A study of the clinical profile, predictors, prognostic features, and survival of patients with hepatocellular carcinoma having macroscopic portal vein tumor thrombosis.

BACKGROUND: Macroscopic portal vein tumor thrombosis (PVTT) is considered a negative prognostic factor in hepatocellular carcinoma (HCC) patients. There is divergent opinion regarding management of these patients worldwide. We aimed to evaluate the clinical profile, predictors, prognostic features, and survival of patients of HCC with PVTT. METHODS: Treatment-naïve HCC patients with and without PVTT were analyzed retrospectively using a prospectively accrued dataset. Patients with PVTT were further divided as per treatment groups for survival analysis. RESULTS: Of 508 patients, 46.1% had radiological evidence of PVTT at presentation. On logistic regression, serum albumin (odds ratio [OR]=0.65, 95% confidence interval [CI]= 0.44-0.96; p= 0.031); international normalized ratio (OR = 3.78,95% CI = 1.42-10.00; p=0.008); alpha-feto protein >400 ng/mL (OR=3.58, 95%CI = 2.00-6.40; p <0.001); size of largest tumor nodule >5 cm (OR =6.37, 95%CI =2.03-19.99; p =0.002); and male gender (OR =1.84, 95%CI = 1.01-3.33; p = 0.045) were independent predictors for PVTT. Patients with PVTT amenable to aggressive therapies had significantly better median overall survival (in months) as compared to those receiving sorafenib or best supportive care only (13.1, 3.9, and 1.8 respectively, p<0.0001). Treatment modality received (p<0.001) and extrahepatic metastasis (p=0.006) were independent predictors of mortality in these patients. CONCLUSION: Size of largest tumor nodule >5 cm and alpha-fetoprotein >400 ng/mL are strongly associated with the presence of PVTT in patients with HCC. A multidisciplinary approach may identify a subgroup of patients who can be offered aggressive therapies like surgery and/or locoregional therapy with significant survival benefit.

Indian Brachytherapy Society Guidelines for radiotherapeutic management of cervical cancer with special emphasis on high-dose-rate brachytherapy.

Brachytherapy (BT) for locally advanced cervical cancer is vital for optimal outcomes. There is heterogeneity in brachytherapy treatment practice for cervical cancer across India. In an attempt to standardize various processes involved in cervical cancer brachytherapy, the expert members of the Indian Brachytherapy Society (IBS) developed a document related to radiation therapy treatment of cervical cancer with special emphasis on brachytherapy. The guidelines are based on high quality clinical evidence, expert opinion and consensus wherever evidence was lacking. The document provides a guide for external beam radiation and details of all the processes involved in high-dose-rate (HDR) brachytherapy including patient selection, preparation, principles and technique of BT applications, target and normal tissue definition, dose prescriptions, BT planning, reporting parameters, common complications of BT and their management, scope for research, etc. In summary, we present here practical tips and tricks, recording and reporting of cervical cancer brachytherapy, which can be implemented in various clinical environments and forms the basis of this report.

Dose escalated concurrent chemo-radiation in borderline resectable and locally advanced pancreatic cancers with tomotherapy based intensity modulated radiotherapy: a phase II study.

BACKGROUND: We report the response and outcomes of borderline resectable and locally advanced pancreatic cancer (BRPC & LAPC) patients treated with dose escalated neoadjuvant intensity modulated radiotherapy (IMRT). METHODS: Thirty newly diagnosed patients with BRPC (n=18) and LAPC (n=12) (NCCN criteria V 2.2.12) were accrued in this prospective study from 2008-2011. All patients received neoadjuvant chemoradiation (NACRT) using Helical Tomotherapy (dose of 57 Gy over 25 fractions to the gross tumor volume (GTV) and 45 Gy over 25 fractions to suspected microscopic extension) along with weekly gemcitabine. RESULTS: Fifteen patients (50%) had a partial response. A complete metabolic response (CMR) on PET was seen in 9 patients (30%). Among BRPC, 9 patients (50%) were surgically explored and 7 underwent R0 resection (39%). The median follow up of surviving patients was 85 [interquartile range (IQR): 64.5-85.8] months. The median progression free survival (PFS) was 13 months for BRPC and 8.8 months for LAPC. The median overall survival (OS) was 17.3 months for BRPC and 11.8 months for LAPC. Among patients undergoing R0 resection, the median PFS and OS was 27 and 35.5 months respectively. CONCLUSIONS: Dose escalated radiotherapy with concurrent chemotherapy is feasible and can downsize some tumors resulting in surgery in about 39% of the BRPC.

