Prospective assessment of patterns of failure after high-precision definitive (chemo)radiation in head-and-neck squamous cell carcinoma.

PURPOSE: To prospectively analyze patterns of failure in patients with head-and-neck squamous cell carcinoma treated with definitive high-precision radiotherapy with a focus on location of failure relative to target volume coverage. METHODS AND MATERIALS: Sixty patients treated with three-dimensional conformal radiotherapy or intensity-modulated radiation therapy were included. Locoregional failure volume was defined on the planning data set at relapse, and dose received was analyzed by use of dose-volume histograms. RESULTS: Thirteen patients were deemed to have had locoregional failures, of which two did not have any viable tumor on salvage neck dissection, leaving eleven patients with proven persistent or recurrent locoregional disease. Of these, 9 patients had in-field failure, 1 marginal failure, and 1 both in-field and marginal failures. Overall, only 2 of 11 patients (18%) with relapse had any marginal failure. Of the 20 sites of locoregional failure, 15 (75%) were in-field and 5 (25%) marginal. Distant metastases were detected in 3 patients, whereas a second new primary developed in 3 others. With a median follow-up of 26 months (interquartile range, 18-31 months) for surviving patients, the 3-year local control, locoregional control, disease-free survival, and overall survival rates were 75.3%, 74%, 67.2%, and 60.5%, respectively. CONCLUSIONS: Locoregional relapse remains the predominant pattern of failure in head-and-neck squamous cell carcinoma treated with high-precision definitive radiotherapy with the majority of failures occurring "in-field" within the high-dose volume. Marginal failures can occur, particularly in the vicinity of the spared parotid gland. The therapeutic index of high-precision conformal radiotherapy is largely dependent on adequate selection and delineation of target volumes and organs at risk.

Diagnostic performance of response assessment FDG-PET/CT in patients with head and neck squamous cell carcinoma treated with high-precision definitive (chemo)radiation.

PURPOSE: To prospectively assess diagnostic performance of response assessment fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in patients with HNSCC treated with high-precision definitive (chemo)radiation. METHODS: Fifty-seven patients treated on a prospective clinical trial having post-treatment response assessment FDG-PET/CT scans were included. Clinico-pathologic findings and follow-up information was considered as reference standard. RESULTS: First response assessment FDG-PET/CT was done at a median of 9 weeks (inter-quartile range 8-10 weeks) from completion of treatment. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of first response assessment FDG-PET/CT for identifying residual disease at primary site was 50%, 91.8%, 50%, 91.8%, and 86%. The corresponding figures for the neck were 62.5%, 98%, 83.3%, 94.1%, and 93%. With a median follow-up of 26 months (range 7-45 months), the 3-year loco-regional control (83.9% vs 58.3%, p=0.001) and overall survival (68.8% vs 58.3%, p=0.063) was significantly better in patients with negative response assessment scans. CONCLUSION: The overall diagnostic accuracy of response assessment FDG-PET/CT is good, but its sensitivity and PPV is somewhat low, particularly for primary site. A negative response assessment FDG-PET/CT scan is highly suggestive of absence of viable disease that could be used to guide decision-making.

Radical radiotherapy with concurrent weekly cisplatin in loco-regionally advanced squamous cell carcinoma of the head and neck: a single-institution experience.

