Lt Col N Kannan, MS and Brig G Rajagopal FRCS

Army Hospital (Research and Referral), New Delhi 110010.

Purpose: To highlight a rare infantile maxillary tumour and its management

The Case and Management: Five month old female child was brought to the Oncology Center Army Hospital (R&R) N Delhi with complaints of a rapidly growing mass of the right maxillary region. CT scan showed the lesion to involve the right upper alveolus, adjacent palate, and anterior wall of the maxilla. There was no soft tissue extension or metastasis. Biopsy done revealed the lesion to be a Melanotic Neuroectodermal Tumour of Infancy.

Problem faced was of a child with a lesion needing surgical excision which had the potential of producing severe disfigurement and functional handicap especially in a breast and bottle fed child with undeveloped dentition.

Surgical excision was done with preservation of the lateral palatal flap and excision of the lower part of the right maxilla and the adjacent tumour bearing palate. The buccal mucosa and the palatal mucosa were sutured together to obturate the palatal defect. Post op recovery was uneventful. Child is under follow up and has now started developing milk teeth which will be used for anchoring the prosthesis to prevent growth related facial dyssymetry.

Discussion: MNTI is a rare lesion of the growing skeleton. Other differential diagnosis in such a case are odontogenic neoplasms and sarcomas. The tumour is a benign lesion with rapid growth potential. Approximately 200 cases are reported in English literature. The mainstay of treatment is surgical excision which is associated with a recurrence in approximately 15% cases in 1-2 yrs. The problem of surgical excision is that it is frequently deforming and disfiguring due to the removal of growing facial skeleton resulting in functional and social handicap. Surgical excison must always be accompanied by enthusiastic and energetic prothetic and orthotic support.

Chemotherapy is not known to be effective in management of these lesions however a recent series of successful chemotherapy has been reported in the Journal of medical paediatric Oncology.

The aim of presentation of the case is to highlight successful surgical management with minimal functional and facial aesthetic impairment.

HDR Brachytherapy in Carcinoma of Lip

Sandeep Jain

Mahavir Cancer Sansthan Patna

Background: Since inception goal of radiotherapy is to deliver a high dose to tumor with sparing of normal tissue. With brachytherapy there is rapid fall of dose beyond implanted area, thus delivering high dose to tumor with sparing of surrounding normal tissue.In node negative lip cancers surgery & radiotherapy produces equal results but radiotherapy is considered superior as it causes less functional & cosmetic deficit.

Method: We present 20 cases of cancer lip treated with HDR BRACHYTHERAPY these include T1-5, T2-8,T3-5,T4-2. Interstitial implatation was done using flexible plastic tubings or rigid stainless steel needles with templates.All the implants were done under local anaesthesia.A dose of 45 to 51 GY in 15 to 17 fraction ,3GY per fraction ,two fractions per day with a gap of six hours between two fractions was delievered for T1 &T2 tumors.For T3 &T4 tumors A dose of 24 to 30 GY was delivered by HDR brachytherapy & 36 to 40 GY by EBRT.

Result: With A mean follow up of 18 months overall local control is seen in 85 % of the patients. One patient with T2 disease had nodal failure after 2 months & was salvaged by surgery.One patient with T3 disease had local residual disease & was salvaged by surgery . One patient with large T4 disease had persistent disease.All patients had localized Gr 111 mucositis wich healed in 4 weeks.

Conclusion: HDR brachytherapy is highly effective in cancer lip & it gives excellent functional & cosmetic results

A Phase II Study Evaluating the Role of Concomitant Paclitaxel (T) and Capcetabine (X) with Conventional External Beam Radiation Therapy (EBRT) in Locoregionally Advanced Squamous Cell Cancer Head & Neck (LASCCHN Stage III-IV)

Pranav Chadha, Ishu Sharma, Sandhya Sood, Parveen Kaur,
Rajesh Vashistha, Arvind Verma

Department of Radiation Oncology, Mohan Dai Oswal Treatment & Research Foundation, Ludhiana, Punjab, India

Purpose: To evaluate the efficacy & toxicity of Concomitant T+X with conventional EBRT in LASCCHN Stage III-IV.

Materials and methods: No. Of Patients (Pts) enrolled in the study=15.
Inclusion Criteria:
1. LASCCHN Stage III-IV, T3-T4, M0
2. Age <65 Years
3. Karnofsky Performance Scale >60
Exclusion Criteria:
1. Diabetes Mellitus, Hypertension, IHD
2. Salivary Gland Tumors, Sinus Tumors.
15 Pts as per the above criteria were treated with following treatment plan:
Conventional EBRT 65-72 Gy on TH-780 (Telecobalt) with Concomitant Chemotherapy:
T 40 mg/m2 weekly 6 cycles + X 450mg/m2 BID for 2 weeks followed by 1 week rest

Results: 15 male patients with Stage III/IV head and neck cancer were entered. 14 evaluable. 62% were T4 and 87 % were N2 or greater. The median age was 50(range 44-64). No. Of evaluable Pts = 14; 1 defaulted. The response (As per RECIST Criteria) assessed at 2 weeks of completion of therapy
Complete Response (CR): 9/14=64%
Partial Response (PR): 3/14=21%
Overall Response (CR+PR)=85%
Stable Disease (SD): 1/14=7%
Progressive Disease (PD): 1/14=7%
2 Months follow up 9/14 Pts. (CR) remain disease free.
1/14 Pt developed PD undergoing Chemotherapy. 4/14 Pts had PR+SD out of which 1PR+1SD underwent surgical intervention. Rest 2 PR were inoperable (fixed lymph nodes) & put on Adjuvant Chemotherapy.
TOXICITY (As per ECOG Criteria)
Hematological G3 Neutropenia 5/14,
Dermatological G3 4/14
Mucosal G3 6/14,
Gastrointestinal G3 2/14

Conclusion: The combination of RT with Capecitabine and weekly Paclitaxel is a highly effective regimen associated with acceptable toxicity.

R. Suwinski, T. Rutkowski, A. Sowa

Dept. of Radiation Oncology, Center of Oncology, Gliwice

Purpose: To evaluate whether hemoglobin concentration (Hb) has the prognostic value in postoperative radiotherapy for laryngeal cancer

Material/Methods: Medical records of 654 patients treated in Gliwice between 1980 and 2000 were analyzed retrospectively. This included 190 patients with glottic, 192 with supraglottic and 272 with transglottic cancer. All patients had squamous cell laryngeal cancer treated with surgery and postoperative radiotherapy. Patients with gross residual disease after surgery were not included. A multivariate Cox proportional hazard model was used to evaluate an influence of the following variables on loco-regional tumor control: age, sex, TN stage, Hb before and at the end of radiotherapy, total radiation dose, dose per fraction, overall radiation treatment time, interval surgery-radiotherapy and pathological margins in surgical specimen.

Results: A 5-year actuarial loco-regional control rate in a group of 654 patients was 77%. The following variables appeared to significantly and independently influence loco-regional tumor control: Hb at the end of radiotherapy, overall radiation treatment time, pathological margins and N stage. A decrease in Hb of 1.0 g/dl reduced the 5-year actuarial loco-regional tumor control rate by 5%, and such detriment was equivalent to protraction of overall radiation treatment time by 10 days. Hb at the end of radiotherapy appeared to better predict the local effect of therapy than Hb at the start of radiotherapy. The influence of Hb concentration on loco-regional control was most apparent in subgroups of patients with T3-T4 disease, and in patients without metastases to loco-regional lymph nodes (N0). In fact, in T3-4 N0 patients Hb at the end of radiotherapy appeared to be the strongest predictor of treatment outcome among all of the analyzed variables.

Conclusion: Hemoglobin concentration at the end of postoperative radiotherapy appears to be a strong and independent predictor of treatment outcome in combined modality treatment for laryngeal cancer.

