Impact of acuros XB algorithm in deep-inspiration breath-hold (DIBH) respiratory techniques used for the treatment of left breast cancer.

AIM: To investigate the impact of Acuros XB (AXB) algorithm in the deep-inspiration breath-hold (DIBH) technique used for treatment of left sided breast cancer. BACKGROUND: AXB may estimate better lung toxicities and treatment outcome in DIBH. MATERIALS AND METHODS: Treatment plans were computed using the field-in-field technique for a 6 MV beam in two respiratory phases - free breathing (FB) and DIBH. The AXB-calculations were performed under identical beam setup and the same numbers of monitor units as used for AAA-calculation. RESULTS: Mean Hounsfield units (HU), mass density (g/cc) and relative electron density were -782.1 ±â€¯24.8 and -883.5 ±â€¯24.9; 0.196 ±â€¯0.025 and 0.083 ±â€¯0.032; 0.218 ±â€¯0.025 and 0.117 ±â€¯0.025 for the lung in the FB and DIBH respiratory phase, respectively. For a similar target coverage (p > 0.05) in the DIBH respiratory phase between the AXB and AAA algorithm, there was a slight increase in organ at risk (OAR) dose for AXB in comparison to AAA, except for mean dose to the ipsilateral lung. AAA predicts higher mean dose to the ipsilateral lung and lesser V20Gy for the ipsilateral and common lung in comparison to AXB. The differences in mean dose to the ipsilateral lung were 0.87 ±â€¯2.66 % (p > 0.05) in FB, and 1.01 ± 1.07% (p < 0.05) in DIBH, in V20Gy the differences were 1.76 ±â€¯0.83% and 1.71 ±â€¯0.82% in FB (p < 0.05), 3.34 ± 1.15 % and 3.24 ± 1.17 % in DIBH (p < 0.05), for the ipsilateral and common lung, respectively. CONCLUSION: For a similar target volume coverage, there were important differences between the AXB and AAA algorithm for low-density inhomogeneity medium present in the DIBH respiratory phase for left sided breast cancer patients. DIBH treatment in conjunction with AXB may result in better estimation of lung toxicities and treatment outcome.

Nodal volume as a prognostic factor in locally advanced head and neck cancer: Identifying candidates for elective neck dissection after chemoradiation with IGRT from a single institutional prospective series from the Indian subcontinent.

OBJECTIVE: Nodal volume as a prognostic factor has been extensively evaluated in head and neck cancer, however there is still no consensus. We attempted to analyze nodal volume as a prognostic factor in head and neck cancer treated with chemoradiation (CCRT) without an elective neck dissection with image guided intensity modulated radiotherapy (IG-IMRT). MATERIAL AND METHODS: We prospectively analysed 87 patients of Stage III-IV cancer of the oropharynx (57), and hypopharynx (30), who subsequently received definitive concurrent chemoradiation. Total Nodal volume (TNV) was the sum of all lymph node volumes calculated by volume algorithm from the planning CT. The impact of TNV on overall survival (OS) & regional control (RC) was assessed. Survival analysis was done using SPSS version 20.0 (SPSS, Chicago, Illinois). A receiver operating characteristics (ROC) curve analysis was done for estimation of cut offs. RESULTS: The 2 year OS & RC were 64% and 83% respectively. On multivariate analysis, the TNV was a significant prognostic factor for OS &RC. ROC curve analysis found an optimal volumetric cut off of 15cc for OS & RC. The 2 year OS & RC for <15cc/>15cc group were 78% /30% (p = 0.001) & 100%/52% (p = 0.001). Similar results were obtained on subset analysis of our oropharyngeal patients with 2 year OS 75%/24% for the <15cc and >15cc group (p = 0.001). CONCLUSION: TNV is an independent prognostic factor for OS & RC in head and neck cancer. TNV can identify patients for consideration of elective neck dissection post CCRT ie for patients with TNV > 15CC.

Hypercellular round cell liposarcoma: A comprehensive cytomorphologic study and review of 8 cases.

