Total ablative stereotactic body radiotherapy to primary and oligometastatic renal cell carcinoma in medically inoperable cases: An institutional analysis.

Introduction: Stereotactic body radiotherapy (SBRT) has been found to be an effective and safe modality with excellent oncological outcome in medically inoperable primary renal cell carcinoma (RCC) and oligometastases. There is scarcity of data on the synchronous delivery of SBRT to primary and oligometastatic RCC in patients unfit for nephrectomy. Here, we report the findings of a retrospective study of prospectively collected data on "total ablative SBRT." Methods: Oligometastatic RCC patients with intact primary tumors were enrolled between May 2021 and June 2022. SBRT was synchronously delivered to the primary tumor and metastases. Demographics, treatment, oncologic outcomes, and toxicity were assessed. Kaplan-Meier estimates were generated for oncologic outcomes. The primary endpoint of this study was feasibility and tolerability. Results: Eleven patients were enrolled between May 2021 and June 2022. One patient died at 2 months after SBRT due to viral pneumonitis (possibly COVID pneumonia). Nine patients (82%) had metastatic disease, while 2 (18%) were stage II. The average maximal diameter of primary was 68.7 mm (range, 23-128 mm). The SBRT doses for primary and metastasis ranged from 40 to 55 Gray (Gy) in 5 to 7 fractions and 22 to 40Gy in 2 to 5 fractions, respectively. The median follow-up period was 10.5 months (Range: 4-15 months). Response assessment was available for ten patients. Local control, marginal control, regional control and initial oligometastatic control (OMC) rates were 100%. OMC declined to 87.5% as one patient had recurrence in irradiated subcarinal lymphnode at 7 months. The metastatic control rate was 80% and loco-regional progression-free survival was 8 months (range, 4-15 months). Toxicities were minimal and manageable. At the last follow-up, 7 of 11 patients were alive with an overall survival of 63.5%. Six patients received systemic therapy after SBRT. Conclusions: Synchronous delivery of SBRT to primary and oligometastatic sites in patients unfit for nephrectomy was feasible and tolerable with good locoregional control. The total ablative SBRT strategy needs to be explored in similar cohorts.

Optimal Combination of Pitch, Modulation Factor and Dosimetric Considerations in Treatment Planning for Total Body Irradiation Using Helical Tomotherapy.

OBJECTIVE: The aim of this study is to makethe standard total body irradiation (TBI) protocol for Helical tomotherapy© (HT) and to analyze the optimal pitch and modulation factor (MF) with respect to dose homogeneity index (HI), target dose coverage, target overdose, beam on time (BOT) and mean lung dose. MATERIALS AND METHODS: Ten patients who underwent high-dose TBI were taken for this study. For each patient, 35 dose plans were created by different combination of pitch and MF. The optimal pitch and MF were deduced using scatter plot and regression methodology based on target coverage, HI, target volume receiving 103%(V103%), 105%(V105%) and 107% (V107%) of the prescription dose and BOT. Using these optimal pitch and MF, the final dose plan was made and the planning aim and achieved dose was compared using two tailed student's t-test. Radiochromic films and ionization chambers were used to measure the delivered dose using anthropomorphic phantom on various points for the head and pelvis regions to verify the skin flash margin and its effect on skin dose. RESULTS: The optimal pitch and MF value were 0.287 and 2.4 respectively. Based on optimal pitch and MF, the mean BOT was 1692 seconds with optimal inhomogeneity (7.4%). For target, D95 and D98 were 97.09% (range:94.7-99.6%, p=0.002) and 93.9% (range:91.5-94.4%,p=0.007) respectively, and mean D2 was within 107% with SD of ±1.22% (p=0.04). The mean of PTV receiving V103, V105 and V107 was 24.48% (range=7.7-36.6%, p=0.03), 5.76% (range=1.4-12.1%, SD=±3.3%), 1.93% (range=0.1-4.6%, p=0.008) respectively. Our measurements show that the flash margin did not increase the skin dose. CONCLUSION: In our study, the optimal combination of pitch value of 0.287 and MF value of 2.4 provided acceptable plans for all patients planned for TBI in HT. The flash margin can provide adequate coverage during patient position uncertainty without increasing the skin dose.