Prevention of Head & Neck Cancer-How Much we Have Progressed?

Mahfuz Ariff, Abhijit Sarkar, Somnath Sorcer Saroj Gupta.

Cancer Centre Welfare Home & Research Institute, Thakurpukur, Kolkata
West Bengal, India.

Purpose: Head & Neck cancers are diverse group of malignancies with different etiopathologies, pattern of disease progression & management strategies. Of these Squamous Cell Carcinoma is the largest group and are preventable. It is well established that tobacco use is the primary cause of cancer in this area. There are many attempts to cut down tobacco uses like
• Compulsory warning in cigarette packets.
• Prohibition of sell to people below 18 years.
• Restriction of smoking in public places.
This study is done to assess the trend whether tobacco use restriction measures at all affected the general population which should reduce the numbers of cases in hospital Head & Neck Cancer Deptt.

Material & Method: Number of Squamous Cell Carcinoma cases in tobacco
users are studied in Cancer Centre Welfare Home & Research Institute, Thakurpukur, Kolkata, West Bengal. Since 1996 to 2003. All new cases studied & ratio of all types of cancer in all age groups to tobacco related Head & Neck cancer assessed.

Result & Conclusion: It is seen that in 1996 among 4625 newly registered
patient 928 were tobacco related Head & Neck cancer (21%). In 2003 the incidence is 811 among 4008 patient (22%). It is observed by this acid test that all attempts to restrict tobacco use has not been able to reflect it?s success in reducing tobacco related Head & Neck Cancer.
In India, tobacco is used in different forms like Khaini, Nassi, Guraku, Jarda, Bidi, Cigarette. Most of the oral cancer is preceeded by precancerous lesion hence primary prevention is possible. Among different methods one to one interaction is the most helpful method. Our dream of Smokeless Society may be achieved if there is complete ban on sell and promotional activity of tobacco use. Can we afford it by loosing million Rupees Govt. income from the industry !?

Safety and Efficacy of Concomitant Boost Radiotherapy with Concurrent Weekly Cisplatin in Advanced Head and Neck Cancers

Manish Pandey ,Shaleen Kumar , Punita Lal, Neeraj Rastogi, K. Joseph Maria Das, Kislay Dimri

Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India

Background and purpose: To determine the safety and efficacy of concomitant boost radiotherapy (CBRT) with concurrent cisplatin chemotherapy (CT) in advanced head and neck cancers.
Patients and methods: Between February 2000 and June 2001, 77 previously untreated patients of advanced head and neck cancers(pharyngeal region) were treated with EBRT and concurrent cisplatin CT. CBRT consisted of: phase I-44 Gy/22fx/4.5 weeks, phase IIa-16 Gy/8fx/1.5 weeks and phase IIb-10 Gy/8fx (delivered as a second daily fraction after a gap of 6 h along with phase IIa). CT (cisplatin 35 mg/m2) was administered weekly usually preceding EBRT by an hour.

Results: The median follow-up was 39 months (range 8-50 months). EBRT compliance (70 Gy in 40-44 days) was seen in 71% (52/77). Six cycles of CT was delivered in 61% (47/77). Acute grade III/IV mucosal toxicity was seen in 69% and resulted, on average, in a total weight loss of 6.9 kg from a mean pretreatment weight of 54 kg. Nasogastric tube placements were required in 16%(12/77). Grade III leucopenia was seen in 2%. Crude incidence of late subcutaneous fibrosis (grade III) was 18% (09/77) and a case of mandibular necrosis and thyroid cartilage necrosis each were seen. Initial loco regional disease clearance was seen in 72% (55/77) and the Kaplan-Meier estimates of 3-year loco-regional control rate and overall survival were 45% and 50% respectively.

Conclusions: Study highlights the need for extreme caution when using CBRT with concurrent cisplatin in a population of the advanced ,unrescetable head and neck cancers treated in a setting of developing countries.

CAIR in Locally Advanced Head and Neck Cancer

Suparna.H.C., Vidyasagar.M.S., Rao Koteshwer.K., Fernandes D.J.,Choudhary Rajiv, Vadiraja B.M., Seetharamiah T.S.

Shirdi Sai Baba cancer hospital, Manipal, Karnataka, India

Purpose: Cancers of head and neck region constitute more than 50 % of cancers diagnosed in India. Advanced head and neck cancers are treated with combined modality with radiation and surgery. When surgery is not feasible, radiation has been used as a sole modality with 5-year survival of less than 10 %. Main factor for failure is loco regional failure. Rapid repopulation has been identified as one of the major cause for this. Various accelerated fractionation schedules have been tried to overcome this. A prospective study was conducted to compare the immediate response of the tumor and normal tissue reactions in patients treated with accelerated fractionation regimen with conventional fractionation.

Materials and methods: Patients with squamous cell carcinomas of head and neck, with Stage III and stage IV a/b were included. Each arm had 25 patients. Study group patients received total dose of 60 Gy/30 # over 4 ½ weeks, 7 days a week (continuous accelerated irradiation- CAIR). Control group patients received 66 Gy/33 # over 6 ½ weeks. Tumor response was assessed at the end of treatment and monthly for 3 months. Acute reactions were scored according to RTOG radiation morbidity scoring criteria and assessed during the treatment.

Results: Tumor control at first month and at the end of 3 months in study group was better, by 10 % and 11 % respectively. But this difference was statistically not significant. Skin reactions were significantly lesser in study group whereas mucosal and salivary reactions were higher.

Conclusion: Response of the tumor to CAIR did not show any statistically significant difference compared to conventional radiotherapy. Assessment of reactions in CAIR group showed reduced skin reactions and more mucosal and salivary reactions. A larger sample size and longer follow up is required for assessment of survival benefit.

Near Total Laryngectomy for Advanced Cancers of the Larynx and Pyriform Sinus: Is It Here To Stay?

Vijayshree Murthy, Ashok Shenoy, Nanjundappa, Hariprasad, Rajshekhar

Department of Head & Neck Services, KMIO, Bangalore.

Aim: The study of Pearson near total laryngectomy (NTL) highlights the efficacy in T2, T3 and early T4 lesions of the larynx and pyriform sinus (PF), which were deemed “too big” for control with either definitive RT or function preserving partial laryngectomy.

Materials and Methods: Till date 172 cases (60-larynx, 112-PF) were prospectively analysed with respect to disease control at 5 years, morbidity and functional outcome associated with the procedure. The material was analyzed after completion of 55 cases, then 105 and 172 cases. The 3-year projected Kaplan Meier survival analysis has yielded 71% and 66% for larynx and PF tumors respectively at the end of first analysis.

Results: At the completion of 105 cases, there was a decline in wound related morbidity from 68% to 28% in lesions of PF and from 21% to 12% for larynx. This was maintained at final analysis. Three perioperative deaths due to other co-morbid conditions at the end of 105 cases and none thereafter. Shunt related transient symptomatic aspiration declined from 44% to 36% and 10.25% to 9.8% in larynx and PF lesions respectively. Three patients required surgical closure. Shunt stenosis, impeding speech was seen in 10 cases of PF and 2 of larynx cases. Intelligible speech was found in 68% and 83% of PF and larynx cases respectively.

Conclusion: Authors feel that Pearson NTL offers comparable disease control to total laryngectomy. Additionally, there seems to be a learning curve for minimizing local wound problems. Finally, gratifying functional outcome with 75% to 80% patients achieving prosthesis free high quality speech and aspiration free swallowing in more than 90% patients makes a strong case for propagation and practice of NTL in Indian subcontinent.

Chemo-Radiotherapy for Advanced Larynx and Pyriform Cancers- Is it Practical in Developing Nations?