BACKGROUND: Myxoid and round cell liposarcomas (RCL) are low and high-grade counterparts of a common subtype of liposarcomas (LPS), representing a histologic continuum. AIMS: The aim was to study the cytomorphology of hypercellular RCL and to look for features that differentiate RCL from other sarcomas displaying round cells with myxoid change. MATERIALS AND METHODS: Eight cases of hypercellular RCL were identified retrospectively in which round cell component constituted greater than 75% of the area. Cytomorphological features were studied in detail. RESULTS: Four cases were predominantly composed of round cells, out of which 2 were entirely composed of round cells. Myxoid metachromatic stroma was absent in 2 cases, while it was present in ample amounts in the remaining 6 cases. Spindle cells were completely absent in 5 cases and lipoblasts were observed in a single case of RCL. Plexiform vascular capillaries were seen in 4 cases. Adherence of neoplastic round cells around thin capillaries (ANAC) was observed in 7 cases. CONCLUSIONS: Plexiform capillary plexus and ANAC should be separately evaluated. The latter feature is the most consistent one, and is an important clue to the adipocytic nature of the neoplasm when hypercellular round cell areas are aspirated. Confident diagnosis of hypercellular RCL can be made on the basis of this feature. Lipoblasts, although specific, are seen in few cases. The rest of the features are nonspecific and useful only in combination.

Role of benzydamine hydrochloride in the prevention of oral mucositis in head and neck cancer patients treated with radiotherapy (>50 Gy) with or without chemotherapy.

PURPOSE: Benzydamine is recommended for prophylaxis of oral mucositis (OM) in head and neck cancer (HNC) patients for radiation doses (<50 Gy). This study evaluates role of benzydamine for higher radiation doses (>50 Gy) with or without chemotherapy. METHODS: One hundred twenty patients of HNC with planned radiation doses of ≥60 Gy were randomized to group A (control radiotherapy alone), group B (study radiotherapy alone), group C (control chemoradiotherapy), or to group D (study chemoradiotherapy). Groups A and C were advised saline mouth rinses, and in groups B and D, additional benzydamine rinses (0.15%) were advised. Mucositis grading was done with both WHO (WHO-M) and CTCAE (CTC-M) version 4.0 (common terminology criteria for adverse events) weekly. RESULTS: Patient characteristics are presented in the table. Patients in group B had lesser grade 3 WHO-M and CTC-M as compared to group A, 62.1 vs. 36.4% (p = 0.038) and 51.7 vs. 27.3% (p = 0.043), respectively. The rates of Ryle's tube feeding (RTF), intravenous fluid supplementation (IVF), and hospitalization were also lesser in group B as compared to A, 34.5 vs. 21.2% (p = 0.18), 27.6 vs. 9.1% (p = 0.06), and 6.9 vs. 0% (p = 0.21), respectively. WHO-M and CTC-M in groups C and D were not statistically different, 64.3 vs. 43.3% (p = 0.091) and 53.6% vs. 43.3% (p = 0.30), respectively. The rates of RTF, IVF, and hospitalization were all lesser but p > 0.05. CONCLUSION: Benzydamine significantly reduces OM even at doses >50 Gy in HNC patients. Its role in patients receiving concurrent chemotherapy further needs to be evaluated.

Exploring new potentials and generating hypothesis for management of locally advanced head neck cancer: analysis of pooled data from two phase II trials.

