and 6-8mm in longitudinal direction. Daily CBCT is a novel method of setup verification and minimizing setup error and nullifying organ motion. A one size fits all method of selecting PTV margin should not be preferred. Ideal modality of treatment should be IGRT with daily CBCT, with a margin of the day approach.
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Prognostic significance of pretreatment hematological parameters in cervical cancer patients treated with radical radio (chemo) therapy: A single institution experience in 1330 patients
C. H. Pushpa Naga, Umesh Mahantshetty, Rohini Hawaldar1, Shivakumar Gudi, Lavanya Gurram, Supriya Sastri, Sudeep Gupta2, Jayaprakash Agarwal
Departments of Radiation Oncology,1 Clinical Research Secretariat and2 Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
Background: Cancer-mediated induction of pro-inflammatory cytokines and immunosuppressive factors, induces immune response in tumor micro-environment as well changes in hematological parameters. Recent emerging evidences support that these systemic indices of immune inflammation can act as independent prognostic factors for various solid cancers including cervical cancer. In this study, we investigate clinical prognostic implications of pretreatment hematological parameters factors with clinical outcomes in locally advanced cervical cancers treated with radical radio(chemo)therapy. Materials and Methods: The electronic medical records of 1330 cervical cancer patients of FIGO stage IB2-IVA, treated between 2003 and 2016 were reviewed. Clinical parameters such as age (dichotomized at median), stage (IB2-IIB Vs III-IVA), histological type (squamous Vs others), nodal involvement (uninvolved Vs involved), treatment (chemoradiation Vs radiation alone) and hematological parameters including haemoglobin, platelets, absolute neutrophil count, absolute lymphocyte count, absolute monocyte count along with their ratios such as neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR) and lymphocyte/monocyte ratio (LMR) and prognostic nutritional index (PNI, defined as 10 x albumin concentration (g/dl)+0.005 x total lymphocyte count (μl)) were recorded and dichotomized on the basis of median values. These values were correlated with disease free survival (DFS) and overall survival (OS) using both univariate and multivariate (Cox regression) analysis. Results: Overall 5 years Kaplan-Meier estimates of DFS and OS were 61.8 % and 62.6 %, respectively and median follow-up was 57 months (range, 6-166 months). On multivariate analysis, LMR (hazard ratio [HR, 0.77; p=0.027) and PNI (HR, 0.83; p=0.035) along with FIGO stage (HR, 1.47; p=0.000) and treatment group (HR, 1.3; p=0.015) were identified as the strongest prognostic factors affecting DFS. Also, LMR (HR, 0.79; p=0.036), PNI (HR, 0.78; p=0.009) and FIGO stage ((HR, 1.75; p=0.000) significantly affected to OS [Table 1]. LMR remained significant prognostic factor for survival (DFS or OS) in a multivariate model that controlled for other ratios (NLR/PLR) along with known clinico-pathological prognostic factors for cervical cancer. Conclusion: Lower pretreatment values of hematological indices such as LMR, PNI and hemoglobin were found to be independent prognostic factors with poor prognosis predictor in cervical cancer patients treated with radio(chemo) therapy. Further investigation is warranted for a better understanding and clinical relevance.
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Correlation of Radiation proctitis with volume based and point based dose evaluation, a single institutional experience
Sampuran Acharya, M. G. Janaki, Mohan Kumar, Milan, Revathy
Need for the Study: Radiation proctitis a common late complication seen in cervical cancer patients treated with radiotherapy. The 3D conformal technique for external beam (EBRT) achieves adequate coverage in terms of target volume and sparing of normal structures (the bladder, the rectum, bilateral femoral heads and bowel bag) followed by brachytherapy. Many of the institutions still follow the point based dose prescriptions instead of volume based one due to heavy work schedule. Since brachytherapy adds considerable amount of radiation to the rectum, its prescription based on the two systems may have a relation with the development of late toxicities. This study compares the volumetric doses to the rectum with the dose at ICRU rectal point for an appropriate predictor of the radiation proctitis. Materials and Methods: Inclusion Criteria: Cervical cancer patients who underwent EBRT with concurrent cisplatin and received BT at our institution. Developed Proctitis of above RTOG Grade 2. Exclusion Criteria: Carcinoma Cervix Patients referred to our institute for brachytherapy while received EBRT at another center. Analyzed all patients treated between May 2016 to April 2017 for cervical cancer retrospectively. 50 patients were evaluated and 4 had developed radiation proctitis as a late complication. EBRT of 45 Gy in 25 fractions to the pelvis with concurrent chemotherapy followed by BT to a dose of 6.5 Gy per fraction for 4 fractions with single implantation. CT-image-based simulation and BT treatment planning was performed. Rectal doses were evaluated and analyzed both using dose volume histograms and International commission on Radiation Units and Measurements (ICRU) rectal point. The ICRU rectal point was located on an anteroposterior line drawn through lowest intrauterine source dwell position, 5 mm behind the posterior vaginal wall. The posterior vaginal wall was visualized on the CT image by intravaginal obturator and posterior most needle for ISBT cases. For ICBT cases, the mid ovoid point was located on the DRR image in lateral view. A line was drawn on from this point to the posterior vaginal wall. The point was located on this line 5 mm behind the posterior vaginal wall. The posterior vaginal wall was visualized, by the gauze used for the packing. The cumulative dose to the rectum was calculated by combining contributions from external beam therapy and BT normalized to dose equivalent of 2 Gy per fraction (EQD2). Results: 50 females with locally advanced cervical cancers were treated among whom 28 underwent ISBT and 22 underwent ICBT. For the patients who developed proctitis, the mean ICRU rectal dose was 65.758Gy compared to rectal D 2cc, D 1cc and D0.1cc doses of 70.396 Gy, 73.417 Gy, and 81.587 Gy, respectively. For the patients who did not develop proctitis, the mean ICRU rectal dose was 64.20 Gy compared to rectal D 2cc, D 1cc and D 0.1cc doses of 69.20 Gy, 72.30 Gy, and 79.50 Gy, respectively. There was no significant correlation between the grade of proctitis and the ICRU rectal dose or the volumetric doses (p=0.583 for 2cc and p=0.592 for ICRU rectal point) using spearman's correlation test. Conclusion: With the limited follow up time and less number of patients who developed symptomatic proctitis requiring medical intervention, a significant correlation between the grade of proctitis and the doses could not be seen.
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Comparison of gastrointestinal toxicity with intensity modulated radiotherapy and three-dimensional conformal radiotherapy in patients of carcinoma cervix
Bikash Ranjan Mahapatra, Tanushree Mishra, Suresh Kumar Rout, Lucy Pattanayak, Sanjukta Padhi, Niharika Panda, S. N. Senapati
Introduction: Radiotherapy plays a major role in radical and adjuvant treatment of carcinoma cervix. Gastrointestinal complications are always of first concern due to its proximity to target. IMRT can achieve greater conformity by modulating the intensity of individual beams and more homogeneous dose distribution can be achieved with sharper fall-off of dose at target boundaries thus sparing adjacent normal tissues & reducing GI toxicity. Aim of Study: To compare gastrointestinal toxicity in pelvic irradiation between 3DCRT and IMRT in carcinoma cervix. Materials and Methods: 20 Patients of carcinoma cervix were randomized to either 3DCRT and IMRT arm. In both groups EBRT dose was 50 Gy in 25 fractions. Patients were interviewed weekly during t/t, reevaluated monthly after t/t for 3 month then 3 monthly for 6 month. RTOG toxicity criteria was used for acute & late toxicity. Results: Patients treated with IMRT had lower incidence of acute GI toxicity compared to the patients treated with 3DCRT. Mean V45 of bowel bag in IMRT arm is 254 cc compared to 428 cc in 3DCRT arm which is statistically significant. The incidence of chronic GI toxicity was not statistically different between the two groups, but the 3DCRTgroup had higher incidence of chronic GI toxicity. Conclusion: IMRT can reduce GI toxicity compared to 3DCRT and this will enhance patients' quality of life and treatment compliance.