Chaturvedi P, D’Cruz AK, Pathak KA, Pai PS, Chaukar DA, Deshpande MS

Tata Memorial Hospital, EB Road, Parel Mumbai 12

Purpose: Chemo-radiotherapy (CT+RT) is gaining popularity globally in an attempt to preserve larynx. There are certain reservations in accepting this larynx preservation protocols (LPP) in its current forms in developing nations.

Material and Method: A systematic review of the chemo-radiotherapy based larynx preservation randomized trials (VA study, EORTC study, RTOG study, MACH NC meta -analysis) was done. A review of other related literature was also done.

Results: CT+RT has a potential role in larynx preservation and concomitant CT+RT offers the best results. The reservations in accepting CT+RT as standard of care in advanced larynx cancer patients in developing countries are as follows-

- Concomitant CT+RT has a definite benefit over RT alone and Induction CT+RT. However its superiority over surgery followed by post operative RT has not been proven. It requires an excellent performance status ( KPS> 80 in 90% of the patients in RTOG trial). Therefore, the poor nutritional status of patients in developing countries is a significant deterrent.
- It is accompanied by significant increase in overall toxicity that warrants increased need for supportive care and patient motivation. It is accepted that incidence of treatment modification, treatment interruption and hospitalizations increase significantly.
- The benefit of LPP is maximum in low volume diseases (> two third of the lesions in RTOG trial were T2/T3 and N0/N1). Its role in high volume disease (T3/ T4 and N2 / N3 ) is still unproven.
- Majority of the lesions in published CT+RT trial are laryngeal cancers. There is no robust evidence that it is equally effective in pyriform cancers, which forms a major component of laryngo-pharyngeal cancers in such countries.
- The indirect costs due to frequent expensive imagings, duration of treatment, duration of recuperation, enhanced need for supportive care and stringent follow up may be exorbitant.
- Given the compliance of our patients a stringent follow-up, a must for LPP, is difficult.
- Post operative morbidity significantly increases when laryngectomy is performed after failure of CT+RT.
- It requires not only a motivated patient but also a team of dedicated oncologists and good infrastructure. Very few cancer centers in India have a specialized Head and Neck service.

Conclusion: Role of CT+RT is not proven in hypopharynx cancers, T4 lesion and N2/N3 lesions. The protocol is feasible in highly selected patients only in good institutions. It would be premature to follow the western “standard of care” in our subset of patients unless its efficacy is proven.

A Prospective Study of Pharyngo-Cutaneous Fistulas Following Total Laryngectomy.

P.Chaturvedi, P.Pai, D.A.Chaukar, M.S.Deshpande, K.A.Pathak, A.K.D’cruz

Tata Memorial Hospital, Mumbai India

Purpose: Pharyngo-cutaneous fistulas (PCF) is one of the major complications following laryngectomy. Varying rates have been reported and majority of these studies are retrospective.

Material and Method: We critically and prospectively studied PCF with respect to patients, tumor and technique related parameters. The study analyzed 164 consecutive laryngectomies performed by consultants, residents and fellows. 2/3rd were pyriform cancers, 90% were T3/T4 lesions and almost 80% required total laryngectomy (TL) with or without partial pharyngectomy. 80% of the TL had primary closure and remaining required reconstruction depending on the extent of pharyngeal excision. We included frank fistula as major leak and minor leak was defined as – delayed initiation of oral feeds.

Results: In 164 consecutive total laryngectomies we encountered overall 33 PCF (20%) of which 15 (9%) were major and 18(11%) were minor.

3/4th of the PCF occurred with in 2 weeks of surgery and most (87%) were lateralized. Patients with PCF had an average hospital stay of 28 days. Extended pharyngectomy, soft tissue infiltration and a pyriform disease were significantly related to PCF. PCF rates were highest (60%) when extended pharyngeal resection was done that required PMMC for reconstruction of neo-pharynx. While In patient with TL with primary closure the PCF rate was only 14%. Other variables such as surgeon ( Resident Vs Consultant ), type of suture, prior treatment ( RT+/- CT), type of closure, age, sex, nutritional status and stage had no association with PCF.

Conclusion: We witnessed a higher PCF rate because majority of our patients were pyriform cancers with extensive soft tissue invasion that necessitates removal of some part of the pharynx. this results in either a tight closure or reconstruction of neo-pharynx with PMMC. Extensive soft tissue removal during a laryngectomy probably leads to loss of support and vascularity of the remaining mucosa. Unless the leak manifests within 72 hours or manifests as hemorrhage, surgical intervention is futile.

Post-Resection Mucosal Margin Shrinkage in Oral Cancer- Quantification and Significance.

Rajesh C Mistry1 MS, Sajid S Qureshi2 MS, DNB, Kumaran C3. Mch, FRCS

Department of Surgical Oncology. Tata Memorial Hospital. Ernest Borges Road, Parel. Mumbai. India.

Background: Importance of tumor free surgical margin in outcome of oncologic surgery is well known. However, often the pathological margin is reported to be significantly smaller than the in situ margin. This discrepancy is due to margin shrinkage the quantum of which has not been studied in patients with oral cancer.

Objectives: Quantify the shrinkage in mucosal margin following excision in patients with tongue and buccal mucosa cancer.

Methods: In 27 patients with carcinoma of the buccal mucosa/tongue, mucosal margins were measured prior to resection and half an hour after excision. The mean margin shrinkage was assessed and the variables affecting the quantum of shrinkage were analyzed.

Results: The mean shrinkage from insitu status to post resection margin status was 22.7 %. [P<0.0001].The mean shrinkage of tongue margin was 23.5%, compared to 21.2% in buccal mucosa margin. The mean shrinkage in T1/T2 tumors [25.6%] was significantly more than in T3/T4 [9.19%, P<0.01).

Conclusions: There is significant shrinkage of mucosal margins after surgery. Hence this should be considered and appropriate margins should be taken at initial resection to prevent the agony of positive surgical margins.

Juvenile Nasopharyngeal Angiofibroma- A Single Institution Study

Qureshi Sajid S 2 MS, DNB, Mistry Rajesh C 1 MS, Gupta Shaikat 3 MS, FRCS, Gupta Sameer4 MS

1, 2, 3, 4 Department of Head and Neck services Tata Memorial Hospital. Ernest Borges Road, Parel. Bombay. India.

Background: Juvenile nasopharyngeal angiofibroma is a rare tumor of adolescent males with a paucity of Indian studies on the subject.

Aims: To present experience of management of juvenile nasopharyngeal angiofibroma at a single institution.

Setting and Design: This is a retrospective observational study of patients with juvenile nasopharyngeal angiofibroma who presented at the Tata Memorial Hospital between May 1988 and August 2001.

Materials and methods: Thirty two patients with juvenile nasopharyngeal angiofibroma were treated in the study period. Since the time period was prolonged and diagnostic and therapeutic protocols had undergone many changes, the patients were divided into two groups, namely 1988-1996 and 1997-2001. The age distribution, disease patterns, management approaches and treatment outcomes of patients in the two groups were recorded. Statistical analyses were done using students‘t’ test and test for proportion.

Results: The mean age at presentation was 16 years and more than 90% of the patients had stage 3 or 4 disease. Preoperative embolisation was carried out in 19 patients. The surgical approaches used were median maxillectomy, infratemporal fossa, transpalatal, maxillary swing and craniofacial approach. The recurrence rate, complete resection rate and cure rates were 12.5%, 41% and 63% respectively.

Conclusion: Surgery is the mainstay of treatment of JNA. Preoperative embolisation and newer surgical approaches results in less blood loss and complete resection. Aggressive re-resection should be done for resectable recurrences reserving radiotherapy for unresectable, recurrent/ residual disease.