BACKGROUND: To study the long term results of two phase II concurrent chemoradiotherapy protocols and conduct pooled data analysis with special emphasis on nodal density. MATERIALS AND METHODS: In the period from April 2001 to May 2003, phase II Mitomycin C (MMC) and late chemo-intensification (LCI) protocols were started in the same institute, enrolling 69 and 74 patients respectively. Long term results for these individual trials are reported along with pooled data analysis. RESULTS: Median follow-up time for whole group, MMC protocol and LCI protocol was 43.8 months (SD619.8), 55 months (SD 618.5) and 47.5 months (SD 620.9) respectively. LRFS, DFS and OS at five years for whole group was 59.4, 43.5 and 47.1% respectively, for MMC protocol was 59.9, 45.5 and 49.5% respectively and for LCI, protocol was 53.6%, 41.5% and 44.4% respectively. Subgroup analysis revealed that MMC protocol was more effective than LCI protocol in terms of DFS and OS in patients with hypo dense nodes while opposite was true for Isodense nodes. Multivariate analysis revealed nodal density as an independent variable that had an impact on treatment outcome. Risk of death in patients with hypo dense nodes was 2.91 times that of Isodense nodes. CONCLUSIONS: Innovative and pragmatic approach is required to address locally advanced head neck cancer. Long term results for MMC and LCI protocols are encouraging. Integrating the basic concepts of these protocols may help develop new protocols, which will facilitate the search for the optimal solution.

Daily online localization using implanted fiducial markers and its impact on planning target volume for carcinoma prostate.

BACKGROUND: Aim of the study was to assess prostate motion on daily basis with respect to setup and to compare the shifts based on bony anatomy and gold fiducial markers. MATERIALS AND METHODS: Gold fiducial markers were inserted in prostate under U/S guidance and daily portal images were taken and compared with digitally reconstructed images, both using bony landmarks and fiducial markers as reference. A dose of 2 MU was given for two orthogonal images daily. The mean and standard deviation of displacement using gold seeds and bone were calculated. Systematic and random errors were generated. The planning target volume (PTV) was calculated using the Van Herk formula. RESULTS: A total of 180 portal images from 10 patients were studied. The mean displacement along x, y and z axes was 1.67 mm, 3.58 mm, and 1.76 mm using fiducial markers and 2.12 mm, 3.47 mm, and 2.09 mm using bony landmarks, respectively. The mean internal organ motion was 1.23 mm (+1.45), 3.11 mm (+2.69 mm); and 1.87 mm (+1.67 mm) along x, y and z axes, respectively. The PTV to account for prostate motion if daily matching was not done was 4.64 mm, 10.41 mm and 4.40 mm along lateral, superoinferior, and anteroposterior directions, respectively. If bony landmarks were used for daily matching, margins of 3.61 mm, 7.31 mm, and 4.72 mm in lateral, superoinferior, and anteroposterior directions should be added to the clinical target volume. CONCLUSION: Daily alignment using gold fiducial markers is an effective method of localizing prostate displacement. It provides the option of reducing margins, thus limiting normal tissue toxicity and allowing the possibility of dose escalation for better long-term control.

Selective nodal irradiation for head and neck cancer using intensity-modulated radiotherapy: application of RTOG consensus guidelines in routine clinical practice.

PURPOSE: We have been using intensity-modulated radiotherapy (IMRT) for selective neck irradiation. This article presents an analysis of patterns of failure and their dosimetric correlation. METHODS AND MATERIALS: Between October 2003 and January 2008, 83 patients with head-and-neck cancer were treated with IMRT. Nodal levels were contoured as per the Radiation Therapy Oncology Group (RTOG) consensus guidelines. RESULTS: There were 32 relapses with 23 local relapses (21 local relapses alone and 2 local and regional relapses, simultaneously), 9 regional relapses (including 2 simultaneous local and regional relapses), and 5 distant relapses, of which 2 patients had local relapses. At 2 and 3 years, the locoregional relapse-free survival rates were was 68.3% and 60.8%, respectively, while the overall survival rates were 84.1% and 81.7%, respectively. Subgroup analyses revealed significant differences in locoregional relapse-free survival rates for total treatment times of <53 days vs. >53 days, a volume of CTV1PTV (i.e., the volume prescribed 70 Gy) <177 cc vs. >177 cc, a V100 for CTV1PTV of <91% vs. >91%, and a minimum dose to CTV1PTV of <54 Gy vs. >54 Gy. There were no failures in the elective nodal volume, substantiating both the nodal selection criteria and the RTOG consensus guidelines for delineation of neck node levels. CONCLUSIONS: IMRT for head-neck cancer is feasible, using elective nodal selection criteria along with RTOG consensus guidelines for the radiological boundaries of levels of neck nodes.