Diagrammatic Approach to Delineate Phrenic Nerve in Central Lung Tumors.

Incremental use of high-dose radiation therapy (RT) with SABR in thoracic tumors has led to identification of many unusual toxicities (chest wall pain, rib fractures, vascular perforation, brachial plexopathy) and consequently additional organs at risk (OARs; chest wall, ribs, bronchial wall, carotid artery, brachial plexus). Phrenic nerve is another structure that may be affected at any point during its long course from origin until end, although symptomatic toxicities have been reported rarely in the setting of reirradiation, large-volume irradiation such as mantle field, or SABR. We undertook a prospective study to describe the delineation of phrenic nerve course on RT planning computed tomography scan as an OAR. An anonymized RT planning computed tomography scan of neck and thorax (1.5-mm slice thickness, intravenous contrast) was used for the study. Radiology textbooks and publications were reviewed, and the course was delineated with the help of 2 radiologists and 6 radiation oncologists well versed with thoracic radiologic anatomy. A step-by-step description in the form of a pictorial essay is given. The adjacent structures including cervical vertebrae, cervical and mediastinal vessels, lungs, heart, and so on were identified, and the course of phrenic nerve on either side is described in relation to these structures. Delineation of the phrenic nerve as an OAR is challenging but feasible. We recommend routine delineation of the phrenic nerve as an OAR during thoracic RT. Although specific dose constraints are not known yet, unnecessary dose to the same during RT planning should be minimized.

Current status and future readiness of Indian radiation oncologists to embrace prostate high-dose-rate brachytherapy: An Indian Brachytherapy Society survey.

Purpose: This survey aimed to understand the practice pattern and attitude of Indian doctors towards prostate brachytherapy. Material and methods: A 21-point questionnaire was designed in Google form and sent to radiation oncologists practicing in India, using texts, mails, and social media. Responses were collated, and descriptive statistical analysis was performed. Results: A total of 212 radiation oncologists from 136 centers responded to the survey questionnaire, with majority (66%) being post-specialty training > 6 years. We found that about 44.3% (n = 94) of respondents do not practice interstitial brachytherapy for any site, and majority (83.3%, n = 175) do not practice high-dose-rate (HDR) prostate brachytherapy. Only 2.8% (n = 6) of doctors preferred boost by brachytherapy compared with 38.1% (n = 80) of respondents, who favored stereotactic body radiation therapy (SBRT) boost. When asked about the indication of HDR prostate brachytherapy in Indian setting, 32.5% (n = 67) of respondents favored monotherapy, 46.1% (n = 95) of oncologists thought boost as a good indication, and 21.4% (n = 44) preferred re-irradiation/salvage setting. The most cited reason for prostate brachytherapy not being popularly practiced in India was lack of training (84.8%, n = 179). It was also noted that out of 80 respondents who practiced SBRT for prostate boost, 37 would prefer HDR brachytherapy boost if given adequate training and facilities. Conclusions: The present survey provided insight on practice of prostate brachytherapy in India. It is evident that majority of radiation oncologists do not practice HDR prostate brachytherapy due to lack of training and infrastructure. Indian physicians are willing to learn and start prostate brachytherapy procedures if dedicated training and workshops are organized.

Nidus delineation and dosimetric comparison in arteriovenous malformation in stereotactic radiosurgery by using MRI and 3DCT angiography.