Squamous Cell Carcinoma of the Maxillary Sinus:
A Tata Memorial Hospital Experience

Qureshi Sajid S. 1 MS, DNB, Devendra Chaukar A.2 MS, DNB,
D’Cruz Anil K. 3 MS, DNB, Talole Sanjay D 4 MSc, DCM

1-3 Department of Head and Neck services, 4 Department of Biostatistics, Tata Memorial Hospital. Parel, Mumbai, India

Context: The optimal treatment of maxillary sinus carcinoma remains to be defined and there is a paucity of Indian studies on the subject.

Aim: To present experience of management of squamous carcinoma of maxillary sinus treated with curative intent at a single institution.

Settings and Design: Retrospective study of patients with squamous carcinoma of maxillary sinus who presented between 1994 to 1999.

Methods and Material: The records of 73 patients with squamous cell carcinoma of maxillary sinus were analyzed. Sixty-two patients were evaluable. Forty patients were treated with surgery followed by postoperative radiotherapy, five patient were treated with radiotherapy alone, five patients were treated with surgery alone; 19% patients received chemotherapy. Statistical analysis used: Statistical analysis was done using Kaplan-Meier method.

Results: The majority of patients presented with locally advanced disease (83%); nodal involvement was observed in 8%. The most common site of recurrence was at the primary site, which was observed in 45% and regional failures occurred in 16%. The 3 and 5-year overall survival was 38% and 35% and the disease free survival was 29% and 26% respectively. The 5-year overall survival after surgery and postoperative radiotherapy was 42%.

Conclusions: Majority of patients present with advanced disease resulting in poor outcomes to conventional treatment modalities. Locoregional tumor progression remains a significant pattern of failure. New approaches such as neoadjuvant or concomitant chemoradiotherapy with aggressive surgery need to be considered and evaluated in prospective studies.

The Role of Subcutaneous Amifostine as a Radioprotector in Head and Neck Carcinoma patients

Suruchi S., Manish S., Fakhruddin,

Department of Radiation OncologyM.G.M. Medical College and Govt. Cancer Hospital, Indore

Head and neck carcinomas constitute 5% of all tumours worldwide and are rather more common in our country. External radiotherapy is the standard modality of treatment for these cases irrespective of the site. The treatment modality is, however, an uphill task for the patient due to many side effects of radiotherapy viz. xerostomia, mucositis, dysphagia and skin toxicity, etc. which sometimes prove to be intolerable and thus lead to non-compliance of the patients. This study aims to ameliorate these side effects by use of amifostine (WR 2721) and test its efficacy as a radioprotector of normal tissues. It also aims to test the advantage of subcutaneous route of administration of amifostine over other routes. 23 patients were included in this study, both in study arm and control arm. Both study and control arm patients received 50-70 Gy by external radiotherapy using bilateral or wedge-paired fields in accordance with stage and status of the disease. The study arm patients, in addition received Inj. Amifostine (250 mg/m2) subcutaneously, 15-20 minutes prior to each fraction. Patients were reviewed daily for tumour response to therapy, acute mucositis and xerosis, skin reaction, dysphagia and haematological toxicity. They were followed-up monthly after completion of therapy for persistence of any side effects and response. At the end of the study it was concluded that Amifostine not only reduces the severity of the side effects of radiotherapy but also delays them, also, subcutaneous route of administration is efficacious, safe and practical.

Laryngeal Preservation: Brachytherapy. A Novel Approach in Suprahyoidal Supraglottic (Epiglottis) Cancers

Rajendra L. Bhalavat, MD• A. R. Fakih, FRCS• Rajesh C. Mistry, MS • Umesh Mahantshetty, MD•

• Department of Radiation Oncology, • Surgical Oncology Tata Memorial Hospital Mumbai, India

Introduction: Radical radiotherapy remained an option without question to surgical treatment for this lesion but with resultant xerostomia and poor quality of life post RT. Brachytherapy with a novel approach through thyrohyoidal membrane was introduced particularly for lingual epiglottis and vallecular lesion to lower the external radiation dose. Aim: To report my experience with the use of interstitial Iridium 192 implant combined with external radiotherapy in the treatment of carcinoma of the epiglottis.

Materials and Methods: Between 1990 and 1999, 20 patients with carcinoma of the epiglottis were treated with a radical intent using moderate dose external radiotherapy and interstitial implant. The mean and median age at presentation was 61 years respectively (Range 40 013 86). There were 17 males and 3 female patients. All patients had squamous cell carcinoma of the epiglottis with varying degrees of adjacent spread. One patient (T1) was treated with a radical implant. Other patients (10 with T2 and 9 with T3) were treated with external radiotherapy and implant, with a mean delay of 30 days. There were five patients with nodal disease (N1). Mean external RT dose was 47 Gy and the mean brachytherapy dose was 28 Gy. Technique: The epiglottis was approached through the thyrohyoidal membrane and two different techniques were used for implant.

Results: Twenty patients were analyzed to determine local control and complications. Complete Response (CR) was observed in 65% (13/20) and Partial Response (PR) was seen in 30% (6/20). After the implant Complete Response was seen 95%(19/20) patients.There were 5 loco-regional recurrences one of which was salvaged. Six patients had edema of the epiglottis and 3 patients had ulcers/necrosis of the epiglottis. Median Disease Free Survival (DFS) and Overall Survival (OAS) was 36 months. There were a total of 7 deaths, 2 due to disease and 5 due to other causes. Five-year DFS and Cause Specific Survivals were 65% and 85% respectively.

Conclusion: Brachytherapy is a viable organ salvage approach to mutilating surgery for cancer of the Epiglottis.

Radical Radiation Vs Surgery Plus Post-Operative Radiation in Advanced (Resectable) Supraglottic Larynx and Pyriform Sinus Cancers - A Prospective Randomized Study

Rajendra L. Bhalavat, MD• A. R. Fakih, FRCS• Rajesh C. Mistry, MS •
Umesh Mahantshetty, MD•

Department of •Radiation Oncology, • Surgical Oncology Tata Memorial Hospital Mumbai, India

Background and Purpose: Survivals in Head and Neck cancers are a reflection of loco-regional control. With an aim of organ and function preservation present study was undertaken to compare local failure and survivals.

Material and Methods: Between Aug '91 - Dec '95, 72 patients with resectable advanced supraglottic cancers, were randomized to radical surgery followed by post-operative radiation therapy [Sx+PORT] (Arm I) or radical radiation therapy followed by salvage surgery [RRT+/-SSx] (Arm II).

Results: Sixty-four of 72 patients were evaluable, 55 were T3 (86%) & 9 - T4 (14%) tumors. In Arm I (n=35), with a mean follow-up of 24 months (2 - 86 months), 21 patients were alive without disease. Six patients had recurrence, 1 each at local and tracheostomy stoma, four had nodal recurrence only and 2 developed 2nd primary in soft palate / tonsil and parotid at 15 months and 18 months resp. In Arm II (n=29), with a mean follow-up of 24 months (3-81 months), 14 patients were alive without disease. Thirteen patients had recurrence, 8 had local (1 patient had persistent disease), 2 nodal only, 3 loco-regional and 2 patients developed distant metastasis (lung). One out of eight local recurrence & 2/2 nodal recurrences were salvaged with Sx. There was a significant difference in disease-free survival between the two treatment arms, DFS (5 years) of 70% in Arm I Vs 50% in Arm II (p= 0.04), but did not have any impact on overall survival OAS (5 years); 73% Vs 77% (p= 0.79). Voice/laryngeal preservation was possible in 18/29 patients (60%) treated with RRT +/- Sx, without significantly affecting the OAS. ‘Pathological upstaging’ was another significant finding seen in 64% of clinical T3 after radical surgery.