BACKGROUND: The dominant pattern of failure for squamous cell carcinoma of head and neck remains loco-regional, although distant metastases are now being increasingly documented. Radical radiotherapy with concurrent chemotherapy is contemporary standard of care in the non-surgical management of these loco-regionally advanced cancers, based on large randomized controlled trials utilizing high-dose cisplatin (80-100 mg/m2) cycled every three-weekly during definitive radiotherapy. Although efficacious, this is associated with high acute morbidity necessitating intensive supportive care with attendant resource implications. The aim of this retrospective study was to assess the efficacy and acute toxicity of an alternative schedule i.e. concurrent weekly cisplatin-based radical radiotherapy and it's potential to be an optimal regimen in advanced head and neck cancers. METHODS: Outcome data of patients with Stage III & IV head and neck squamous cell carcinoma, excluding nasopharynx, planned for radical radiotherapy (66-70 Gy) with concurrent weekly cisplatin (30 mg/m2) treated in a single unit between 1996-2004 was extracted. RESULTS: The dataset consisted of 264 patients with a median age of 54 years. The median radiotherapy dose was 70 Gy (range 7.2-72 Gy) and median number of chemotherapy cycles was 6 (range 1-7). Two-thirds (65%) of patients received > or = 85% of planned cisplatin dose. With a mean follow-up of 19 months, the 5-year local control; loco-regional control; and disease free survival was 57%; 46%; and 43% respectively. Acute grade 3 or worse mucositis and dermatitis was seen in 77 (29%) and 92 (35%) patients respectively, essentially in patients receiving doses > or = 66 Gy and 6 or more cycles of chemotherapy. Other toxicities (hematologic, nausea and vomiting) were mild and self-limiting. Overall, the acute toxicity of this concurrent weekly chemo-radiation regimen though mildly increased did not mandate intensive supportive care. Stage grouping, primary site, and intensity of treatment were significant predictors of loco-regional control and disease free survival. CONCLUSION: Radical radiotherapy with concurrent weekly cisplatin has moderate efficacy and acceptable acute toxicity with potential to be an optimal regimen in loco-regionally advanced squamous cell carcinoma of the head and neck, particularly in limited-resource settings. Stage grouping, primary site, and treatment intensity are important determinants of outcome.

Do all patients of breast carcinoma need 3-dimensional CT-based planning? A dosimetric study comparing different breast sizes.

Evaluation of dose distribution in a single plane (i.e., 2-dimensional [2D] planning) is simple and less resource-intensive than CT-based 3-dimensional radiotherapy (3DCRT) planning or intensity modulated radiotherapy (IMRT). The aim of the study was to determine if 2D planning could be an appropriate treatment in a subgroup of breast cancer patients based on their breast size. Twenty consecutive patients who underwent breast conservation were planned for radiotherapy. The patients were grouped in 3 different categories based on their respective chest wall separation (CWS) and the thickness of breast, as "small," "medium," and "large." Two more contours were taken at locations 5 cm superior and 5 cm inferior to the isocenter plane. Maximum dose recorded at specified points was compared in superior/inferior slices as compared to the central slice. The mean difference for small breast size was 1.93 (standard deviation [SD] = 1.08). For medium breas size, the mean difference was 2.98 (SD = 2.40). For the large breasts, the mean difference was 4.28 (SD = 2.69). Based on our dosimetric study, breast planning only on the single isocentric contour is an appropriate technique for patients with small breasts. However, for large- and medium-size breasts, CT-based planning and 3D planning have a definite role. These results can be especially useful for rationalizing treatment in busy oncology centers.

HPV screening for cervical cancer in rural India.

BACKGROUND: In October 1999, we began to measure the effect of a single round of screening by testing for human papillomavirus (HPV), cytologic testing, or visual inspection of the cervix with acetic acid (VIA) on the incidence of cervical cancer and the associated rates of death in the Osmanabad district in India. METHODS: In this cluster-randomized trial, 52 clusters of villages, with a total of 131,746 healthy women between the ages of 30 and 59 years, were randomly assigned to four groups of 13 clusters each. The groups were randomly assigned to undergo screening by HPV testing (34,126 women), cytologic testing (32,058), or VIA (34,074) or to receive standard care (31,488, control group). Women who had positive results on screening underwent colposcopy and directed biopsies, and those with cervical precancerous lesions or cancer received appropriate treatment. RESULTS: In the HPV-testing group, cervical cancer was diagnosed in 127 subjects (of whom 39 had stage II or higher), as compared with 118 subjects (of whom 82 had advanced disease) in the control group (hazard ratio for the detection of advanced cancer in the HPV-testing group, 0.47; 95% confidence interval [CI], 0.32 to 0.69). There were 34 deaths from cancer in the HPV-testing group, as compared with 64 in the control group (hazard ratio, 0.52; 95% CI, 0.33 to 0.83). No significant reductions in the numbers of advanced cancers or deaths were observed in the cytologic-testing group or in the VIA group, as compared with the control group. Mild adverse events were reported in 0.1% of screened women. CONCLUSIONS: In a low-resource setting, a single round of HPV testing was associated with a significant reduction in the numbers of advanced cervical cancers and deaths from cervical cancer.

Prognostic factors in oropharyngeal cancer--analysis of 627 cases receiving definitive radiotherapy.