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Variation in Dosimetric parameters for two rectal retraction methods in 3D CT based Intracavitary Brachytherapy for Cervical Cancer
Aim: The objective of this study is to find out the variation in dosimetric parameters in patients who received 3D CT based intracavitary brachytherapy for cervical cancer based on two rectal retraction methods. Materials and Methods: Bladder and rectum dosimetric data were obtained for 40 patients who received intracavitary brachytherapy for cervical cancer using Manchester applicators, and randomised to 2 rectal retraction techniques. All patients had received 50 Gy External beam radiation to the pelvis prior to initiation of brachytherapy. Dose was prescribed as 7 Gy to point A for each fraction for all patients. OAR contoured based on 3D CT imaging were the rectum and bladder. The procedure was carried out using conscious sedation by Midazolam. Rectal retractor was used in half of the patients, and Vaginal Packing was used for the other half. CT based planning was used for all patients. Data was collected regarding the D2cc, D1cc, D0.1cc for bladder and rectum, the volume of bladder and rectum contoured, V50 for bladder and rectum and the minimum and maximum dose received by bladder and rectum. To determine if the median dose differences between methods were statistically significant, t test was used. Results: Median central tandem loading was 5cm, and ovoid loading was 2.5 cm. The Median D2cc for Rectum and bladder for patients with rect al retractor were 416 cGy and 457cGy respectively, and that for patients using vaginal packing was 490 cGy and 420 cGy. Median V50 for rectum and bladder were 9.24cc and 16.75cc with rectal retractor, and, 15.65cc and 10.3cc by using vaginal packing. Median volume of rectum and bladder respectively contoured by using rectal retractor was 49.8cc and 52.5cc and 63cc and 46.9cc by packing. Median Dmax rectum with retractor was 853.1 cGy, with packing was 935.5 cGy. Median Dmax bladder with retractor was 818.5 cGy and with packing was 805 cGy. Median Dmin rectum with retractor was 99.4 cGy, with packing was 81.8 cGy. Median Dmin bladder with retractor was 125.1 cGy and with packing was 118.3 cGy. Using t test, the variation in V50 for bladder with and without rectal retractor was significant (p = 0.017), favouring arm with packing, but for rectum, it was not statistically significant (p=0.08). Variation in D2cc for bladder (p=0.09) and rectum (p=0.1) was not significant between the two arms. Variation in D1cc and D0.1cc was also not significant for bladder and rectum between the two arms (p>0.05). Dmax for bladder showed significant variation (p=0.04) when compared between vaginal packing and rectal retractor, favouring vaginal packing. Dmax for rectum between the two arms showed statistically significant variation.(p=0.008), favouring rectal retractor. Dmin for rectum and bladder between 2 arms showed no statistically significant difference. Conclusion: Dmax for rectum shows significant higher dose with packing, and significantly lower dose for bladder with packing. As there is no statistically significant difference between the D2cc, D1cc, D01cc, between the 2 arms for the bladder and rectum, and V50 bladder variation favours the vaginal packing arm, adequate vaginal packing can be used as a suitable non inferior alternative in place of the conventional rectal retractor.
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Computed tomography based image guided intravaginal HDR brachytherapy – A retrospective dosimetric and clinical study
H. U. Avinash, S. Nirmala, Sandeep Muzumder, H. C. Suparna, Mazhar H. Shariff, John A. Michael Raj
Department of Radiation Oncology, St John's Medical College Hospital, Bengaluru, Karnataka, India
Background: Intravaginal brachytherapy (IVBT) is an important component in postoperative treatment of carcinoma of uterine cervix and endometrium. IVBT is either used alone or in combination of External Beam Radiotherapy (EBRT+IVBT) depending on the risk factors. American Brachytherapy society guidelines does not routinely recommend the use of volumetric imaging for IVBT. Aims and Objectives: The aim of the present study is to identify the subset of patients who might benefit from a volumetric image guidance. The objective of the study is to analyse the factors affecting the treatment outcome and long-term toxicities. Materials and Methods: 63 consecutive patients who were treated with intravaginal brachytherapy from May 2013 to June 2017 in Department of Radiation Oncology, St John's Medical College Hospital were retrospectively analysed after institutional ethical clearance. Patients were treated either with intravaginal cylinder or ovoids. All patients underwent CT simulation during first fraction of brachytherapy. Patient characteristics, length of vagina treated, orientation of applicator, number of air pockets, EBRT and brachytherapy dose, D2cc and D5cc of OARs (urinary bladder, urethra, rectum, sigmoid and small bowel). The EQD2 (Equivalent dose at 2Gy) was calculated for each OAR assuming α/β ratio of 3. The local control and the long-term toxicities were recorded and analysed. Results: Median (IQR) age was 56 years (11). 66.7% (42 patients) were of carcinoma endometrium and rest 33.3% (22 patients) were carcinoma of uterine cervix. 52.4% (33 patients) were treated with combination of external beam radiotherapy and brachytherapy. Most common dose schedule of brachytherapy was 22 Gy in 4 fractions (5.5 Gy per fraction) and 11 Gy in 2 fractions (5.5 Gy per fraction) in patients treated with IVBT alone and EBRT+IVBT respectively. There was statistically significant increase in EQD2 of all the OARs in EBRT+IVBT as compared to IVBT alone [EQD2 (median, IQR) of Rectum (63.6 Gy, 4.93 vs 43.8 Gy, 9.18), Bladder (59.7 Gy, 8.57 vs 30.6 Gy, 13.03), Sigmoid (43.2 Gy, 4.74 vs 14.4 Gy, 11.01), Small bowel (43.2 Gy, 8.52 vs 17.5 Gy, 21.78) and Urethra (53.5 Gy, 7.76 vs 17.4 Gy, 13.55)]. The posterior orientation of vaginal cylinder increased dose to rectum (both D2cc and D5cc), however there was no impact on the doses to other OARs. 51 out of 63 patients (81%) had air gaps between the applicator and vaginal wall. However only 1 out of 51 patients had a dosimetric impact due to air gap, but did not affect local control. Median duration of followup was 30 months. 9 patients had died. 1 patient had vaginal recurrence, outside the field of irradiation. 2 patients had hemorrhagic radiation proctitis (1 patient required argon laser photocoagulation); both the patients were treated with combination of EBRT+IVBT. Conclusion: Based on our study, CT scan-based image guided IVBT should be used in patients treated with EBRT+IVBT. It is preferable to use CT scan in patients who have posterior orientation of vaginal cylinder. Airgaps are common but did not affect the outcome. Although rare, chronic radiation proctitis can occur in patients being treated with IVBT.
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A prospective clinical evaluation of the short-term toxicities and dosimetric comparison of tandem and ring versus tandem and ovoid applicators in cervical cancer
Ancy George1, Aswin Kumar1, Francis V James1, Susan Mathews1, Naveen P Kumar1, Raghu Kumar2, Saju Bhasi2, Sarika Menon2
Departments of1 Radiation Oncology and2 Radiation Physics, Regional Cancer Centre, Thiruvanathapuram, Kerala, India
Objective of The Study: To estimate the differences in dosimetry profile of tandem and ring (T&R), and tandem and ovoid (T&O) applicators in the treatment of carcinoma of the cervix, to assess the difference in variability in doses to the organs at risk (OAR) and the the reproducibility of application in subsequent sittings, and to compare the short-term toxicities of both applicators. Materials and Methods: 17 patients received intracavitary brachytherapy with T&R and 23 patients with T&O applicators, respectively. The dose received by 0.1cc, 1.0cc, 2.0cc, 5.0cc and 10.0cc volumes of the organs at risk namely the bladder and rectum were analysed using independent T-test. V95% (per cent volume that received at least 95% of the prescription dose) of the high-risk volume which includes the entire cervix and residual disease was analysed using independent T-test. Inter-fraction variation in dose to OARs was evaluated using students t-test. Differences in short-term toxicities were examined in the third week of brachytherapy, at six weeks after completing brachytherapy and at the third month by Fisher's exact test. Results of The Study: The mean dose to the rectum was significantly reduced (p< 0.05) with the T&R applicator compared to the T&O applicator. The mean dose to the bladder was also less, but not significantly so. This difference in dose to the OAR was seen in all the volumes analysed. V95% (93% Vs 94.6%) of target volume was similar between the applicators. There was no statistically significant inter-fraction variation between sittings with either applicator. Short-term toxicities were comparable for both the applicators except for diarrhoea at the 3rd week of brachytherapy and cystitis after six weeks of brachytherapy which was significantly higher for tandem and ovoids. Conclusion: The use of tandem and ovoids resulted in a more homogenous dose, though not significantly, to the target volume at the cost of a higher dose to the organs at risk. Both applicators had good reproducibility. The incidence of short-term toxicities like diarrhoea at third week and cystitis after six weeks of brachytherapy were significantly higher for patients treated with tandem and ovoids and could be attributed to the relatively higher dose to rectum and bladder with these applicators.