Conclusion: RRT+/-SSx can be a feasible option in low volume, favourable resectable stage III and IV supraglottic lesions for better quality of life.

Head & Neck Squamous Cell Carcinoma: The Role of Post-Operative Adjuvant Radiotherapy

*K.A.Dinshaw, *S.K.Shrivastava, *J.P.Agarwal, *S.Ghosh Laskar, *T.Gupta, $A.K.D’cruz

Department of Radiation Oncology $ Department of Head & Neck Surgical Oncology Tata Memorial Hospital, Mumbai, India.

Introduction: Head and Neck Squamous Cell Carcinoma (HNSCC) is one of the leading cancers in India. Since a large majority present in loco-regionally advanced stages, surgery followed by adjuvant post-operative radiotherapy (PORT) has been the mainstay of treatment for resectable HNSCC.

Aim: To identify clinicopathologic factors that could have an impact on outcome in HNSCC in the post-operative setting.

Material & Methods: A retrospective review of 348 previously untreated HNSCC who received PORT following curative surgery. The outcome measures were local control, loco-regional control and disease free survival (DFS).

Results: With a median follow-up of 36 months (range: 2-127 mths) for surviving patients, the 5-year local control, loco-regional control, and DFS was 79%, 63% and 56%, respectively for the entire group. On univariate analysis site of primary was an independent prognostic factor for all outcome measures (p=0.005;0.02;& 0.04, respectively) with oral cavity lesions faring the worst. Peri-nodal extension (PNE) affected loco-regional control (p=0.002) and DFS (p=0.0005) but was not predictive for local control (p=0.9852). Cut margin positivity predicted for inferior local control alone (p=0.03), the significance of which was lost on multivariate analysis. Cox regression analysis however confirmed the significance of primary site and PNE as independent prognostic factors. Conclusion: Primary site and PNE are independent factors predicting outcome in the post-operative radiotherapeutic management of HNSCC.

Submandibular Salivary Gland Transfer (SMSGT) in Patients Undergoing Radical Radiation Therapy for Head and Neck Cancer: A Pilot Study

R.L.Bhalavat1, A Budrukkar1, K A Pathak1, M S Deshpande1, B.L.Malpani2, S.R.Desai1,

1Tata Memorial Hospital and 2 Radiation Medicine Center, Mumbai India

Introduction: Permanent xerostomia is a reflection of damage to salivary glands and is invariably observed in patients with head and neck cancers treated with radical radiation therapy (rRT). Submandibular salivary gland transfer (SMSGT) is a novel technique of transferring one of the submandibular salivary glands into the submental space so as to improve the salivary function. Here we report our experience with upfront SMSGT for patients with early oropharyngeal or laryngeal cancers treated with rRT+/-brachytherapy.

Aim: To assess the feasibility of SMSGT prior to rRT in patients with early oropharyngeal and laryngeal cancers and evaluate its impact on salivary output, radiation compliance and QOL post radiation.

Patients and methods: From April 2000, 32 patients of SCC of oro-hypopharynx T3/2, N0-1 receiving curative radical radiotherapy were considered suitable for SMSGT. Baseline salivary function was assessed through salivary scintigraphy (SCT), sialography (SG) and sialometry for each patient and was repeated after the surgery and at subsequent follow ups. Contralateral submandibular salivary gland was transferred to the submental space and radio-opaque markers were placed to identify the transferred gland. Patients were planned for rEBRT with simulated bilateral portals and the transferred salivary gland was blocked during the treatment. Subjective evaluation of quality, quantity with resultant xerostomia, odyno/dysphagia, speech and taste disturbances were recorded for each patient at 20Gy, 40Gy, 60Gy, and at subsequent follow-ups (3,6,12,18---months).

Results: Quantity and quality of saliva was found to be practically normal in 53% at 20Gy, viscous (sticky) in 78% at 60 Gy and improved to near normal by 1 year. Xerostomia was none to acceptable in 49% at 20Gy while grade II / III xerostomia was observed in 50 % of the patients at completion of R T, 23% at 6 months and 11% at 1 year. There was improvement in both the mean salivary output as measured by suction method in the transferred gland which is a reflection of total salivary output as measured by spit method.

Conclusion: SMSGT is a surgically feasible procedure (oral oncology 04). SMSGP of contralateral side as an adjunct to rRT leads to improved compliance during radiation and possibly helps in reducing xerostomia Early results show both subjective & objective improvement of xerostomia. Long term improvement of xerostomia and it’s translation into improved QOL is a subject of long follow up.

Carcinoma of Cervix: External Beam Radiotherapy alone External Beam with HDR Brachytherapy: A GMC Experience

Dr. Vijay K Mahobia, Dr. O P Singh, Dr. HU Ghori, Dr. Ashok Diwan

Dept. of radiation oncology, Gandhi Medical College and Hamidia Hospital, Bhopal, M. P

Carcinoma of cervix is most common malignancy seen among the Indian women. Due to lack of awareness low socioeconomic status and shyness, these patients present with advanced stage. In our department too, carcinoma of cervix is a common malignancy. Before HDR installation they were treated with external beam radiotherapy because they do not want to go for intracavitary elsewhere. After HDR installation, suitable patients of these were treated with combination of external beam radiotherapy and HDR intracavitary application. 30 patients in each arm were compared and it was observed that patient receiving combination radiotherapy responded better in terms of tolerance survival and quality of life.

A Prospective Study of Various Regimens using External Radiation Therapy and HDR Brachytherapy in Locally Advanced Carcinoma Cervix

M.Nagarajan, N.R.Tulasi, V.Nagarajan.

V.N.Cancer Center, GKNM Hospital, Coimbatore, India

Methods: From June 2000 to August 2002, 55 patientswere enrolled in a study to evaluate the variousregimens of external radiation therapy and HDR Brachytherapy with (or) without platinum based chemotherapy. External radiation
therapy of 50- 60 Gywas given followed by brachytherapy by Nucletron Microselectron HDR machine, 5 - 8 Gy/ fraction x 2 fractions to point A depending on the bladder and rectal dose was delivered.

Results: The Bladder dose by Brachytherapy was < 40% in 3 patients, 41-60% in 15 patients, 61 - 80 % in 20 patients, 81 - 100% in 10 patients, > 100% in 6 patients. The Rectal dose by Brachytherapy were < 40% in 1 patient; 41 - 60% in 10 patients; 61-80% in 31 patients; 81-100% in 11 patients and > 100% in 1 patient. Total doses were 1-62 Gy eq ; 3 -70 Gy eq; 2 -72 Gy eq; 2 -74 Gy eq; 37-76 Gy eq; 4 -78 Gy eq; 4 -80 Gy eq and 1 -85 Gy eq.

Response and Survival: 4(7.5%) Patients had residual disease. 6 (11%) patients had local recurrence. 3 (6%) patients had nodal failure. 3 (6%) patients had distant failure. The follow-up ranged from 24 months to 51 months, The average disease free survival was 22 months and average overall survival was 31 months.

Conclusion: External radiation dose of 60 Gy in 30 fractions by 4 field box technique, 200 c Gy /fraction, 5 days a week followed by 2 fractions of HDR Brachytherapy of 5 - 7 Gy/fraction with (or) without chemotherapy gives a good local control of 82%at 2 years for locally advanced Carcinoma Cervix. The bladder and rectal toxicities were acceptable.

A Prospective Comparative Study of Concurrent Chemoradiation Vs Radiotherapy Alone in Locally Advanced Carcinoma of Cervix

Asha Arjunan, PG Jayaprakash, M. Krishnan Nair.

Regional cancer centre, Trivandrum.

Aims: To compare overall survival, disease free survival and local control rate in patients receiving concurrent Chemoradiation Vs Radiotherapy alone in locally advanced Carcinoma of Cervix.
To define pattern of failure
To assess treatment related toxicity.