Analysis of prognostic variables among patients with locally advanced head and neck cancer treated with late chemo-intensification protocol: impact of nodal density and total tumor volume.

OBJECTIVE: The aim of the present study was to define the prognostic impact of nodal density (ND) and total tumor volume along with many other tumor, treatment and patient related variables using the late chemo-intensification treatment regimen with conventionally fractionated radiotherapy (70 Gy/7 weeks). METHODS: A total of 74 patients with Stage III and IV biopsy proven squamous cell carcinoma of oropharynx, hypopharynx and larynx were treated with this regimen. ND and total tumor volume was measured on high resolution CT scans for all the patients. Chemotherapy consisted of continuous infusion of 5 FU at 350 mg/m(2)/day and cisplatin as 1 h infusion at 10 mg/m(2)/day on days 1-5 of week 6 and 7 of radiotherapy. RESULTS: Grade III mucositis was present in 48 (64.9%) patients. Overall complete response rate was 77%. At 28 months, locoregional relapse-free survival (LRFS), overall survival (OS) and distant metastases-free survival (DMFS) was 70.8%, 66.9% and 81.9%, respectively. In the final multivariate Cox-regression model tumor stage, ND, primary site and nodal stage were independent variables predicting for LRFS. Similarly AJCC group staging, ND and total treatment volume were found to have significant impact, independently over LRFS. CONCLUSIONS: There is tremendous variation in terms of ND and total tumor volume within AJCC nodal staging and tumor staging, respectively. ND had significant impact over LRFS and OS. Future phase III trial may need stratification on the basis of these variables.

Late chemo-intensification with cisplatin and 5-fluorouracil as an adjunct to radiotherapy: a pragmatic approach for locally advanced head and neck squamous cell carcinoma.

The aim of this study was to define the feasibility of a late chemo-intensification treatment regimen with conventionally fractionated radiotherapy (70 Gy/7 weeks). Seventy four patients with Stage III and IV biopsy proven squamous cell carcinoma of oropharynx, hypopharynx and larynx were treated with this regimen. Chemotherapy consisted of continuous infusion of 5-FU at 350 mg/m(2)/day and cisplatin as 1h infusion at 10 mg/m(2)/day on days 1-5 of week 6 and 7 of radiotherapy. Grade III mucositis was present in 48 (64.9%) patients. After surgical salvage 59 (79.7%) patients had overall complete response. Locoregional control rate at 3 year was 80.8%. Three year locoregional relapse free survival (LRFS), overall survival (OS) and disease free survival (DFS) was 63.1%, 66.7% and 44.4%, respectively. The late chemo-intensification regimen was feasible in terms of response rate, toxicity and survival functions.

Mitomycin and fluorouracil in combination with concomitant radiotherapy: a potentially curable approach for locally advanced head and neck squamous cell carcinoma.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of radiotherapy and concurrent mitomycin-C (MC) plus 5-fluorouracil (5FU) infusion in locally advanced squamous cell carcinoma of the head and neck (SCCHN). METHODS: Sixty-nine patients with SCCHN (6 Stage III and 63 Stage IV patients) were treated with external beam radiotherapy (70 Gy) and simultaneous intravenous chemotherapy with 5FU (600 mg/m(2)/day, Days 1-5) and MC (10 mg/m(2), Days 5 and 36). RESULTS: After a mean follow-up of 28.5 months, 59.4% of patients were alive without disease. Complete response was seen in 76.8% of patients. The 3 years overall survival, locoregional relapse-free survival and disease-free survival was 62.3, 63.1[corrected] and 49.5%, respectively. Treatment was well tolerated (Grade III mucositis in 43.5% and Grade II leukopenia in 5.8%). CONCLUSIONS: This concurrent chemoradiotherapy regimen offers a curative option for our patients where primary and nodal disease is fairly large resulting in hypoxic radioresistant tumors.