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A cross-sectional study on malignant mixed müllerian tumour and its prognostic factors
Kawya Karunagaran, N. V. Kalaiyarasi, R. Giridharan, Sundaresan, Sanjal Kumar, Poonkodi, Vijey Karthik, Senthil Kumaran, Viswanathan, Rajkumar
Department of Radiotherapy, Madras Medical College, Chennai, Tamil Nadu, India
Introduction: Malignant mixed müllerian tumours (MMMT) or carcinosarcomas of the uterus are highly aggressive, rare, biphasic tumours composed of epithelial and mesenchymal elements believed to arise from a monoclonal origin. They represent approximately 2–3% of all uterine cancers but account for 16.4% of all deaths caused by a uterine malignancy. Objectives: The aim of our study was to evaluate the clinico-pathological features and prognostic factors of uterine carcinoma. Materials and Methods: In this cross-sectional, institutional based study, Out of 2154 cancer cases registered in IOG department from 2013 to 2017, 1670 and 256 were ca cervix and ca endometrium registered respectively. A total of that 9 patients with MMMT and their clinical characteristics of were evaluated. The Study was conducted among diagnosed MMMT patients from 1st OCTOBER 2018 to 31 OCTOBER 2018 in IOG, Chennai. The diagnosed uterine cancer patients from 2013-2017 were enrolled in the study. Those who are giving consent to participate were included in the study. Data has been analyzed using SPSS software. Univariate analysis of the prognostic factors are analyzed. Survival curves were estimated by the Kaplan-Meier method and compared by the log-rank test. Results: Nine patients with uterine carcinosarcoma were referred to our unit between 2013 and 2017. Their mean age was 54.8 years. All women underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Myometrial invasion was seen in 77.8% of the cases. Five of the patients presented with FIGO stage I/II disease. Pelvic lymphadenectomy was performed in 55.6% of the cases. Recurrences were observed in 22.2% of the cases. Radiotherapy and chemotherapy were given in 33.3% and 11.1% of the women, respectively. The FIGO stage, myometrial invasion and radiotherapy affect survival the cases. Conclusions: Uterine MMMT is an aggressive tumour, often diagnosed at an advanced stage. Further it has a high rate of metastases or recurrences. Because of its aggressive nature and poor prognosis, early diagnosis and multimodality treatment may be beneficial.
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Does two-dimensional planning underestimate organs at risk doses in intracavitary brachytherapy for carcinoma cervix in comparison with three-dimensional planning? A prospective study
Sowmiya Sampathrajan, Kesavan Govindarajan
Objectives: To estimate the differences in International Commission Radiation Units and Measurements (ICRU) bladder and rectum points doses with volumetric doses in Computerised Tomography (CT) scan based High Dose Rate (HDR) intracavitary brachytherapy (ICBT) for carcinoma cervix. Materials and Methods: From January 2017 to October 2018, 103 carcinoma cervix patients treated in our institute were included in our study. Each patient was initially treated with whole pelvic radiotherapy by 3Dimensional Conformal Radiotherapy Technique (3DCRT) to a total dose of 50 Gy in 25 fractions followed by HDR Intracavitary brachytherapy, 3 sessions of 7Gy each, 1 week apart using Manchester type applicator with uterine tandem and semiovoids. All patients underwent 3D CT simulation for each session, outer walls of bladder and rectum were contoured in each CT. Dose was prescribed to point A and optimization done to keep dose to OAR'Ss less than 90% of prescribed dose. Dose to 2cc (D2cc) of the most irradiated part of the OARs was obtained from the dose-volume histogram (DVH) and ICRU bladder (bICRU), rectum (rICRU) points were defined according to ICRU Report 38 on the CT images and point doses calculated accordingly for same plan. Results: The mean 2cc volume dose (D2cc) of bladder, 5.99 Gy ± 0.53 and the mean bICRU point dose 5.3 Gy ± 0.73 was found to be different significantly (p = 0.001) and so was the mean D1cc 6.4 Gy ± 0.74. Similarly for rectum, the mean 2cc volume dose (D2cc) 5.29 Gy ± 1. 02 and the mean rICRU point dose 4.76 Gy ± 0.73 were found to be different significantly (p = 0.0023) and so was the D1cc dose of rectum, 5.76 Gy ± 1.03 (p = 0.001). The bICRU point dose and rICRU point dose underestimated D2cc dose with an average ratio of 1.13 ± 0.24 and 1.11 ± 0.13 respectively. Conclusion: Hence, the difference between mean D2cc volume doses and ICRU point doses of OAR's has been demonstrated statistically significant which explains that the ICRU point dose does not actually reflect the volumetric dose (D2cc, D1cc) and underestimates the dose to OAR's. This results in overdosing of bladder and rectum in 2D planning which may lead to significant long term toxicities in future clinical follow up of such patients.
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A prospective randomized controlled trial to study the role of sulfasalazine in prevention of acute diarrhoea associated with concurrent chemoradiation in carcinoma cervix pateints
Abhinav, A. D. Prahal, Siva Sankar Kotne, Chandra Sekhar, Anand Rao, Anusha, Naveen
Aim: To assess effect of sulfasalazine in prevention of acute diarrhoea in Carcinoma Cervix patients receiving pelvic radiation therapy. Materials and Methods: Between November 2016 and March 2018 a total of 60 patients of locoregionally advanced Carcinoma of Cervix (30 each in study and control arms) were enrolled in this study. Patients in both the arms were treated with External Beam Radiation Therapy (EBRT) to the whole pelvis with conventional four field box technique to a total dose of 50 Gy in conventional fractionation. Injection Cisplatin was given concurrently at the dose of 40mg/mg2 every week during course of radiotherapy for 5 weeks. Concurrent chemoradiation was followed by 3 applications of HDR brachytherapy. Patients in the study arm received prophylactically tablet sulfasalazine 1,000 mg orally twice daily from the day of starting of radiotherapy to end of EBRT and patients in control arm didn't receive any prophylactic medication. Weekly review of all patients during EBRT to assess acute diarrhoea was done and highest grade was noted using common toxicity criteria version 4.0 (CTC v4.0) toxicity scores. Data analysis was carried out by SPSS version 20.0 software. Results: Incidence of grade II or grade III diarrhoea was 33.3% (10/30) in study arm and 76.66% (23/30) in control arm which was statistically significant (p<0.05). The mean EBRT treatment time was 35.4 days in study arm and 39.5 days in control arm which was also statistically significant (p<0.05). Conclusion: The study shows that sulfasalazine can significantly reduce the Acute Radiation Induced Diarrhoea (ARID) in patients undergoing whole pelvis external beam radiotherapy for carcinoma cervix. The drug is safe, cost effective, orally available, well tolerable and prevents prolongation of treatment time.