Materials and methods: Women with locally advanced carcinoma of cervix seen at Regional cancer centre Trivandrum between May 200 and May 2001 were included in the study. Locally advanced disease was defined as International Federation of Gynaecology and Obstretics (FIGO) stages IIB – IVA and those with stage IB/ IIA lesions >/= 4 cm in diameter
Patients meeting above criteria were divided into two arms:
Arm I: Radical radiotherapy with concurrent chemotherapy using Inj. Cisplatin 40 mg/m2 weekly x 5 cycles.
Arm II: Radical radiotherapy alone.

Results: A total of 141 patients satisfied the eligibility criteria and were enrolled in the study. 72 patients were assigned to receive concurrent Chemoradiation and 71 patients were assigned radiotherapy alone. 6 patients were excluded from study due to various reasons, thus leaving a total of 137 patients for analysis. Maximum follow time was 27 months and median follow up was 18 months. 61 patients in Chemoradiation arm (89.7%) and 53 patients (76.8%) were alive at the time of analysis. (7 patients in Chemoradiation arm and 16 patients in RT alone arm died). Kaplan –Meier analysis was used to calculate survival rates. 2 years overall survival was 73.5 % in Chemoradiation arm compared to 61.2 % in radiation alone arm (p=0.52). Disease free survival at 2 years was 75.1 % in Chemoradiation arm and 65.8 % radiation alone arm (p=0.19). Local failure occurred in 5 patients (7.4 %) in Chemoradiation arm and 10 patients (27.5 %) in radiation alone arm. Kaplan –Meier analysis revealed that 2- year local control was 91.8 % for Chemoradiation arm compared to 82.8 % for radiation alone arm (p=0.14). Acute toxicity was more frequent with combined arm than with radiotherapy alone.

Conclusion: This prospective study revealed a tendency towards improved survival in patients with locally advanced carcinoma of cervix receiving concurrent Cisplatin based chemotherapy along with pelvic radiation. However long term follow up is necessary to evaluate whether this improvement in survival is of statistical significance.

Interstitial Brachytherapy using MUPIT in Carcinoma Uterine Cervix

Dr.J.P.Neema

Gujarat Cancer & Research Institute, Ahmedabad

Carcinoma uterine cervix is the most common malignancy among female in our setup. Most of them report to hospital in advanced stage of their disease. Hence external radiotherapy followed by brachytherapy remains the best treatment for them. Many times due to poor geometry of pelvis, dose delivered by intrcavitary method is not adequate. Hence for better dose homogeinty, interstitial brachytherapy using HDR Microselectron and MUPIT [Martinez Universal Perineal Interstitial Template is performed. So far we have treated 160 patients in last 5 years. Maximum followup is 45 months and 5 years control rate is about 35%. Complications were observed in 8 to 10 % of cases.
It appears that MUPIT is very useful method of internal radiation among patients with poor pelvis geometry.

Cancer Screening

N. THOPPA GOUNDAN, M.D.,DMRT.

Govt.Arignar Anna Memorial Cancer Hospital Karapettai, Kancheepuram.
Tamil Nadu State.

Govt. Arignar Anna Memorial Cancer Hospital, Kancheepuram was conducting cancer screening for cancer cervix and oral cancers from 1969. The cervical cancer screening was started at Kancheepuram and extended to Districts. In 2003 screening was conducted in Govt.Arignar Anna Memorial Cancer Hospital, Kanchepuram, one at Head Quarters Hospital, one at Govt.Hospital (Taluk) and four taluk Head Quarters Hospital. Total No.of camps conducted 158. No.of pap smears done was 9861. 225 at risk cases and 99 cancer cervix cases were detected in the year 2003. The stage wise cancer cervix patients treated in Govt.A.A.M.Cancer Hospital, Karapettai, Kanchepuram was as follows:

Cancer cervix cases treated in 2003

In the year 2004 National Cancer Control Programme (NCCP) was taken to 4 Districts and screening was conducted in:
Govt.Arignar Anna Memorial Cancer Hospital, Kancheepuram
Two District Head Quarters Hospital
3. One Govt.Hospital
4. 9 Taluk Head Quarters Hospital
5. 10 Primary Health Centres.
Total no. of cancer screening done was 457, total no. of pap smear done was 21,812.The total no. of at risk cases detected was 267 and the total no. of cancer cervix cases detected was 243 (including 23 cases which were at risk cases turned ut to be malignant)

Cancer Cervix cases treated in 2004

Due to effective screening the no.of late stages of cancer cervix was reduced and early stages like stage I & II were detected and treated. The District Cancer Control Program conducted effectively in all the Districts will be able to detect the at risk cases and by treating them and preventing them to proceed to cancer cases.

Concurrent Cisplatin with Radiotherapy in Carcinoma Cervix- A Report on Toxicity Profile and Outcome

Anu Tiwari, Punita Lal, Partha P Mohanty, Neeraj Rastogi, Saibish Kumar E P*, Shaleen Kumar.

Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Science, Lucknow.

Purpose: Impact of concurrent cisplatin(CDDP) with external radiotherapy (RT) on compliance, degree of acute and late toxicities and outcome.

Methods: Advanced /postoperative cervical cancer treated with concurrent CTRT (Single (108)/combination(8)) in 2 schedules i.e. 35mg/m2 at weekly or 100mg/m2 at 3 weekly interval in 2-5 cycles during external RT. Whole pelvis RT was given by a 4 field technique (50.0-50.4Gy/25-28 fr) followed by 3 intracavitary insertions using standard applicators or 2 sorbo applications (post operative). 6Gy to point A (0.5 cm from applicator surface for sorbo) was delivered in a once weekly fraction by a Microselectron HDR unit.

Results: 116 patients received concurrent CDDP and RT between February’98 to October’04. Median age was 50years. Definitive CTRT was administered in 108 cases; postoperative CTRT -8 cases. Planned 5 weekly cycles could be administered in 72 patients. Reasons for non compliance were obstructive uropathy (7); hematological toxicity (15); GI(13); extraneous reasons(5). Acute toxicity was 4% grade III upper GI; 9% grade III/IV lower GI ; 2% grade III/IV GU; 4.5% grade III hematologic. Late grade III/IV bladder and rectal toxicity were seen in 3.5% and 7% respectively; vaginal stenosis - 5%. No acute toxicity related death was seen; 2 patients died of grade IV late rectal toxicity. Complete response and good partial response (80% resolution) were seen in 63% and 28% respectively. At 3yrs, DFS and OS were 45% each.

Conclusions: Although acute and late morbidity were enhanced, but manageable. The outcomes are encouraging and is being compared in a randomized trial.

Identification of Molecular Markers in Carcinoma of the Uterine Cervix for the Predictions of Patients’ Response to Radiotherapy

Muhammad Jamal*, U. Samant*, H.D. Dani*, S.K. Shrivastava#, K.A. Dinshaw#,
D. Bandopadhyaya*

Division of Laboratory Medicine*, Department of Radiation Oncology#
Tata Memorial Hospital, Parel, Mumbai.

Radiotherapy is considered to be the most important non-surgical treatment option for the carcinoma uterine cervix. Several clinical markers such as stage, volume, histological type and grade, presence of lymphovascular invasion and lymph node status are known to correlate with radiation response. However, the benefit from radiotherapy in carcinoma cervix remains limited due to the association with radiation resistance.

Studies in last decade have indicated that knowledge of radioresponsiveness of individual tumors might influence the radiotherapeutic outcome. A number of assays have been developed for the assessment of radiosensitivity of tumors. Clonogenic assay quantitates the surviving fraction of the tumor cells after 2 Gy(SF2) and has been shown to be helpful in predicting the radiotherapeutic outcome mainly in arcinoma of cervix. However, conventional form of clonogenic assay is not suitable for routine clinical use due to longer assay time and high failure rates.