Purpose/Objectives: Accurate delineation of target is key to any successful radiosurgery. C-arm Dyna CT/ 3DCT angiography (3DCTA) has the potential of improving the accuracy of nidus delineation in intracranial arteriovenous malformations (AVM) due to high temporo-spatial resolution of vessel architecture. Here, we present a comparison of nidus delineation and dosimetric parameters between digital 3DCTA and MRI. Materials/Methods: Ten consecutive patients treated for intracranial AVMs were included in this study. All patients underwent MRI/MRA, and 3DCTA and all images were co-registered. AVM were delineated using 3DCTA (GTV3DCTA) and contrast enhanced MRI/MRA (GTVMRI). Hausdorff distance (HD) matrices and dice similarity coefficient (DSC) matrices were analysed. Stereotactic radiosurgery plans were developed for both the volumes for all patients and statistical analysis were performed with T-test. Results: Mean volumes of GTV3DCTA and GTVMRI were 1.771 cc (SD 1.794cc, range 0.124-4.191cc) and 2.183cc (SD 2.16cc, range 0.221-6.133cc), respectively. Significant deviation (p=0.018) was found when taking GTVMRI as a primary and comparing it to GTV3DCTA (MD=0.723cc±0.816cc). Similar result was observed with GTV3DCTA as primary and GTVMRI as secondary (MD=0.188cc, SD=0.193cc, p=0.024). Maximum HD was in the range of 1.71 to 7.44mm (mean=4.27mm, SD=1.56). For GTV3DCTA based plans, significant deviation was found between GTVMRI and GTV3DCTA in dose coverage and the mean difference was 22.17% (SD 16.73). In GTVMRI based plans, the mean CIRTOG deteriorated from 1.33 to 2.18 for GTVMRI and GTV3DCTA, respectively. Significant deviation was found in CIRTOG (0.005) and mean deviation was 0.86(SD=0.72) when comparing GTVMRI and GTV3DCTA. Highly significant (p=0.002) deviation was found in CIPaddick between GTVMRI and GTV3DCTA for GTVMRI based plans with mean difference of 0.26(SD=0.4, for GTVMRI=0.3, GTV3DCTA=0.46). Conclusion: Nidus volume was significantly altered with the use of 3DCTA compared to that of MRA/MRI images. Multimodality imaging is crucial for accurate target delineation, and successful radiosurgical obliteration of nidus.

Commissioning and Dosimetric Results of an Indigenously Developed Intra-Vaginal Template for Interstitial Plus Intracavitary High dose Rate Image-Guided Brachytherapy of Advanced Cervix Cancer.

Aim: The goal of this study is to discuss the commissioning and dosimetric parameters achieved during the clinical implementation of an indigenously developed intracavitary (IC) plus interstitial (IS) template for high dose rate (HDR) image-guided brachytherapy (IGBT) in cancer (Ca) cervix. We want to discuss our achieved values of cumulative equi-effective doses (EQD2) for high-risk clinical target volume (HRCTV) and organ at risk (OAR) and compare it with available published results. Materials and Methods: Medanta anterior oblique/lateral oblique template has a total of 19 needles including the central tandem. For commissioning the template with needles, the indigenously made acrylic phantom was used. Oblique and straight needles were placed inside the acrylic phantom and a computed tomography (CT) scan was performed. Sixteen patients were treated in HDR IGBT using this template after external-beam radiotherapy. The IGBT plans were evaluated based on EQD2 of target coverage i.e., dose received by 98% (D98%_HRCTV), 90% (D90%_HRCTV), and 50% (D50%_HRCTV) volume of HRCTV, and dose received by 2 cc (D2cc) and 0.1 cc (D0.1cc) of OAR using linear quadratic (LQ) radiobiological model. Results: The autoradiographic in radiochromic film shows that the distance between the needle tip and the middle of the source position is 6 mm. The mean D98%_HRCTV and D90%_HRCTV was 76.8 Gy (range: 70-87.7 Gy, P < 0.01) and 84.49 Gy (range: 76.6-96.7 Gy, P < 0.01), respectively. Mean EQD2 of D2cc of the bladder, rectum, and sigmoid was 85.6 Gy (range: 77.5-99.6 Gy, P < 0.03), 74.3 Gy (range: 70.9-76.7 Gy, P < 0.05), and 58.3 Gy (range: 50.6-67.9 Gy, P = 0.01), respectively. The mean total reference air kerma at a 1 m distance is 0.489cGy (range: 0.391-0.681cGy). Conclusions: The indigenously developed template could attain satisfactory standards in terms of set parameters for commissioning and acceptable dose volume relations in our clinical use for treating the advanced Ca cervix patients who need IC + IS type of HDR IGBT. The comparative analysis with contemporary applicators was acceptable.