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Comparison of organs at risk doses between conventional and computed tomography based intracavitary brachytherapy planning for cervical cancer
G. Naveen Reddy, P. B. Anand, Rao, K. V. L. Anusha, E. Prahalad, Sivasankarkotne, Chandra Sekhar Darsi, Abhinav Vasireddy
Aim: Dosimetric comparision of Orthogonal Radiograph and Three-Dimensional Computed Tomography (3D-CT) based dose distributions with High-Dose-Rate (HDR) IntraCavitary Radiotherapy (ICRT) for carcinoma cervix in terms of doses to Bladder and Rectum. Materials and Methods: 28 HDR ICRT applications were analysed. External Beam Radiotherapy to pelvis to a dose of 50 Gray in 25 fractions followed by HDR ICRT 21 Gray to point A in 3 applications, one week apart was planned. All patients underwent 2D-Orthogonal and 3D-CT simulation for each application. Treatment plans were generated using 2D-Orthogonal images and dose prescription was made at point A. 3D plans were generated using 3D-CT images after delineating Organs At Risk. Comparative evaluation of 2D and 3D treatment planning was made for each application in terms of doses to Bladder and Rectum: ICRU-38 Bladder and Rectum point dose in 2D planning and dose to 0.1cc, 1cc and 2cc of Bladder and Rectum in 3D planning. Results: Doses received by 0.1cc, 1cc and 2cc volume of bladder were more than the ICRU bladder reference point. Similarly, doses received by 0.1cc, 1cc and 2cc of rectum were higher than ICRU rectal reference point. Conclusion: Dosimetric comparative evaluation of 2D and 3D CT based treatment planning for the same brachytherapy application demonstrates underestimation of OAR Doses in 2D based treatment planning.
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A comparative study of acute and late complications in cervical cancer patients treated using cobalt-60 versus iridium-192 source HDR barchytherapy
S. Jayavignesh, N. V. Kalaiarasi, R. Giridharan, Sundaresan, Sanjalkumar, Poonkodi, Vijeykarthik, Senthilkumar
Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India
Aim: The purpose of this study is to compare the locoregional complications associated with co-60 source in HDR brachytherapy and its comparison with similar toxicities in ir-192 source HDR brachytherapy in cervical cancer patients. Materials and Methods: This is a comparative, retrospective study of patients treated with iridium HDR brachytherapy (arm a) from Janaury 2007 to December 2009 with respect to patients treated with cobalt source HDR brachytherapy (Arm B) FROM August 2015 to August 2017. 40 patients were taken in each arm. the follow up period was taken as 3 years to look for acute and late complications in each arm. in both the group, patients were treated with ebrt using telecobalt therapy of 50 Gy in 200 cGy per fraction with cisplatin based concurrent chemo prior to brachytherapy. The grading for late gastrointestinal and genitourinary complications were graded using RTOG late radiation morbidity scale. Results: ???. Conclusions: The acute and late complications arising in patients treated with high dose rate brachytherapy using iridium-192 source is similar compared to cobalt-60 source.
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Observational study of inflammatory markers in cancer of uterine cervix
Aneesha Rakesh, Francis V. James
Aim: To evaluate the prognostic significance of inflammatory markers: C R P, Albumin, Neutrophil to Lymphocyte ratio, Platelet to lymphocyte ratio in patients with cancer of uterine cervix. Materials and Methods: Data of 87 patients who received radical treatment (EBRT and Brachytherapy) for Carcinoma Cervix between January 2016 to September 2017were analyzed. Prospective documentation of Differential count, platelet count, CRP and albumin were done for patients reporting with carcinoma cervix in RCC, Trivandrum from January 2016 to September 2017. This was evaluated along with other known prognostic factors like stage, tumour size, lymph node metastasis and histology. Univariate analysis of individual markers was done using Chi-square/Fisher's exact test. The significance as predictors of loco-regional control were assessed using Student's t-test. Results: There were 87 patients included in the study. When CRP was compared with the nodal status and stage, t failed to show a statistically significant association. N/L Ratio showed no significant correlation with stage or lymph node metastasis. P/L Ratio also failed to show any correlation with the lymph node status and stage. Albumin level was compared with the stage and nodal status and failed to show any significant association The stage wise comparison of each parameters was done using Students t test. With regard to CRP values and stage, it showed a trend towards association (P-value 0.083) in the univariate analysis. Other markers did not show any statistical association. The comparison of inflammatory markers with respect to local control also showed no statistical association. Conclusion: This prospective study demonstrated no significant correlation between CRP, Albumin, Neutrophil Lymphocyte Ratio (NLR) and Platelet Lymphocyte Ratio (PLR) with respect Stage, Lymph node status and Local control.
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Comparison of compliance and subjective response for neoadjuvant chemotherapy followed by concurrent chemo radiation versus chemo radiation alone in carcinoma cervix FIGO stage IVA - A single institution experience
M. Pandu Ranga Kumari, G. Mehar Kumar, D. Niharika
Aims/Objectives: Cervical cancer is the second most cancer in women in India. Patients presenting with stage IVa have 5 year survival rates of only 16% and are not able to complete the full course of radiation. The aim of this retrospective study is to study the compliance of the stage IVa patients to neoadjuvant chemotherapy (NACT) followed by concurrent chemo radiotherapy and their completion of radical dose of radiation and subjective response in comparison to patients without NACT. Materials and Methods: We retrospectively studied stage IVa cervical cancer patient's case sheets from January 2016 to September 2018. The patients are divided in to 2 arms: Arm-A: 11 patients - who received NACT with Paclitaxel 175mg/m2 and carboplatin AUC 6 every 3 weeks of 4 cycles followed by external beam radiotherapy(EBRT) of 5040 Gy/28 fractions with weekly cisplatin of 40 mg/m2, followed by brachytherapy of 700cGy of 3 fractions. Arm-B: 9 patients-who received external beam radiotherapy (EBRT) of 5040 Gy/28 fractions with weekly cisplatin of 40 mg/m2, followed by brachytherapy of 700 cGy of 3 fractions. The compliance to complete radical dose of radiotherapy with concurrent chemotherapy and subjective response by telephonically were compared. Results: Arm A: 10 patients (91%) completed radical dose of RT and weekly cisplatin, one patient (9%) defaulted for EBRT, all patients tolerated 4 cycles of NACT. During 3 months follow up 1 patient (9%) developed liver secondaries and 1 patient (9%) developed other complication (jejunal obstruction) and there were no deaths. We could contact (telephonically) total 7 patients out of which 6 patients (54%) are asymptomatic, one patient died. Arm B: 4 patients (44.5%) completed radical dose of RT and 5 patients (55%) defaulted radiation [one for EBRT and 4 for HDR]. During 3 months follow up one patient (11%) developed liver secondaries and 1(11%) developed uraemia and died. We could trace 6 patients and in that 4 patients (44%) are asymptomatic, one patient have dysuria, one patient died. Patients who defaulted for radical dose of concurrent RT were more in arm-B (55%) with p value (0.0049, significant) when compared to arm-A. More patients are asymptomatic in arm-A than arm-B with p value (0.5). Conclusions: Response and compliance to treatment was better in the patients who received NACT followed by concurrent chemo radiation and are able complete treatment and majority of them are asymptomatic. From this it may be concluded that NACT may be considered in stage IVa cervical cancer. However a prospective trial with large number of patients is needed to come to a conclusion.
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A medical audit of VMAT planning done in pelvic malignancies
Dinesh Makuny, M. P. Arun Krishnan, C. P. Ranjith, Shamsudeen Cholayil, P. ArunLal, K. S. Vijaygopal, K. Afzal, P. Niya
Department of Radiation Oncology, MVR Cancer Centre and Research Institute, Calicut, Kerala, India
Introduction: Use of high-end technologies in radiation delivery is generally used only in the curative setting due to the low cost-effectiveness and the higher time required for its planning and execution. We conducted a medical audit to see the utilization of Volumetric arc therapy planning in advanced pelvic gynecological malignancies during the past 1 year. Materials and Methods: The cases were identified from the radiation records during the period (2017-18). The cases were tabulated and analyzed for the type and stage of cancer. A total of 12 cases were identified,7 cervical cancer and 5 endometrial cancers receiving the VMAT treatment. The plans were evaluated to see the coverage of the targets and the dose to the normal structures. Follow up imaging was used to compare the response rates. The structural responses, extent of palliation of symptoms were also evaluated in the cases. Results: The cases evaluated mainly comprised of Vault (5) and nodal disease (7) with a combination of both. The bladder and rectal max dose (2cc) were kept under 50 Gy EQD2 Gy in 80% of cases. The normal bowel receiving a dose of 45 Gy EQD2 Gy was less than 195cc was possible in 75 % of the cases. 95% of the target receiving 95% of the prescribed dose was achieved for all cases. Local responses evaluated in five cases showed a complete response in PET and MRI imaging. Conclusions: VMAT plans for pelvic malignancies with vault and nodal recurrences offered good local control conferring very low toxicities due to RT due to the low doses achievable to the organs at risk.