INTRODUCTION: The aim of this retrospective analysis was to analyze the results of conventional radical radiotherapy in the treatment of oropharyngeal cancer and to identify pre-treatment and treatment-related prognostic factors for outcome. MATERIAL AND METHODS: The records of 627 patients with oropharyngeal cancer treated with radical radiotherapy with conventional techniques were analyzed. RESULTS: The median age was 56 years. History of tobacco abuse was present in 80.5%. Eighty six percent had stage III or IV disease. Radical radiotherapy alone was the treatment modality for 71.2% and concomitant or neoadjuvant chemotherapy was used in 28.8%. The 3-year local control (LC), loco-regional control (LRC), disease-free survival (DFS) and overall survival (OS) was 49%, 40.6%, 38.9% and 36.1% respectively. The 3-year DFS rates were 80.3% for stage I, 65.8% for stage II, 46.1% for stage III and 25.2% for stage IV disease. Multivariate analysis was performed for prognostic factors. Prior history of tobacco abuse was an independent prognostic factor for both DFS and LRC. Karnofsky Performance Score (KPS) < 80, higher nodal stage, lower total radiotherapy dose (<66 Gy) in those receiving > 60 Gy, and overall treatment time > 50 days were other independent prognostic factors for inferior DFS and LRC. KPS < 80, higher T stage, higher nodal stage, RT dose < 66 Gy and longer overall treatment time (>50 days) were independent prognostic factors for poorer local control. CONCLUSIONS: Several patient-, disease- and treatment-related variables independently affect survival outcomes after radical radiotherapy for oropharyngeal cancer. Oropharyngeal cancers in those without a history of tobacco abuse may be biologically different and more amenable to cure with radiotherapy.

Prevalence of tobacco use and tobacco-dependent cancers in males in the Rural Cancer Registry population at Barshi, India.

BACKGROUND: In the Rural Cancer Registry at Barshi (western Maharashtra, India), it has been found that the incidence of cancer is relatively low. AIM: To explain the low incidence of tobacco related cancers in males on the basis of prevalence of their tobacco habits. SETTING AND DESIGN: Simple random sample of villages from Barshi Rural Cancer Registry. MATERIAL AND METHODS: A tobacco survey was carried out in 5,319 adult males. Site specific incidence data for Barshi and Mumbai Cancer Registries were available from published reports in the National Cancer Registry Programme. Published report of prevalence of tobacco habits in Mumbai males was available. RESULTS: The tobacco survey showed that the prevalence of smoking compared to Mumbai was low (9.9% vs 23.6%) and the incidence of smoking dependent cancers viz., cancers of oropharynx, larynx and lung were significantly low (P< 0.05). However, although the proportion of tobacco chewers is higher in Barshi compared to Mumbai, the incidence rates for cancer of hypopharynx and oral cancer which are predominantly chewing dependent did not show higher rate than in Mumbai. CONCLUSIONS: The low incidence of smoking dependent cancers in males can be explained by the low prevalence of smoking habit but further studies are needed to explain the observed incidence of predominantly chewing dependent cancers.

Squamous cell carcinoma of the hypopharynx: single-institution outcome analysis of a large cohort of patients treated with primary non-surgical approaches.

INTRODUCTION: Hypopharyngeal cancers have extensive submucosal spread, high risk of nodal involvement and relatively high propensity of distant metastases. Contemporary paradigms for hypopharyngeal cancers aim to maximize loco-regional control while attempting to preserve laryngo-pharyngeal form and function. AIMS: To retrospectively review outcome of large cohort of patients with hypopharyngeal cancers treated with curative intent radiotherapy with or without systemic chemotherapy in an academic tertiary referral centre. MATERIAL AND METHODS: Medical records of patients with hypopharyngeal cancers treated with primary non-surgical approaches over a 15-year period were reviewed retrospectively. Loco-regional control (LRC) and disease-free survival (DFS) were considered as outcome measures. RESULTS: Electronic search of database identified 501 patients with hypopharyngeal cancers treated with definitive radiotherapy. The median age was 55 years (range 20-87 years) and median radiotherapy dose 70 Gy (range 5.4-72 Gy). With a mean follow-up period of 22 months (median 12 months), the 3-year LRC and DFS was 47.1% and 40.9% respectively. Stage (T-stage, N-stage, overall stage grouping), and age influenced outcome significantly. The 3-year LRC for T1-T2 disease was 49.7% versus 43.1% for T3- T4 stage (p0.056). The 3-year DFS was 49.4% and 36.9% respectively (p0.014). The 3-year LRC and DFS for N0; N1; and N2-3 disease was 57.3% & 54.3%; 40.5% & 35.3%; and 33% & 27% respectively with highly significant p-values. CONCLUSION: This is an outcome analysis of the largest cohort of patients with hypopharyngeal cancers managed with primary non-surgical approaches. Stage and age remain the most important determinants of outcome.