Quantitative and qualitative application of clinical drawings for image-guided brachytherapy in cervical cancer patients.

PURPOSE: Clinical drawings are integral part of image-guided adaptive brachytherapy (IGABT) of cervical cancer. It was used in EMBRACE study protocol as a useful tool. In our study clinical drawings from EMBRACE study were modified to include scales in all the dimensions for more accurate representation of various tumor related volumes. The aim of the present study was to understand patterns of tumor regression and relationship between gross tumor at diagnosis (GTVD) and high-risk clinical target volume (CTV-THR)/intermediate-risk clinical target volume (CTV-TIR) in brachytherapy (BRT), using modified clinical drawings. MATERIAL AND METHODS: 42 cervical cancer patients, staged as FIGO IIB-IIIB according to EMBRACE study, were enrolled. Advanced schematic 3D mapping diagram (3D-MD) in axial, coronal, and sagittal orientations, with a measurement scale (grid with 10 mm distance) for precise assessment and documentation was applied (through MRI at diagnosis and during brachytherapy). Dimensions, including height, width, and thickness as well as volumes (GTVD, CTV-THR and CTV-TIR) were compared both qualitatively and quantitatively. RESULTS AND CONCLUSIONS: We found qualitative and quantitative correlation of the dimensions of final CTV-THR with initial GTVD. Meticulous mapping of tumor volumes can provide useful insights to CTV-THR volume during brachytherapy.

CyberKnife Stereotactic Ablative Radiotherapy for Recurrent or Oligometastatic Gynecological Cancers.

Purpose Use of stereotactic ablative radiotherapy (SABR) in the treatment of recurrent or metastatic lesions from a primary gynecologic cancer is a relatively new concept. The present study aims to assess the safety, efficacy, and possible toxicity profile of CyberKnife SABR, recurrent or metastatic disease. Materials/Methods CyberKnife VSI-based SABR was offered to 20 oligometastatic/recurrent gynecological cancer patients between 2013 and 2019. Patient, tumor, and treatment characteristics including radiotherapy details, clinical outcome in terms of local control rates, and toxicities are reported in this study. Results Twenty-five recurrent or oligometastatic lesions for 20 primary gynecologic cancer patients including cervical ( n = 8), ovarian ( n = 6), endometrial ( n = 5), and vulvar ( n = 1) cancers were analyzed. Of these, 4 (16%) were intracranial lesions and remaining 21 (84%) were extracranial, consisting of 14 (67%) extrapelvic and 7 (33%) pelvic lesions. The median SABR dose delivered was 60 Gy biologically effective dose (range 42-133 Gy) in an average of four fractions (range 1-6). The mean follow-up was 18 (range 2-70) months. Local tumor control was achieved in 82% of patients. There was no grade ≥ 3 toxicity recorded. Conclusion Our study results suggest that CyberKnife SABR is an effective treatment modality with no major morbidity in patients with recurrent or oligometastatic gynecological cancers.

Dosimetric Comparison of Robotic and Linear Accelerator Multi-Leaf Collimator-Based Stereotactic Radiosurgery for Arteriovenous Malformation.