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Interstitial brachytherapy in recurrent/residual disease of carcinoma cervix
Sheeba Santhmayer, A. G. Hasib
Aim/Objectives: Response assessment after interstitial brachytherapy in recurrent/residual disease of carcinoma cervix. Materials and Methods: 10 patients with histologically proven recurrent/residual disease of carcinoma cervix at the department of radiotherapy, father muller medical college, mangalore from 2015 to 2018, were taken up for this study.response was assessed both clinically and radiologically after 6 months. Results: All patients were of squamous cell carcinoma histology, with mean age 55.2 years. carcinoma cervix stage IIIB was the most common FIGO stage prior to recurrence/residual disease.9 patients did receive definitve chemoradiation with intracaviatary brachytherapy previously.1 patient was post op carcinoma cervix stage IB. interstitial brachytherapy with mean dose of 12.6 Gy (dose ranging from 9 Gy-18 Gy) was given. Complete response was seen in 2 pateints parital response was seen in 6 patients. Stable disease in 2 patients after 6 months of the interstitial brachytherapy. Conclusion: In recurrent/residual disease of carcinoma cervix interstitial brachytherapy seems feasible.
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Outcome of elderly women (≥65 years) with cervical cancer treated with radio (chemo) therapy - A retrospective analysis
Naziba Khondekar, Bhavin Visariya, Lavanya Naidu, Supriya Chopra, Sudeep Ghosh, Umesh Mahantshetty
Tata Memorial Centre, Mumbai, Maharashtra, India
Background: Data from various hospital-based cancer registries (HBCR) of India show that patients aged >65 years with cervical cancer account for approximately 12% of all patients. Elderly patients with cervical cancer often receive suboptimal treatment and data regarding the optimal management and its outcomes in the elderly are limited. Aims and Objectives: To evaluate the treatment patterns and survival outcomes in elderly patients with cervical cancer. Methods: One hundred and eleven e lderly patients with cervical cancer with age > 65 years treated with radical radio(chemo)therapy between March 2010 to November 2015 were evaluated. All the demographic, tumor and treatment characteristics including external beam, brachytherapy details, toxicities, disease status at last follow-up were noted and compiled. Results: With a median age of 66 years (Range: 65-75 years), 99 (89 %) patients were between 65 and 70 years and squamous cell carcinoma was the most common histology (101 patients,91%). The FIGO (2009) stage distribution were as follows: 11 patients (10%): IB1-IIA1; 47 patients (42%): IIB; 42 patients (38%): IIIB; 1 patient: IVA and in 10 patients stage was not known. The treatment patterns were as follows: chemo-radiation (cisplatin based) in 51 patients (46%), radical radiation alone in 54 patients (49%), 5 patients (4%) adjuvant radio(chemo)therapy and 1 patient (1%) received palliative hypofractionated radiation. External beam Radiotherapy (EBRT) was with conventional two [49 pts (44%)] or four field technique [59 patients (53%)] and 3 (3%) patients with IMRT. Median EBRT dose was 46 Gy with 18 patients (16%) received 40 Gy; 46 patients (42%) received 46 Gy and 36 patients (33%) received 50 Gy. Ninety seven percent patients completed planned EBRT. Median number of HDR-BT applications was 4 (Range: 1-5) with 83 patients (79%) receiving atleast 3 fractions. In patients undergoing chemo-radiation, a median of 4 (range: 1-6) cycles of cisplatin chemotherapy was delivered with 43 (84%) patients receiving >3 cycles. The median OTT was 60 days (Range: 27-149) with 44 patients (40%) completing treatment within 56 days. Acute toxicities could not be compiled due to poor documentation. With a median follow-up of 38 months (range:2 - 94), the overall 3 year DFS and OAS were 65.2% and 71.4% respectively. Similarly, it was 70% and 73.6% for IIB while 55% and 62.4% for Stage III respectively. The DFS and OAS were significantly better with chemo-radiation compared to RT alone (3 year DFS 75.6% Vs 51.6%; p=0.015 and 3 year OAS 83.6% Vs 55%; p=0.018). Symptomatic late toxicities was seen in 11 patients (9%) with proctitis, 2 patients (1.8%) with cystitis and 1 patient (0.9%) with both. Conclusion: In elderly patients with cervical cancer, the compliance to radiation therapy and concomitant cisplatin chemotherapy was acceptable. The outcome (disease free and overall) survivals are significantly better with concomitant chemoradiation irrespective of stage.
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Refractory, progressive and symptomatic endometriosis in young female - Radiation therapy is an option
Shabin K. Sidhique, K. Beena, Anjali Menon, Appu Thomas1, Raghavendra Holla2, Debnarayan Dutta
Departments of Radiation Oncology,1 Medical Physics and2 Urology, Amrita Institute of Medical Science, Kochi, Kerala, India
Background: Endometriosis is a common clinical condition and usually responds to medical management. Only in few occasions surgical intervention is required. However, a small proportion of patient does not respond to either medical or conservative surgical approach. Radiation therapy (RT) may be considered as an option in refractory, symptomatic endometriosis. The present case report evaluates the effectiveness of RT for symptomatic, refractory endometriosis. Aim/Objective: A twenty-eight year old female patient was a known case of primary infertility. On evaluation, advanced endometriosis (stage IV) involving the bowel loops and bladder was diagnosed. CT scan showed extensive involvement of intestinal loops, mesentery, bladder and uterus. She had underwent cystoscopic biopsy and confirmed as endometriosis. She was symptomatic with cyclical hematuria for 4 years and had to transfuse blood on regular basis. She had received medical management with LHRH antagonist, but did not have any radiological or clinical benefit. She was considered for exenteration, but the patient refused the extensive surgery. She was considered for radiation therapy as ‘hemostatic RT’ to control hematuria. Materials and Methods: She was planned for hemostatic RT after CT simulation and planning. CT scan was done without contrast and vacloc. Images were taken from D10 to mid thigh level. Bladder protocol as standard was followed [after empty bladder, 500 ml water intake and imaging after 30 min]. Contouring was done in Monaco contouring station and planning done in Oncentra planning system. Whole bladder was contoured as GTV, 1 cm margin for CTV and 0.5 cm margin for PTV given. 3DCRT planning was done with 6 MV photon four field ‘box’ technique. Dosage prescription was 20 Gy in 5 fractions in 5 consecutive days (Prescription at 100% isodose). She completed the treatment without any acute toxicity. Results: The patient was evaluated two months after radiation therapy, and she had significant clinical and radiological response. Haematuria was completely inhibited after 2 weeks of RT, and did not have any history of hematuria till last follow up (1 year). CT scan images showed significant regression of intra-vesicle mass lesion. She did not have any relative long term toxicity at 1 year follow up. She did not have menstruation after RT. Conclusions: Low dose RT is an effective non-surgical option in endometriosis, refractory to standard medical management, recurrent disease or inoperable due to extensive adhesions.