Factors affecting the quality of voice in the early glottic cancer treated with radiotherapy.

AIMS: To prospectively analyze the objective voice quality before and after radiotherapy (RT) for early glottic cancer and to evaluate the role of different factors that may affect it. METHODS: Patients with T1-T2N0M0 glottic cancer underwent voice quality assessment before treatment and after radical RT. Post-RT voice quality was compared to the voice at diagnosis and the voice of healthy individuals used as controls. A comprehensive set of voice parameters were measured. The effects of age, smoking history, T stage, anterior commissure (AC) involvement, radiation dose, fractionation and volumes on pre-treatment and post-treatment voice quality were analyzed. RESULTS: The voice quality data of 50 patients were analyzed. Following treatment, there was a significant improvement in the majority of measured parameters. However, perturbation and HNR remained inferior compared to controls. A history of smoking, AC involvement and larger RT volumes resulted in poorer voice parameters following RT. There was no significant impact of age alone. T2 tumors had an inferior voice quality before treatment, but did not remain inferior following RT. Hypofractionated RT did not show any negative impact. CONCLUSIONS: There is a considerable improvement of voice quality following RT. Several factors may have specific effects on pre-treatment and post-treatment voice.

Proteomic profiling of cancer of the gingivo-buccal complex: Identification of new differentially expressed markers.

Tobacco-related oral cancer is the most common cancer among Indian males, gingivo-buccal complex (GBC) being the most affected subsite due to the habit of chewing tobacco. Proteins from the lysates of microdissected normal and transformed epithelium from clinically well-characterized tissue samples of the GBC were separated by two-dimensional gel electrophoresis to identify differentially expressed proteins. Eleven protein spots showed differential expression, which could withstand the stringency of statistical evaluation. The observations were confirmed with additional tissues. Nine of these differentiators were identified by MS as lactate dehydrogenase B, α-enolase, prohibitin, cathepsin D, apolipoprotein A-I, tumor protein translationally controlled-1, an SFN family protein, 14-3-3σ and tropomyosin. Cluster analysis indicated that these proteins, as a coexpressed set, could distinguish normal and transformed epithelium. Functionally, these differentiator molecules are relevant to the pathways and processes that have been previously implicated in oral carcinogenesis and could therefore be investigated further as a panel of markers for management of cancer of the GBC.

Nasopharyngeal carcinoma in children: comparison of conventional and intensity-modulated radiotherapy.

PURPOSE: To evaluate the efficacy of intensity-modulated radiotherapy (IMRT) in reducing the acute toxicities associated with conventional RT (CRT) in children with nasopharyngeal carcinoma. PATIENTS AND METHODS: A total of 36 children with nonmetastatic nasopharyngeal carcinoma, treated at the Tata Memorial Hospital between June 2003 and December 2006, were included in this study. Of the 36 patients, 28 were boys and 8 were girls, with a median age of 14 years; 4 (11%) had Stage II and 10 (28%) Stage III disease at presentation. All patients had undifferentiated carcinoma and were treated with a combination of chemotherapy and RT. Of the 36 patients, 19 underwent IMRT and 17 underwent CRT. RESULTS: After a median follow-up of 27 months, the 2-year locoregional control, disease-free, and overall survival rate was 76.5%, 60.6%, and 71.3%, respectively. A significant reduction in acute Grade 3 toxicities of the skin (p = 0.006), mucous membrane (p = 0.033), and pharynx (p = 0.035) was noted with the use of IMRT. The median time to the development of Grade 2 toxicity was delayed with IMRT (skin, 35 vs. 25 days, p = 0.016; mucous-membrane, 39 vs. 27 days, p = 0.002; and larynx, 50 vs. 28 days, p = 0.009). The duration of RT significantly influenced disease-free survival on multivariate analysis (RT duration >52 days, hazard ratio = 5.49, 95% confidence interval, 1.14-26.45, p = 0.034). The average mean dose to the first and second planning target volume was 71.8 Gy and 62.5 Gy with IMRT compared with 66.3 Gy (p = 0.001) and 64.4 Gy (p = 0.046) with CRT, respectively. CONCLUSION: The results of our study have shown that IMRT significantly reduces and delays the onset of acute toxicity, resulting in improved tolerance and treatment compliance for children with nasopharyngeal carcinoma. Also, IMRT provided superior target coverage and normal tissue sparing compared with CRT.