PURPOSE: To investigate the dosimetric comparison of different collimators which are used in robotic radiosurgery (cyberknife-CK) and linear accelerator (LINAC) for stereotactic radiosurgery (SRS) in arteriovenous malformation (AVM). MATERIALS AND METHODS: Twenty-five AVM patients were planned in CK using FIXED cone, IRIS collimator, and multi-leaf collimator (MLC) based in LINAC. Dosimetric comparison was performed using Paddick conformity index (CIPaddick) and International Commission on Radiation Units and measurements (ICRU) homogeneity index (HIICRU), gradient score (GS), normal brain dose received by 10cc (D10cc) and critical structure (brain stem, optic chiasma, optic nerves) doses. Paired sample t-test was used for statistical analysis. RESULTS: Mean treatment volume was 3.16cc (standard deviation ± 4.91cc). No significant deviation (P =0.45, 0.237 for FIXED vs. IRIS and FIXED vs. MLC, respectively) was found in target coverage. For CIPaddick, the mean difference (MD) between FIXED- and MLC-based plans was 0.16(P = 0.001); For HIICRU, difference between FIXED and IRIS was insignificant (0.5, P = 0.823); but, when FIXED versus MLC, the deviation was 7.99% (P = 0.002). In FIXED- and MLC-based plans, significant difference was found in GS70 and GS40 (P < 0.041 and 0.005, respectively). MD between FIXED- and MLC-based plans for normal brain for 5Gy, 10Gy, 12Gy, and 20Gy were 36.08cc (P = 0.009), 7.12cc (P = 0.000), 5.84cc (P = 0.000) and 1.56cc (P = 0.000), respectively. AVM volume <0.7cc should be treated with CK FIXED and >0.7cc were treated by using FIXED or IRIS collimators. AVM volume > 1.4cc can be treated by either LINAC MLC-based SRS or CK. CONCLUSION: Our study shows CK collimator (IRIS and FIXED) could be able to treat brain AVMs in any size. Linac MLC-based SRS has some limitations in terms of conformity and low-dose spillage, and advantages like reduced treatment time and MU.

Artificial intelligence in brachytherapy: a summary of recent developments.

Artificial intelligence (AI) applications, in the form of machine learning and deep learning, are being incorporated into practice in various aspects of medicine, including radiation oncology. Ample evidence from recent publications explores its utility and future use in external beam radiotherapy. However, the discussion on its role in brachytherapy is sparse. This article summarizes available current literature and discusses potential uses of AI in brachytherapy, including future directions. AI has been applied for brachytherapy procedures during almost all steps, starting from decision-making till treatment completion. AI use has led to improvement in efficiency and accuracy by reducing the human errors and saving time in certain aspects. Apart from direct use in brachytherapy, AI also contributes to contemporary advancements in radiology and associated sciences that can affect brachytherapy decisions and treatment. There is a renewal of interest in brachytherapy as a technique in recent years, contributed largely by the understanding that contemporary advances such as intensity modulated radiotherapy and stereotactic external beam radiotherapy cannot match the geometric gains and conformality of brachytherapy, and the integrated efforts of international brachytherapy societies to promote brachytherapy training and awareness. Use of AI technologies may consolidate it further by reducing human effort and time. Prospective validation over larger studies and incorporation of AI technologies for a larger patient population would help improve the efficiency and acceptance of brachytherapy. The enthusiasm favoring AI needs to be balanced against the short duration and quantum of experience with AI in limited patient subsets, need for constant learning and re-learning to train the AI algorithms, and the inevitability of humans having to take responsibility for the correctness and safety of treatments.

The Medanta AOLO template for locally advanced cancer cervix brachytherapy: design and clinical implementation.

PURPOSE: In advanced cervical cancers, improved techniques using both intracavitary and interstitial brachytherapy (IC + IS) should be used to adequately cover the residual tumor volume, resulting in better clinical results. Confronted with some limitation in implementing available applicators, we devised our own indigenous template that would also serve as an applicator. MATERIAL AND METHODS: First, a graphical design was drawn, keeping in mind the extent of volumes that need to be targeted in various brachytherapy scenarios. It was validated in a computer system and a physical template was manufactured. The template underwent modified versions through iterative dosimetric and planning exercises. The final model was successfully implemented in a clinical scenario. RESULTS: Cylindrical templates of diameter 3, 4, and 5 cm were produced with central aperture for central tandem, combining surrounding holes spaced at pre-planned points. The instrument can be used for IC + IS brachytherapy in cervical cancers. This easy to use applicator/template can direct needles to treat a distance of 4.5 cm laterally at the level of point A. In two initial applications 55 and 54 cc of high-risk clinical target volumes (HRCTV) were treated, and 90% of the HRCTV was covered by 96% and 97% of prescribed doses, respectively. Additionally, the needles guided by the template helped in sculpting the dose from bladder and rectum. CONCLUSIONS: We have developed an easy to use IC + IS type of template/applicator, which was successfully implemented in our clinical practice.