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Patterns of failure in carcinoma cervix: An A.H.R.C.C. experience
Ajitesh Avinash, S. N. Senapati
Department of Radiation Oncology, A.H.R.C.C. Cuttack, Odisha, India
Aim: To study the pattern of failure in carcinoma cervix undergoing treatment at A.H.R.C.C. Materials and Methods: A total 102 patients histo-pathology proved carcinoma cervix with local/ loco-regional and distant failure after treatment at A.H.R.C.C. from January 2016 to December 2016 were analysed retrospectively from the hospital and radiation treatment records. Results: Out of 102 patients of carcinoma cervix, majority i.e 45% of patients were in the age range of 51-60 years followed by 29% in 41-50 years. Moderately differentiated squamous cell carcinoma was the most common histology accounting for 97% of cases and only 3 cases of adeno-carcinoma was found. 47.1% of patients were seen in the stage IIIB followed by 19.6% in stage IIB, 8.8% in stage IIIA, 8.8% in stage IB, 6.9% in stage IVA, 5.9% in stage IVB, 2.9% in stage IIA. In early stage carcinoma cervix, 50% of cases had inappropriate hysterectomy. Out of 102 patients, 15% of patients did not complete radiation, 30% of patients did not receive radiation in adjuvant setting, 17% of patients did not receive radiation in radical intent and presented with upfront metastasis. In this study, 79.4% of patients had loco-regional failure, 49% had distant metastasis and 28.4% had both loco-regional and distant metastases. In loco-regional failure, recurrence at vault accounted for 64.5% (maximum). Most common site of distant failure was para-aortic node (40%) followed by lungs (28%), liver (16%) and bones (16%). Majority i.e. 48% of failure was seen within 12 months of radiation followed by 34.3% seen within 24 months. Conclusions: Both loco-regional and distant failure in carcinoma cervix depends upon the age at presentation, initial stage, and histological subtype. Failure is seen in those patients who had inappropriate hysterectomy and who did not receive the full course of radiation. The failure can be reduced if the patients are educated regarding the importance of completing radiation therapy (both external beam and brachytherapy) without defaulting the treatment. The patients of carcinoma cervix, after completion of radiation should be kept under close observation, so that failure can be detected early and treatment can be delivered for better outcome.
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Does graphical optimisation increase vaginal morbidity? A retrospective single institutional dosimetric analysis of vaginal dosimetry in cervix patients treated with image guided brachytherapy
M. Arunlal, Amrutha Babu, P. Niyas, K. S. Vigayagopal, Shamshuden Cholayil, K. Afsal, Jayashankar, Arun Krishnan, C. P. Ranjith, R. Vysakh, M. Dinesh
MVR Cancer Centre and Research Institute, Calicut, Kerala, India
Introduction: Image guided Brachytherapy with optimisation of dose to HR CTV and restricting dose to normal structures like rectum, bladder and Sigmoid has been the cornerstone of modern brachytherapy practice. Dose optimisation by adjusting isodose lines, called as Graphical optimisation is a commonly used technique in modern computerised brachytherapy planning. There has been a concern that use of this will increase the vaginal dose leading to more toxicity.Materials and Methods: 60 CT scans of 12 patients were retrospectively evaluated who underwent EBRT to a dose of 46 Gy in 23 fractions followed by Brachytherapy (BT) to a dose of 7 Gy x 4 fractions using graphical optimisation. An anatomical vaginal reference point was defined at the level of the Posterior – Inferior of Symphysis (PIBS), plus two points ±2 cm (mid/ introitus vagina). For BT extra points were selected for the upper vagina at 12/3/6/9 o'clock at the level of vagina surface and 5 mm depth. A vagina reference length (VRL) was defined vagina top to PIBS. Results: The mean value of total EQD2 doses at PIBS and ± 2 cm were 51.79 Gy (38.21-67.12), 98.06 Gy (51.51-199.63) and 19.72 Gy (4.86-52.24) respectively. Vaginal surface doses were respectively 168.95 Gy (97.45-254.89), 163.98 Gy (118.55-268.02) at 3/9o'clock, and 156.36 Gy (90.13-290.36), 107.55 Gy (49.45-214.57) at12/6 o'clock. Mean VRL on CT was 4.97 cm (2.87-7.38). Conclusion: We could not demonstrate a significant increase in vaginal doses compared to literature in our cohort of patients who has undergone a graphical optimisation. Careful optimisation under experienced physicians may not result in additional vaginal dosimetry.
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The effect of bladder volume on dose to OARs and HR CTV during computed tomography based high dose rate brachytherapy in carcinoma cervix
Sharief K. Sidhique, S. Arvind, Kaalindhi Singh, Neenu O. John, Tarun Jose, Jeba Karunya, Thomas S. Ram
Department of Radiation Oncology, Christian Medical College, Vellore, Tamil Nadu, India
Aim: Dosimetric correlation between the bladder volume and the dose received by the OARs during CT-guided HDR brachytherapy in carcinoma cervix, and to determine an optimum bladder volume to limit the dose to OARs. Materials and Methods: Fifteen intracavitary applications in patients diagnosed to have carcinoma cervix treated at our institute between August- September 2018 were studied. All the patients received external beam radiotherapy with concurrent chemotherapy followed by CT-based HDR intracavitary brachytherapy four fractions of 7Gy in two applications. Patients underwent catheterization during the procedure and after adequate bladder emptying by supra pubic pressure no further bladder filling or emptying protocol was used. During the CT scan 5cc contrast was instilled through the Foley's catheter for better visibility and the bladder was then delineated by contouring the entire bladder as seen on the CT scan. The Bladder volumes were categorised and noted as Category A: <80cc, Category B: 80 -110cc and Category C: >110cc and were correlated with the radiation dose received by 2cc, 1cc and 0.1cc of bladder, rectum, small bowel and sigmoid colon.D90 and V95 of HRCTV was also noted. Results: The Mean Bladder volume was 98.26 cc (range 66.57 - 146.56 cc). The Dose-volume histogram (DVH) parameters (D2cc, D1cc, D0.1cc) of the bladder decreases with increase in the volume of the bladder. Rectum doses does not show a significant correlation, however it increases up to a bladder volume of 110cc and then starts decreasing. The highest rectal dose observed was in the bladder volume range of 80-110 cc while the minimum doses were recorded when the bladder volume was >110cc. Sigmoid Colon dose did show any particular trend. The minimum doses were recorded when the bladder volume were between 80-110 cc. Small bowel doses did not have a significant correlation with the bladder volumes. Due to the small sample size the optimal bladder volume could not be assessed. Conclusions: The bladder dose showed a decreasing trend when the bladder volume was increasing. However, the correlations between the bladder volume and the doses received by the other OARs were not statistically significant. Further large studies are desirable to correlate the effect of bladder volume.
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Analysis of impact of different dose fractionation regimens and source activity on long term rectal morbidity in high dose rate intracavitary brachytherapy of carcinoma uterine cervix: A retrospective analysis
G. Selvaluxmy, Vasanth Christopher, S. Krithikaa
Department of Radiation Oncology, Cancer Institute Adayar, Chennai, Tamil Nadu, India
Introduction: A shift from the traditional practice of Low Dose Rate to High Dose Rate Intracavitary brachytherapy came with practical gains of shorter treatment time, less radiation hazard to health care givers, more patient comfort. However, with no universal optimal dose fractionation regimen, the rates of late toxicity differs with different fractionation regimens.,,, The Dose rate and toxicity o have been reviewed well however dose rate effects within the HDR range have not been studied extensively. Aim: To analyse the impact of different dose fractionation regimens on long term rectal morbidity and to identify its relationship if any to the activity of source at the time of intracavitary brachytherapy. Materials and Methods: We retrospectively analysed caserecords of 400 patients with carcinoma of uterine cervix treated with External Beam Radiotherapy (EBRT) and High Dose Rate Intracavitary Brachytherapy (HDR- ICBT), point A based dosimetry, between 2015 January to 2016 December. The dose fractionation regimens, rectal point doses, applicator used, source activity at the time of intracavitary application, overall dwell time in seconds, long term toxicity were analysed. Given our institutional rate of long term grade III rectal morbidity of 2 %year, to establish a cause response relationship we also analysed similar data profile of 50 patents who developed long term rectal morbidity treated since the year 2000. Results: The rate of long term rectal morbidity per year was 2%. 250 patients were treated with a dose fractionation of 8Gy x 3 fractions, 150 patients were treated with 7Gy x 3 fractions, 50 patients with lower than 650 Gy/fraction. The rectal doses were within acceptable limits. However among the patients who developed rectal morbidity, dose per fraction was a significant determinant and there was a corelation with high source activity, with the rate of rectal morbidity being high among patients with high dose per fraction and high specific activity. Conclusion: With no optimal dose fractionation regimen available we observed that when the source activity is high using lower dose per fraction regimens would be preferable with regard to long term rectal moridity.
