Pelvic nodal CTV from L4-L5 or aortic bifurcation? An audit of the patterns of regional failures in cervical cancer patients treated with pelvic radiotherapy.

OBJECTIVE: To assess the patterns of recurrence in cervical cancer patients treated with pelvic nodal clinical target volume at L4-L5 junction instead of aortic bifurcation. METHODS: Records of patients with locally advanced cervical cancer treated with chemo-radiation were reviewed. Patients treated with standard pelvic fields (superior border of the field at L4/L5 junction), without any radiological evidence of regional lymphadenopathy (<10 mm) were included in the study. The level of aortic bifurcation was retrospectively documented on computed tomography. Patterns of recurrences were correlated to the aortic bifurcation and the superior border of the radiation fields (L4/L5). RESULTS: Aortic bifurcation was above the radiation fields (above L4/5) in 82 of 116 (70.7%) patients. Of the nine patients that recurred above the radiation field, 5 (55%) were above L4/5 failures, i.e. between aortic bifurcation and L4/5, and 4 (45%) had para-aortic failures. On retrospective analysis, 16 patients were found to have subcentimeter lymph nodes and higher nodal failures (7/16) were observed in patients with subcentimeter regional lymph nodes at diagnosis. CONCLUSIONS: Superior border of nodal clinical target volume should ideally include the aortic bifurcation instead of L4-L5 inter space in patients with locally advanced cervical cancer. Radiotherapy fields need to be defined cautiously in patients with subcentimeter pelvic lymph nodes.

Surgical Management of Locoregional Recurrence in Breast Cancer.

Locoregional recurrences from breast cancer represent a heterogeneous group of disease that poses a therapeutic challenge and needs a multidisciplinary team management. The incidence of local recurrence after breast conservation surgery ranges from 10 to 22% and 5-15% after mastectomy at 10-year follow-up. Management of locoregional recurrence depends on tumor biology, stage at presentation, and prior local and systemic therapy. With improvements in diagnostic, pathological, and surgical techniques, radiation and systemic therapy approach, outcomes in these patients have improved. In this review, we discuss the risk factors, prognostic factors, surgical and reconstruction options, re-irradiation, and role of systemic therapy to define a reasonable treatment approach without compromising oncologic safety and achieve good cosmetic and survival outcomes.

Stereotactic ablative body radiotherapy (SABR) for inoperable, chemorefractory retroperitoneal lymph node relapse from non seminomatous germ cell tumour of testis: a case report.

We describe a case of non-seminomatous germ cell tumour (NSGCT) of the testis with oligorecurrence in para-aortic nodal mass, which was inoperable and chemorefractory. Conventionally fractionated radiotherapy in this setting is generally believed to achieve poor results, because the dose is limited by the tolerance of surrounding normal tissues. Use of stereotactic ablative body radiotherapy (SABR) for para-aortic nodal recurrence from a few sites has been reported; its application in NSGCT has not been described in literature to our knowledge. SABR allowed us to deliver highly precise, ablative dose of radiation to the recurrent para-aortic nodal mass with long-term disease control (more than 6 years). The ablative dose delivered with SABR proved to be effective in NSGCT, traditionally considered radioresistant. While, in the present case SABR was delivered due to the inoperability of the lesion, further data on its successful use in NSGCT recurrences is warranted.

Significance of perineural invasion in locally advanced bucco alveolar complex carcinomas treated with surgery and postoperative radiation ± concurrent chemotherapy.

BACKGROUND: The purpose of this study was to evaluate prognostic factors, locoregional control, and survival in locally advanced bucco-alveolar complex cancers. METHODS: A retrospective review of 83 patients treated between January 2009 and December 2012 with bucco-alveolar complex cancers was conducted. All patients had surgery and adjuvant radiotherapy with intensity-modulated radiotherapy (IMRT) with/without concurrent chemotherapy. Survival analysis was performed using Kaplan-Meier and multivariable Cox regression model. RESULTS: On univariate and multivariate analysis, perineural invasion (PNI) was found to be an independent adverse risk factor. Patients with PNI-positive disease had significantly worse 2-year disease-free survival (DFS), locoregional failure free survival, and overall survival (OS) as compared to patients with PNI-negative disease (P < 0. 001, 0.001 and < 0. 001) respectively. CONCLUSION: Compared with patients with PNI-negative disease, patients with PNI-positive disease had much worse outcome despite aggressive adjuvant treatment. It warrants escalation of therapy and modification in radiation portals to cover neural pathways in patients with PNI-positive disease.

Literature review with PGI guidelines for delineation of clinical target volume for intact carcinoma cervix.

For definitive treatment of carcinoma cervix with conformal radiation techniques, accurate target delineation is vitally important, yet a consensus definition of clinical target volume (CTV) remains variable within the literature. The aim of the present article is to review the guidelines for CTV delineation published in the literature and to present the guidelines practiced at our institute. For this a literature pub med/medline search was performed from January 2000 to December 2012 and reviewed to identify published articles on guidelines for CTV primary and pelvic lymph node (LN) delineation for carcinoma cervix. Taking into consideration the traditional bony landmark based fields for treating cancer cervix, the knowledge of the patterns of disease spread and recurrence and the findings from imaging studies identifying typical anatomic distributions of areas at risk of harbouring subclinical disease, the differences in various guidelines have been analyzed and discussed. The CTV in cervical cancer consists of the CTV nodal and CTV primary. In all the published guidelines, CTV nodal consists of common iliac, external iliac, internal iliac, pre-sacral and obturator group of lymph nodes, and CTV primary consists of the gross tumor volume, uterine cervix, uterine corpus, parametrium, upper third of vagina and uterosacral ligaments. The various guidelines differ however, in the definition for these individual component structures. This is the first report to provide the complete set of guidelines for delineating both the CTV primary and CTV nodal in combination.

Conventional four field radiotherapy versus computed tomography-based treatment planning in cancer cervix: A dosimetric study.

BACKGROUND: With advancements in imaging, wide variations in pelvic anatomy have been observed, thus raising doubts about adequate target volume coverage by conventional external radiotherapy fields based on bony landmarks. The present study evaluates the need for integrating computed tomography (CT)-based planning in the treatment of carcinoma cervix. AIMS: To estimate inadequacies in target volume coverage when using conventional planning based on bony landmarks. MATERIALS AND METHODS: The study consisted of 50 patients. Target volume delineation was done on planning CT scans, according to the guidelines given in literature. The volume of target receiving 95% of prescribed dose (V95) was calculated after superimposing a conventional four field box on digitally reconstructed radiograph. The geographic miss with conventional four field box technique was compared with the CT-based target volume delineation. RESULTS: In 48 out of 50 patients, the conventional four field box failed to encompass the target volume. The areas of miss were at the superior and lateral borders of the anterior-posterior fields, and the anterior border of the lateral fields. The median V95 for conventional fields marked with bony landmarks was only 89.4% as compared to 93% for target delineation based on CT contouring. CONCLUSIONS: Our study shows inadequate target volume coverage with conventional four field box technique. We recommend routine use of CT-based planning for treatment with radiotherapy in carcinoma cervix.