Phase I/II Study of Extreme Hypofractionated Stereotactic Body Radiation Therapy Boost to Prostate for Locally Advanced, Node-Positive and Oligometastatic Cancer.

INTRODUCTION:  Stereotactic body radiation therapy (SBRT) is increasingly being utilized to deliver escalated radiation doses for improving outcomes in various malignancies. We analyzed our cohort of locally advanced, node-positive, and bone oligometastatic prostate cancer patients, that were treated with a combination of pelvic RT using conventional fractionation (CF) and SBRT boost to prostate using extreme hypofractionation (EH), along with hormone therapy (HT). MATERIALS AND METHODS:  Outcomes of 44 prospectively treated patients were analyzed. Volumetric modulated arc therapy (VMAT) was utilized to deliver a dose of 45 Gy to pelvic nodal region, 50 Gy to prostate, and 54-56 Gy to gross nodes in 25 fractions. EH boost 18 Gy in three fractions was delivered to the prostate using CyberKnife (Accuray, Sunnyvale, CA, USA) SBRT. Bone oligometastasis, if any, were treated to a dose of 16 Gy in two fractions, delivered on weekends. Serum prostate-specific antigen (PSA), multi-parametric magnetic resonance imaging (MRI) of pelvis, and prostate-specific membrane antigen-positron emission tomography (PSMA-PET) were used for response assessment during follow-up. HT was given as per standard guidelines. RESULTS:  There were 33 (75%) locally advanced, nine (20.5%) node-positive, and two (4.5%) oligometastatic cases. At a median follow-up of 63.5 months, the five-year progression-free survival (PFS) was 88.2%, biochemical PFS (bPFS) was 91.4% and overall survival (OS) was 96.9%. Grade III or greater acute genitourinary and gastrointestinal toxicity was 2.3% each, and late toxicity was 4.5% and 0%, respectively. CONCLUSION:  Excellent five-year outcomes can be attained even for locally advanced, node-positive and bone oligometastatic prostate cancer, by means of dose-escalation using EH-SBRT boost to the prostate.

Artificial intelligence in oncology, its scope and future prospects with specific reference to radiation oncology.

OBJECTIVE: Artificial intelligence (AI) seems to be bridging the gap between the acquisition of data and its meaningful interpretation. These approaches, have shown outstanding capabilities, outperforming most classification and regression methods to date and the ability to automatically learn the most suitable data representation for the task at hand and present it for better correlation. This article tries to sensitize the practising radiation oncologists to understand where the potential role of AI lies and what further can be achieved with it. METHODS AND MATERIALS: Contemporary literature was searched and the available literature was sorted and an attempt at writing a comprehensive non-systematic review was made. RESULTS: The article addresses various areas in oncology, especially in the field of radiation oncology, where the work based on AI has been done. Whether it's the screening modalities, or diagnosis or the prognostic assays, AI has come with more accurately defining results and survival of patients. Various steps and protocols in radiation oncology are now using AI-based methods, like in the steps of planning, segmentation and delivery of radiation. Benefit of AI across all the platforms of health sector may lead to a more refined and personalized medicine in near future. CONCLUSION: AI with the use of machine learning and artificial neural networks has come up with faster and more accurate solutions for the problems faced by oncologist. The uses of AI,are likely to get increased exponentially . However, concerns regarding demographic discrepancies in relation to patients, disease and their natural history and reports of manipulation of AI, the ultimate responsibility will rest on the treating physicians.

Treatment of locally advanced carcinoma cervix with special emphasis on brachytherapy: A practice pattern survey among young radiation oncologist of India.