- Okkan S, Atkovar G, Sahinler I, Oner Dinçbaş F, Koca A, Köksal S, et al. Results and complications of high dose rate and low dose rate brachytherapy in carcinoma of the cervix: Cerrahpaşa experience. Radiother Oncol 2003;67:97-105.
- Petereit DG, Pearcey R. Literature analysis of high dose rate brachytherapy fractionation schedules in the treatment of cervical cancer: Is there an optimal fractionation schedule? Int J Radiat Oncol Biol Phys 1999;43:359-66.
- Orton CG. Width of the therapeutic window: What is the optimal dose-per-fraction for high dose rate cervix cancer brachytherapy? Int J Radiat Oncol Biol Phys 1995;31:1011-3.
- Azad SK, Choudhary V. Treatment results of radical radiotherapy of carcinoma uterine cervix using external beam radiotherapy and high dose rate intracavitary radiotherapy. J Cancer Res Ther 2010;6:482-6.
- Clark BG, Souhami L, Roman TN, Chappell R, Evans MD, Fowler JF, et al. The prediction of late rectal complications in patients treated with high dose-rate brachytherapy for carcinoma of the cervix. Int J Radiat Oncol Biol Phys 1997;38:989-93.
- Ogino I, Kitamura T, Okamoto N, Yamasita K, Aikawa Y, Okajima H, et al. Late rectal complication following high dose rate intracavitary brachytherapy in cancer of the cervix. Int J Radiat Oncol Biol Phys 1995;31:725-34.
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Management and outcomes of carcinoma cervix IVA – A single institution experience
Neenu Oliver John, Jebakarunya Rami Reddy, Arvind S. Murthy, Kaalindi Singh, Thomas Samuel Ram
Department of Radiation Oncology, Christian Medical College, Vellore, Tamil Nadu, India
Aim: To study the clinical profile and treatment outcomes of patients with carcinoma cervix stage IVA. Materials and Methods: The demographics, tumor characteristics and treatment modalities of 41 patients diagnosed with carcinoma cervix Stage IVA between January 2013 and December 2017 in our institution were analysed. Results: The mean age was 50.4 years (Range 30-84 years). 90.25% of the patients were ECOG performance status 1 and 9.75% ECOG 2. The most common histology was squamous cell carcinoma (97.61%) and one patient (2.4%) had adenosquamous histology. The imaging modalities used were USG (78%), CT (29.26%), PET-CT (12.19%) and MRI (12.19%). In 65.85% of patients no nodal involvement was detected. 75.6% had hydroureteronephrosis. The mean creatinine was 2.46 mg% (0.51-28.68 mg%) and the mean Hemoglobin was 9.92 g/dl (4.4-12.4 g/dl). Of the various treatment modalities given 2.4% received neoadjuvant chemotherapy, 60.97% radiation therapy alone, 21.9% chemo-irradiation and 2.4% best supportive care. Among the 36 patients who received radiation therapy, the various techniques used were Cobalt-60 (44.4%), Conventional Linac (36.1%), 3DCRT (11.1%) and IMRT (8.3%). The most common dose schedule used was 50 Gy in 25 fractions (38.8%) and the median dose of radiation delivered was 47 Gy. 30.5% received External radiation therapy boost, 11.1% interstitial brachytherapy, 11.1% HDR intracavitary, 8.3% LDR brachytherapy. Among the 11 patients who received chemo-irradiation the median number of cycles of concurrent chemotherapy was 3 (range 1-5). During the treatment period 60.9% patients did not undergo any diversion procedure. 24.3% underwent bilateral PCNs, 7.31% underwent unilateral PCN, 4.8% patients underwent rectal diversion, 2.4% had dialysis and 2.4% underwent DJ stenting during the course of their treatment. Acute toxicities noted were grade 2 dermatitis (17.1%), grade 3 dermatitis (8.5%), grade 2 enteritis (5.7%) and grade 3 neutropenia (2.8%). Two patients expired during treatment. 65.85% completed the planned treatment while 24.39% did not. 4.8% did not take any treatment in our Institution while one expired due to septic shock prior to starting any treatment. The median follow-up period was 11 months (3-44 months). During the follow up, 22.2% were found to be disease free clinically, 37% had local failure, 22.2% had distant failure, 7.4% had local and distant failure. One patient was lost to follow-up. The median time to progression was 8 months (2-20 months). Conclusion: Carcinoma Cervix IV A can be treated with multiple modalities including definitive radiation therapy and chemotherapy with acceptable toxicities and modest progression free survival.
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Comparison of applicator based point A with Anatomical point A in position and dosimetry in intracavitatory brachytherapy in carcinoma cervix patients
Poornachandra Tejaswi, Vezo Khoto, Mahantesh, Maya Devi, Anup Hegde, Shija Merin, Gowtham Raj, S. Sathyan, Ibrahim Khaleel
Aim: To compare the position and dosimetry of Applicator based point A with anatomical point A in patient with carcinoma cervix undergoing ICBT. Materials and Methods: A total of 30 post external beam radiotherapy carcinoma cervix patients were taken for this prospective observational study. Brachytherapy application was done as per our instituitional protocol. CT simulation was done with 1mm CT slices with 3 phase from the level of diaphragm to mid thigh. In arterial phase CT scan taken at 15-30 seconds, venous phase at 2 minutes and delayed phase at 8 minutes. Anatomical point A was obtained by tracing the uterine artery at arterial phase CT scan and ureter was traced in delayed phase CT scan. The crossing point obtained is defined as Anatomical point A. With the Eclipse 13.7 software, brachytherpay planning was done with prescription of 7 Gy to Applicator based point A. The variation in position of Anatomical point A to Applicator based point A were documented in craniocaudal, transverse and anterio-posterior direction. Both points were documented with relation to the wall of the uterus. And the variation in dose to anatomical point A when compared to Applicator based point A were calculated. Results: In our study, Anatomical point A was lying superiorly in 40% and inferiorly in 60% of patients to Applicator based point A, with a mean distance of 1.1cm superiorly (0.3-2.2 cm), 1.38 cm inferiorly(0.49-2.97 cm), 1.71 cm laterally (0.2-2.92 cm), 1.9 cm anteriorly (0.9- 3.09 cm), 0.91 cm posteriorly (0.2-2.24 cm) on right side and 0.81 cm superiorly (0.3-1.47 cm), 1.33 cm inferiorly (0.69-2.5 cm), 1.76 cm laterally (0.57-2.63 cm), 1.07 cm anteriorly (0.2-1.07 cm), 0.34 cm posteriorly(0.1-1.52 cm) on left side. And also the Applicator based point A was lying inside the uterus in 50% patients, at the edge of uterus wall in 27% patients and outside the uterus in 23% patients. with a mean distance of 0.64cm outside the uterine wall (0.1-1.5 cm), 0.98 cm inside from the uterine wall (0.2-2.5 cm) on the right side and 0.15 cm outside the uterine wall (0.1-0.2 cm), 0.3 cm inside from the uterine wall (0.1-0.6 cm) on the left side. But the Anatomical point A was always lying outside the uterus with a mean distance of 1.02 cm (0.2-3.5 cm) on right side and 1.15 cm (0.2-3.35 cm) on the left side from the uterine wall. When the prescription was planned based on Applicator based Point A, we found that Anatomical point A received 48% less dose compared to Applicator based point A. But when the prescription was planned based on Anatomical point A, Applicator based point A received 128% higher dose than to Anatomical point A. Conclusions: From this study we conclude that point A has to be re-defined and further studies to be done to make consensus about the prescription point in the intracavitary treatment of carcinoma cervix. And this also shows the importance of volume based prescription and optimization compared to point based prescription in Carcinoma cervix.