Identification of new radiobiological factors and predictive markers are therefore necessary for developing a simple, reliable and rapid assay that can predict the radiosensitivity of the tumor before the commencement of the radiation treatment. This knowledge willl help to individualize radiotherapeutic regimen and reduce normal tissue morbidity in patients with carcinoma cervix.

We are presenting here the differential expression pattern of different regulatory molecules of cell cycle, hypoxia and angiogenesis and their correlation with intrinsic radiation sensitivity and telomerase activity. The relationship of telomerase activity ith SF2 might be a useful predictor of radiation resistance in carcinoma cervix. A more detailed study on these molecules might also help in predicting radiation resistance in carcinoma cervix.

Combined Modality In Locally Advanced Early Invasive Cervical Cancer - Ten Years Of Kmio Experience.

*K. Uma Devi, * U.D.Bafna, + KumaraSwamy, # C. Ramesh, ^Geetha Mukherjee

*Dept of Gynaecogical Oncology, + Dept of Radiation Oncology, # Epidemiology & Hospital Cancer Registry, Dept of Pathology, Kidwai Memorial Institute of Oncology, Bangalore -560029, India.

Objectives: To study the clinico-pathological response, to assess the extent of Radical hysterectomy followed by preoperative irradiation and to review the treatment benefits with stage IB, IIA, &IIB Cervical Cancer.

Patients & Methods: Between July 1990 and December 2000, one hundred and fifty four patients with histologically confirmed stage IB-IIB Cervical carcinoma, who underwent Radical hysterectomy followed by preoperative radiotherapy were reviewed retrospectively. All these patients were clinically staged according to the guidelines of FIGO.Those patients with Endophytic / Barrel shaped lesions Ib1/ Ib2, IIa & IIb were subjected to preoperative external pelvic irradiation and clinically assessed at three to six weeks interval prior to Radical surgery. The data was analysed by using SPSS database.

Results: The mean age was 45.8years(ranged between 21-78). Majority of thses patients presented with bulky exophytic lesions (63.6%) of squamous cell carcinoma (89.8%) with large cell non-keratinising (63.2%) and grade III tumour (63.6%). Of the 154 patients, 61% had complete clinical response and overall clinical response was 82.4%. However, postoperatively no residual disease was found in 9.9%, 23.1% had full thickness stromal involvement, less than 2% had vascular emboli & 49 % had pelvic node involvement. The survival benefit was comparatively better in the high-risk patients subjected to Chemoradiation followedc by surgery. The followup ranged between 10 to 76 months.

Conclusion: The present study indicates that the preoperative pelvic radiotherapy helped in downstaging the disease and those patients who received highdose (45-50 Gy) radiotherapy preoperatively showed a complete histological response. However, more randamised study is required in the developing world to prove the benefits of chemoradiation VS preopertive irradiation followed by radical surgery in locally advanced early invasive Cervical Cancer.

CT Scan Imaging: Role in Advanced Ca Cervix

S Bhatnagar

Army Hospital (Research and Referral), New Delhi 110010

Purpose: Cancer of Uterine cervix is the commonest malignancy in females in India (AAR =17 to 30 per 1,00,000). Most of he patients in our country are diagnosed in advanced stage and treated by radiotherapy. FIGO staging of cancer cervix includes basic radiological investigations like CxR , IVP and Ba enema. However with the advent of CT Scan and its widespread availability, this modality is increasingly being used in the staging workup. In view of its high cist this modality needs to be judiciously used based on its specificity and sensitivity.This study analyses the CT Scan abdomen findings in 50 patients of stage II/III ca cervix with emphasis on nodal mets which is a poor prognostic factor, though not included in FIGO staging.

Material and methods: 50 patients of locally advanced Ca Cervix treated with radical radiotherapy at our centre were retrospectively analysed. All patients underwent clinical workup and biopsy to confirm the diagnosis. The treatment included EBRT to pelvis with weekly concurrent chemotherapy ( Cisplatin based) followed by ICRT (HDR : 9 Gy X 2#, 1 week apart). After treatment response rate was CR in 37 patients, PR in 8 , while one patient died during treatment. Relapse was seen in 6 patients and was correlated with CT Scan. The pretreatment CT Scan findings were listed with respect to size of tumor, involvement of parametrium/ nodes/ bladder and rectum, hydronephrosis and hydroureter. CT scan was not used to upstage the disease as per FIGO recommendation. The bladder or rectal involvement was based on cystoscopy and procto-sigmoidoscopy, respectively. All patients were followed up for a period of 18-36 months.

Results: Host factors, tumor factors and treatment factors were also considered in our followup and outcome. Fifty patients, aged 34-67 years with clinical stage II or III were included. The KPS of our patients was 70-80 and Hb range was 5.6-14.2 gm% at presentation. The clinical tumor size was known in 43 patients and parametrial involvement was noted in all ( 9-unilateral para , 41- bilateral para). Nodal involvement in pelvis and paraaortic region was as per CT scan findings. All patients had Histologically confirmed squamous cell cancer of cervix and grad was known in 38 patients.
CT scan findings-
Systemic/ local relapse in patients with pelvic nodes positive : 2/0 patients
Systemic/ Local Relapse in Patients without pelvic nodes involved: 1/2 patients
Systemic/ Local relapse in patients with paraaortic nodes involved: 1/0 patients
Systemic/ Local relapse in patients without paraaortic nodes: 3/2 patients

Conclusions: CT Scan is a widely available, expensive imaging modality which has a moderate overall accuracy in staging and detection of nodal metastasis in patients of cancer cervix. Pelvic node involvement does appear to predict a slightly higher risk of systemic relapse in the follow-up, while paraaortic node involvement does not show a similar outcome in our patients. The standard staging procedures in use today are adequate at present to manage most of our patients and routine use of CT scan cannot be recommended.

Radiotherapy after inadequate surgery in invasive carcinoma cervix - A retrospective analysis from India.

E.P.Saibishkumar, M.D., F.D.Patel, M.D., S.C.Sharma, M.D.

Department of Radiotherapy, Post-Graduate Institute of Medical Education and Research, Chandigarh, India.

Purpose: To evaluate the results of radiotherapy after inadequate surgery in patients of invasive carcinoma cervix.

Materials and Methods: Between 1996 and 2001, 105 patients of carcinoma cervix (stage 1-IIIB) were treated at our center with radiotherapy after having undergone total or subtotal hysterectomy outside. All patients were treated with external radiation with or without intracavitary radiation (ICRT).

Results: Median follow up was 34 months. Gap between surgery and radiation ranged from 23 days to 198 days with a median of 80 days. Clinically visible residual disease was present in 71.1% of cases. Stage wise distribution of patients were as follows: stage I 14.3%;Stage IIA 31.4%;stage IIB 24.8% and stage IIIB 29.5%.5year OS, DFS and pelvic control of all patients were 55.2 %, 53.3 % and 72.4 % respectively. In univariate analysis; older age, Hb>10gm%, non squamous histology, early stage, use of ICRT, shorter gap between surgery & radiation and absence or small volume of residual disease were found to affect the outcomes favorably. In multivariate analysis by Cox’s proportional hazard model, use of ICRT and stage were the only factors emerged significant to influence OS.For pelvic control and DFS, use of ICRT was the only significant factor. 5year actuarial rates of late toxicities (RTOG) were 19% in rectum, 4.8% in bladder, 24.8% in skin and 14.3% in small intestine.

Conclusions: Inadequate and inappropriate surgery in invasive cancer cervix with gross residual disease is common in Indian scenario. Factors like use of ICRT, correction of anemia and shorter gap between surgery and radiation enable salvage radiotherapy to achieve acceptable results with minimum morbidity.