BACKGROUND: Carcinoma cervix is one of the two most common cancers of Indian women with very high morbidity and mortality burden. Although India probably is the leading country in numbers patients of cervix treated radically with combination of teletherapy and brachytherapy (BT), there is presumed diversity of practice across the country due to the inequality of available infrastructure, absence of uniform the training of the radiation oncologists, and absence of any national guidelines. The present survey was conducted to determine current practice patterns in management of locally advanced carcinoma cervix with regard to gynecologic high-dose-rate among the radiation oncologist across the country. METHODOLOGY: A 25-item survey was undertaken to study the standard management pattern of Stage IIB-IIIB cervical cancer with special emphasis on the BT practice patterns among various young radiation oncologist working across the country. The survey was undertaken in person in the form of interview questionnaire among the younger members of association of radiation oncologist of India during two national conferences, along with telephonic interview of other members as obtained from the national directory. RESULTS: About 57 young radiation oncologists from 57 centers across the country were surveyed. 25 of them represented private nonacademic centers, 24 represented government academic centers, the rest were from private academic, nongovernmental organization (NGO) run and other centers. The most common teletherapy dose prescribed was 46 Gy/23# for Stage II, and50 Gy/25 # for Stage III disease. HDR after loader with 192Ir is the most common machine (82.6%) in use and computed tomography scan is the most commonly (30/57) used imaging for planning. The most common intracavitary dose pattern for all stages was 7 Gy × 3 fractions (30/57s) and 9 Gy × 2 (12/57) fractions. Although in most centers, computed tomography-based delineation of organs at risk is done routinely; however, target volume delineation and dose prescription/optimization for the same is routinely done in handful of centers (5/57). The mean planned dose to Point A for combined external-beam radiation and BT (EQD210) was about 77.5 Gy for Stage IIIB and 72.6 Gy for Stage II disease. CONCLUSION: Although fractionation patterns may vary, the overall mean dose administered for cervical cancer is similar across the country, which is slightly lower than the recommended doses as per stage by various international guidelines.

Use of ultrasound in image-guided high-dose-rate brachytherapy: enumerations and arguments.

Inherently, brachytherapy is the most conformal radiotherapeutic technique. As an aid to brachytherapy, ultrasonography (USG) serves as a portable, inexpensive, and simple to use method allowing for accurate, reproducible, and adaptive treatments. Some newer brachytherapy planning systems have incorporated USG as the sole imaging modality. Ultrasonography has been successfully used to place applicator and dose planning for prostate, cervix, and anal canal cancers. It can guide placement of brachytherapy catheters for all other sites like breast, skin, and head and neck cancers. Traditional USG has a few limitations, but recent advances such as 3-dimensional (3D) USG and contrast USG have enhanced its potential as a dependable guide in high-dose-rate image-guided brachytherapy (HDR-IGBT). The authors in this review have attempted to enumerate various aspects of USG in brachytherapy, highlighting its use across various sites.

Modulated Radiotherapy with Concurrent and Adjuvant Temozolomide for Anaplastic Gliomas: Indian Single-center Data.

OBJECTIVE: To evaluate early clinical outcome for anaplastic gliomas (AG) treated in the era of modulated radiotherapy (RT) and concurrent plus adjuvant temozolomide (TMZ) in an Indian setting. MATERIALS AND METHODS: Fifty-three patients with AGs treated with modulated RT and concurrent (95%) and adjuvant TMZ (90%) were analyzed. About 80% of patients had Karnofsky performance status (KPS) at least 90 with 30% seizure at presentation. Postoperative magnetic resonance imaging was available in 65% cases and RT dose was 60 Gy in 30 fractions. First posttreatment imaging was performed at 1 month and then at 3 and 6 months post-RT and then every 3 months. Kaplan-Meier analysis was used to estimate disease-free survival (DFS) and overall survival (OS), and analysis was done using SPSS version 18.0. RESULTS: With median follow-up of 25 months, 2-year DFS and OS were 75% and 88%. There were only 5% symptomatic central nerves system and 8% symptomatic hematological toxicities. At the 1st evaluation, 30.4% had complete response (CR), at 3 months 40%, and at 6 months 43%. At 6 months, only 4% had progressive disease. Forty-six patients were evaluable till the last follow-up with and 55% had stable to CR. On univariate analysis for DFS, KPS at presentation >90 (P = 0.001) and response at 6 months (P = 0.02) were significant and for OS KPS at presentation (P = 0.004) alone. CONCLUSION: Modulated RT with TMZ among Grade III glioma patients resulted in minimum treatment-related toxicities and encouraging survival. Molecular prognostic markers will determine most favorable groups in future.