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Clinical correlation of dose volume histograms of pelvic bone marrow in patients of cancer cervix treated with chemo-radiotherapy
V. Naidu, P. Kumar, A. K. Chauhan, NigamJ, P. Kumar
Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
Aims and Objectives: To evaluate theBone Marrow toxicities (heamoglobin, tlc, platelets) &Dose Volume Histograms of Pelvic Bone Marrow in Patients of Cancer Cervix Treated with Conventional and 3-Dimentional Conformal Radiotherapy along with concurrent cisplatin. Materials and Methods: 74 patients were included between November 2015 to October 2017 & randomised to Conventional & 3D-CRT groups of 37 patients each. All the patients were delivered 50 Gy/25 fractions in 5 weeks followed by 3 applications of intracavitary brachytherapy of 7 Gy/fraction each. Dose Volume Histograms of Pelvic Bone Marrow (V10, V20, V30, V40) was calculated for the subsites lower lumbosacral spine, ilium, lower pelvis & entire pelvis. The median follow up was for 1 year. Heamatological toxicity was evaluated by Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. Results: In Group A, Lumbosacral spine showed a much higher dose distribution especially in the V10, V20 & V30 volumes & in group B the lumbosacral spine showed higher dose distributions in V10 & V20 volumes. The p value was significant in the V50 volume. (p=0.04; significant) In group A, Lower Pelvis showed least dose distribution especially in the V40 & V50 volumes & in group B the Lower Pelvis showed least dose distribution in all the volumes. The p value was significant in the V50 volume. (p=0.049; significant). In group A, Ilium showed moderate dose distribution especially in the V30, V40 & V50 volumes & in group B the Lower Pelvis showed least dose distribution in all the volumes. The p value was significant in the V40 & V50 volumes. (p=0.04 & p=0.03; significant). In group A, Whole bone marrow showed a much higher dose distribution in all the volumes & in group B the Whole bone marrow showed lower dose distributions in V40 & V50 volumes, the p value for all the sites were not significant except for V50 volume when compared in both the groups. (p=0.02; significant) The Haematological grade I toxicity (hb) & grade II (tlc) was more in conventional arm. Conclusion: The present study shows a significant differencebetweenConventional and 3-DCRT in terms of clinical outcomes and Grade III/IV toxicities of haematological toxicities especially TLC. The subsites of the pelvic bone marrow which had the the maximum dose was Lumbo-Sacral Spine & Lower Pelvis.
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Comparison of outcomes, complications and dose volume histograms of 3D-CRT and IMRT in patients of cervical carcinoma treated with concurrent chemoradiotherapy
M. Navya, P. Kumar, A. K. Chauhan, J. Nigam, P. Kumar
Department of Radiation Oncology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
Aims and Objectives: The increasing use of concomitant chemotherapy in cervical carcinoma patients have raised the concern of various toxicities like hematological, bladder, rectal and bowel. The present study comparesoutcomes, complications & dose volume histograms of 3D-CRT and IMRT in patients of cervical carcinoma treated with chemoradiation. Materials and Methods: Fifty patients were included in this study between November 2016 to March 2018. All patients were delivered Radiotherapy dose of 50 Gy in 25 fractions in 5 weeks at 200 cGy/day followed by 3 applications of intracavitary brachytherapy of 7 Gy/fraction each at weekly interval. The total treatment was completed in 8 weeks. These patients were divided into two groups (Group A- 3D-CRT and Group B- IMRT). The Dose Volume Histograms of PTV, rectum, bladder, femur, bowel bag & pelvic bone marrow was evaluated. Assessment of toxicity was done by RTOG scoring criteria. Clinical response assessment was done using WHO response criterion. Results: The median follow up was of 6 months. Haemoglobin levels were 9(36%) grade I anemia in group A and 6 (24%) grade I anemia in group B. Comparing TLC levels, 17 (68%) patients in group A and 20 (80%) in group B had normal TLC level 5 (20%) patients had grade I and 3 (12%) patients had grade II leukocytopenia in group A and 5 (20%) patients had grade I and none had grade II leukocytopenia in group B (p-value 0.01). Comparing DLC levels 5 (20%) patients had grade I neutropenia 2 (8%) patient had grade II neutropenia in group A and 6 (24%) patients had grade I neutropenia but no any grade II or grade III neutropenia (p-value 0.008). There was grade 1 thrombocytopenia in 2 (8%) patients in group A, but no any thrombocytopenia seen in group B. The mean doses of PTV in arm I & arm II was 50.92 Gy & 49.93 Gy & PTV-95% was 49.37 Gy & 45.71 Gy. The means of D50 of rectum in both the groups were 50.22 Gy & 44.75 Gy, The means of D50 of bladder in both the groups were 50.46 Gy vs 46.92 Gy. The means of V45 of bowel bag in both the groups were 730 cc vs 486 cc. The means of Dmax of left femur in both the groups were 51.17 Gy vs 45.19 Gy. The means of Dmax of right femur in both the groups were 51.22 Gy vs 45.11 Gy. The means of V50 of pelvic bone in both the groups were 22.57 cc vs 11.56 cc. there was a statistical difference in the parameters compared in both the groups. The difference is more pronounced in the volumes of bowel bag, femoral heads and pelvic bone marrow irradiated, where IMRT plans showed significantly lower volumes of OARs irradiated. Conclusion: The present study shows no significant difference between 3D-CRT and IMRT in terms of clinical outcomes and Grade III/IV toxicities of haematological, bladder, rectal and bowel. Irradiated volumes of OARs are significantly lower in IMRT plans. Longer follow-up is needed to assess the late toxicities.
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The role of interstitial brachytherapy in the management of uterine cervical cancer - single institutional study
R. Resmi1, T. N. Vijayasree2, S. Saravanan2
Aims: This study aims to report the clinical results of uterine cervical cancer patients treated by Radiation therapy including brachytherapy, using Template based interstitial brachytherapy (ISBT), in whom conventional Intracavitary brachytherapy is not possible and to determine the local control and the incidence of acute and late radiation-induced toxicities. Materials and Methods: From April 2016 to March 2018, among histologically proven uterine cervical cancer patients with 30-70 yrs of age, stages from IB to IIIB, completed Concurrent Chemoradiation (Radical/Adjuvant) and referred for High dose rate (HDR)Brachytherapy, thirty patients, in whom conventional Intracavitary brachytherapy (ICA) is not possible are treated using Template based, Image-guided Interstitial brachytherapy (ISBT) and are further investigated for clinical outcomes and related toxicities. The prescription dose per fraction of HDR-ISBT at our department varied from 3-4Gy/# to a total of 12-21Gy in 4-6#. D90 for HR-CTV of BT, cumulative EQD2 including previous EBRT and present BT for HR-CTV, D2cc for the bladder, rectum, and sigmoid, were analyzed. Patients were investigated for disease-related parameters and treatment-related complications and tumor-response rates at 6weeks, then every month for first 3 months and every 3 months after that. MRI is done at the end of 3 months. Results: Out of 735patients referred for brachytherapy, 30 patients, who are not fit for conventional ICA, are treated by HDR ISBT.19 patients were treated using Syed-Neblett and 11 using the MUPIT template. The median number of needles used was 15. The median BT Dose planned 23.6Gy and median HR-CTV D90 received by BT 17.5Gy. The median cumulative EQD2 for HR-CTV, D2cc for the bladder, rectum, and sigmoid were 67.5Gy 62.6, 64.36, 54.83 respectively. The median V100 for HR-CTV was 70ml. Local control (LC) rate at first follow up (3 months) is 43.3% (95% Confidence interval 24.51% - 62.15%) and at 1yr is 41.38 % (95%C.I. 22.31% – 60.45%). The median survival time for two-year follow-up was 22.398 months (95% C.I. 20.26 – 24.54). The median Progression-free survival time for two-year follow-up was 19.92 months (95% C.I. 17.030 – 22.803). One patient(3.33%) had Distant metastasis, Two patients (6.67%) experienced grade 2 rectal bleeding, but no one had bladder complications. Conclusion: Treatment by Image-guided ISBT for cervical cancer patients in whom the conventional application is not possible, results in good dose-volume histogram (DVH) parameters and favorable local control with acceptable toxicities is demonstrated through this single institutional experience with a small number of patients.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]