Dosimetric Comparison of Conventional 3D-CRT and IMRT In Carcinoma Cervix

U Mahantshetty**, S Saju*, RA Kinhikar*, SV Jamema*, DD Deshpande*,
SK Shrivastava**, KA Dinshaw**

Department of *Medical Physics, **Radiation Oncology,Tata Memorial Hospital, Parel, Mumbai 400012.

Introduction: With an aim to evaluate the feasibility of IMRT in cervical cancers, a comparative dosimetric study of 3D-CRT and IMRT to pelvic fields was carried out and is the basis of this report.

Methods and Materials: Eleven patients of Carcinoma cervix treated with pelvic IMRT as a part of pilot study were evaluated for comparison. All these patients underwent immobilization, evaluation for set-up uncertainties and planning CT scan with oral, rectal and intravenous contrast. The Planning target volume (PTV) included gross disease, cervix, bilateral parametrium, pelvic nodes with margins. Critical organs (OAR) included Small Bowel Region (SBR), rectum and bladder. A Standard conformal four field box plan with MLC was compared to the accepted IMRT (5fields) plan for all these patients. Plan evaluation and comparison of 3D-CRT and IMRT was done using DVH, mean, maximum and minimum doses to various volumes in accordance with ICRU 50 recommendations. The doses of OAR were compared using V95% and V70% isodose lines.

Results: The IMRT plans provided an excellent PTV coverage. On average, 95% of the PTV received 96% of the prescribed dose. The hot-spot volume (V107%) was limited to <8% and were located in the GTV. The hot spot volume with IMRT was 25% less than the 3D-CRT plan. V70% is reduced by 23% for bladder, 22% for rectum and 18% for small bowel region as compared to 3DCRT plans. Also, IMRT pelvis significantly reduced the high dose volumes to the adjacent critical organs namely, small bowel region (SBR), rectum and bladder. Various doses received by rectum in 3DCRT (80-140cc) are 42, 57, 51 Gy (Min, max, mean) as compared to 25, 57, 42 Gy in IMRT plan. Similarly, Various doses received by SBR in 3DCRT (800-1100cc) are 25, 54, 48 (min, max, mean) as compared to 23, 50, 40 Gy in IMRT plan. In the case of bladder, the volume covered by 95% and 70% isodose lines are less by 72% and 23% respectively in IMRT plan.

Clinical Outcome: All patients tolerated the treatment well and completed the treatment within 6-8 weeks. None of the patients had Acute Grade III toxicity with 6 and 3 patients experiencing Grade II GI and GU acute toxicities respectively. Later 8 patients also received weekly scheduled cisplatin chemotherapy and none had any grade III hematological toxicity. With a median follow-up of 12 months (6 – 24 months) till date, all 11 patients are loco-regionally controlled. None of the patients has Grade III late sequelae documented so far, however, one patient has developed radiation proctitis Grade II at 16 months follow-up.

Conclusions: IMRT pelvis in patients with advanced carcinoma cervix results in good PTV Coverage and spares surrounding critical structures. IMRT Pelvis in patients with advanced carcinoma cervix is feasible and initial experience is enterprsing. So to further validate IMRT in advanced carcinoma cervix, we are currently conducting a Phase II Randomized Trial comparing IMRT to 3D-conformal radiation therapy.

Evaluation of CT - Based Treatment Planning with Conventional Radiography Based Treatment Planning for High Dose Rate (HDR) Intracavitary Brachytherapy for Carcinoma Cervix

S Saju*, SV Jamema*, S Deshpande*, U Mahantshetty**,DD Deshpande*,
SK Shrivastava**, KA Dinshaw**

Department of *Medical Physics, **Radiation Oncology,Tata Memorial Hospital, Parel, Mumbai 400012.

Introduction: The main stay of treatment for carcinoma cervix is radiation therapy. Brachytherapy can be delivered by either low dose rate (LDR) or high dose rate (HDR). All the ICA's are reported according to ICRU 38 recommendations. However, the bladder and rectal reference points defined may not always be a true representation of rectum and the bladder wall doses. Conventional dosimetric calculation uses orthogonal radiographs for the computation of dose to bladder and rectal points. Three - Dimensional CT planning with accurate delineation of OAR’s would suggest the actual radiation doses to bladder and rectum. In an attempt to compute and correlate 3-Dimensional CT planning with conventional radiography based treatment planning, we undertook this study and is the basis of this report.

Materials and Methods: A cohort of 15 patients with carcinoma cervix treated with radical radiation and HDR Brachytherapy were studied. After the HDR application using Modified Fletcher Suit Applicator, patients underwent simulation for orthogonal radiographs and planning CT Scans. Manchester system of dosimetry was used for the computation of dose to point A and B. The rectal and bladder points defined according to ICRU 38 recommendations. The CT Scan protocol included a 5mm axial CT images from 4cm superior to the tandem tip extending till anus inferiorly. Bladder and rectal volumes were delineated on all axial sections. PLATO 3D Planning system was used for the dose computation. The dose delivered to 5% volume of the OAR (D5%) was computed and compared with ICRU reference points. The dose prescribed for each fraction was 7Gy to point A (Optimized) and treatment delivered using Ir-192 high dose rate remote after loading machine (Micro Selectron - Nucletron).

Observation and Results: The mean volume of rectum and bladder on CT scans was 34cc and 61cc respectively. The mean of the maximum dose to rectal reference points from 2D planning was 68% the prescribed dose of 7Gy to point A (478cGy). 17.2% of the volume of rectum received a dose higher than 68% in 3D Planning. Similarly the mean of the maximum dose to bladder reference points from the 2D planning was 75% of the prescription dose (527cGy). When compared with 3D CT planning, 23% of the volume of bladder receives a dose higher than the maximum bladder dose. There was no difference in the volume encompassed by the prescription isodose line between 2D and 3D CT planning. Also, the average maximum dose from CT planning is 1.4 times higher for rectum and 1.63 times higher for bladder as compared to the ICRU reference points.

Conclusion: This study suggests that there is no difference in the target volume coverage between 2D and 3D planning. However, ICRU 38 reference points do underestimate the doses to the bladder and rectum. Although ICRU 38 recommendations for conventional radiography treatment planning are time tested and still continues to be used routinely, the advances in imaging and planning system does mandate for further refinement and alterations for prescribing, reporting and documentation of ICA application today.

Epididymal Metastasis - Rare Entity

K.S.Kirushna Kumar*, G. Amarnath*, T.R.Murali #, U Ravikumar $
*Radiation Oncologist. # Urologist, $ Pathologist.

Meenakshi Mission Hospital & Research Centre, Madurai.

Mr.K. aged 46 years diagnosed as a case of Carcinoma bladder in January 2002, Cystoscopy and TURBT done revealed growth in the right posterior wall and Right ureteric orifice. Biopsy reported as TCC Grade III. CT scan showed Bladder mass with seminal vesicle involvement. T4 disease. Patient received External Radiation therapy with Telecobalt 60Gy/ 30 fractions / 6 weeks from 30.04.02 to 15.06.02. Later presented here again on 05.08.03 with a nodular hard right Inguino scrotal swelling. On evaluation, US abdomen & TRUS was normal. Chest x.ray was normal. FNAC was positive for malignancy, Cystoscopy was normal. Biopsy from the mass - TCC Grade II. On 13.08.03, Right high orchidectomy and Hemiscrotectomy was done, proved to be transitional cell carcinoma. Testis was normal. IHC done showed CK positive, EMA – Locally positive - CEA negative.

Conclusion: Epididymis is a rare site of metastasis from bladder. Only 1 case is reported so far from bladder, that is also an autopsy finding.

A Modified Technique for Intracavitary Application In Advanced Cancer Cervix