Patterns of cervical cancer brachytherapy in India: results of an online survey supported by the Indian Brachytherapy Society.

PURPOSE: Cervical cancer is the most common gynecological cancer in India. Uniform protocol-based treatment is important for achieving optimal outcomes. We undertook a survey to investigate patterns of care with special regard to patterns of care in cervical cancer brachytherapy in India. MATERIAL AND METHODS: A 17-question online survey was sent to radiation oncologists across India. Respondents were required to have a minimum of 1-year experience. One response per center was accepted and deemed as representative. RESULTS: Out of 116 centers, 59 responses were generated. Two-thirds (66.1%) were from academic centers and the majority (96.6%) used high-dose-rate (HDR) brachytherapy. The centers treated an average of 255 patients per year (median 161 patients, IQR 76-355). The majority were locally advanced cancers (FIGO 2009 stage II-IV 87.5%). External beam radiotherapy (EBRT) schedules were fairly consistent, administering doses of 45-50 Gy over 5 weeks. Brachytherapy was performed towards EBRT completion by 37/59 (62%) and 43/59 (74.3%) centers used a schedule of 7 Gy × 4 fractions (HDR). Brachytherapy was commonly performed under anesthesia (spinal/general: 44% each) with ultrasound (USG) guidance (29%). Computed tomography (CT) imaging (65%) and orthogonal X-rays (35%) represented the most common imaging for planning, while point A prescription (66%) or GEC-ESTRO based parameters (35%) with manual/geometric methods represented the most common methodology for dose volume prescription and optimization. Overall treatment time (OTT) reported was within 49-56 days in 50%. Complex implants (IC + IS) were performed for more than 30% of cases by 3 centers. CONCLUSIONS: Our survey suggested a fairly uniform treatment paradigm for cervical cancer brachytherapy, with a progressive shift from 2D to 3D image-based parameters for planning, with persistence of point A based prescription. Further efforts are needed to augment and ease this transition.

Cancer cervix: Establishing an evidence-based strategy, an experience of a tertiary care centre in India.

Carcinoma cervix is a common cancer among Indian women. Evidence based management is essential for best practice in treatment of carcinoma cervix for its effective control. The current imaging system like CT, MRI and PET CT scans have contributed in identifying the patients for optimal treatment and delivering treatment accurately. For stages IB2 to IV, concurrent chemoradiation is advocated with improvement in overall survival proven with randomized trials. Brachytherapy is an integral part in the radiation treatment. Imaged-guided brachytherapy using MRI is desirable, however less expensive imaging modalities such as CT and ultrasonography has been evaluated. In special situation such as for HIV positive patients and patients with neuroendocrine tumors have role of radiotherapy. For further improvement in control of cancer, it is required to integrate basic research to answer clinically relevant questions.

Clinical outcome of high-dose-rate interstitial brachytherapy in vulvar cancer: A single institutional experience.

PURPOSE: With an aim to evaluate and report high dose date interstitial brachytherapy (HDR-ISBT) in vulvar cancers, we undertook this retrospective analysis. METHODS AND MATERIALS: Histologically proven vulvar cancers treated with HDR-ISBT between 2001 and 2016 were analyzed. Radiotherapy details, clinical outcome in terms of local control rates, survivals, and toxicities were evaluated. RESULTS: A total of 38 patients received HDR-ISBT, with definitive radiation in 29 (76.3%), adjuvant postoperative in six (15.8%) and salvage radiation in three (7.9%) patients. Of them, 29 patients received brachytherapy boost and nine patients ISBT alone. BT procedure included freehand plastic tube technique in 23 (single [n = 5] or multiple plane [n = 18]), 13 patients with template based and two patients combined approach. Patients with brachytherapy alone received median EQD2 of 38.4 Gy10 (35.5-46.7 Gy10), as boost received median 23.3 Gy10 (13-37.3 Gy10). At 3-month post-treatment response evaluation, 30 patients achieved clinically complete response, two patients partial response and six maintained postoperative status. With a median follow-up of 30 months, 29 (76.3%) were disease free, and 9 (23.7%) patients had relapsed disease with four patients expired due to disease and two died of other causes. The 5-year overall survival, disease free survival, and local control rates were 82%, 51%, and 77%, respectively. CONCLUSIONS: HDR-ISBT in vulvar cancer is a feasible and a viable option with acceptable and comparable outcomes.