Estimation of survival rates of breast cancer patients--a hospital-based study from Mumbai.

PURPOSE: To estimate the survival rates of breast cancer patients with reference to various factors like age, literacy status, residential status, T-stage and treatment. This is because there are very few studies reported from Indian subcontinent. METHODS: Survival rates were obtained by using the actuarial method and loss-adjusted survival rate method (LAR) for the above factors and the rates were compared. The present study carried out at the Tata Memorial Hospital (TMH), includes newly diagnosed (who were not treated elsewhere before attending TMH) primary breast cancer patients and having completed the initial treatment. RESULTS: The survival rates, actuarial survival and rates corrected for losses to follow-up (LAR) are presented. It showed that younger patients ( 50 years), with statistical significance ( p=0.024). There was no variation in survival with regard to the residential status but literate patients had a better ( non-significant) survival (77%) than their illiterate counterparts. T3-stage patients had the worst prognosis showing a 5-year survival of 60% (p=0.0002). Survival for those treated with surgery as the only modality and also in combination with other modalities did not show any remarkable differences except for the group that were treated with 'surgery in combination with chemotherapy'. The 5-year survival for those treated with surgery as the only modality was 83%. This study yielded useful information on breast cancer survival, especially in a situation with incomplete follow-up. The method applied (LAR) also clearly demonstrates the bias in estimates obtained by direct application of the standard actuarial method.

Radiation therapy planning of a breast cancer patient with in situ pacemaker--challenges and lessons.

A postmenopausal lady with an in situ pacemaker developed a lump in the left breast and was diagnosed to have breast cancer. The patient underwent breast conservative surgery and was planned for post operative radiotherapy. The location of the tumor relative to the pacemaker provided a unique challenge in planning radiotherapy and the patient had an uneventful post radiotherapy course. A literature review revealed that modern generation pacemakers are very sensitive to radiation compared to their older counterparts. The present article makes suggestions towards reducing dose in radiotherapy planning in pacemaker patients.

Prognostic factors in node negative premenopausal women treated with breast conserving therapy without adjuvant systemic therapy.

PURPOSE: To study the prognostic factors in node negative premenopausal women treated with breast conserving therapy (BCT) without any adjuvant systemic therapy. METHODS: Of the 1022 women treated with BCT at Tata Memorial Hospital, there was a cohort of 175 women who were premenopausal, node negative and had not received any adjuvant systemic therapy. BCT consisted of wide excision, complete axillary clearance, whole breast radiotherapy (45 Gy in 25 fractions) with 6 MV photons plus tumour bed boost either with brachytherapy or electrons. RESULTS: The median age at presentation was 38 years (range 22-51 years) and the median pathological tumour size was 3 cm (1-5 cm). The 5-year actuarial local control rate was 89.5% and the overall survival (OS) was 88%. On univariate analysis, lymphovascular invasion (LVI) was the only prognostic factor affecting all failures and disease-free survival. The 5-year local control rate in absence of LVI was 93.5% in contrast to 76.5% (p=0.0098) when LVI was present. Similarly, the OS in absence of LVI was 91% in contrast to 74% in presence of LVI (p=0.02). On multivariate analysis, LVI was the independent prognostic factor affecting the disease-free survival (p=0.001; 95% CI: 1.46-4.96). CONCLUSION: LVI emerged as the most important prognostic factor for node negative premenopausal women not receiving adjuvant systemic therapy. There is a need to take into consideration the presence of LVI while deciding adjuvant systemic therapy in T1N0 patients.

Estimation of risk of radiation-induced carcinogenesis in adolescents with nasopharyngeal cancer treated using sliding window IMRT.

PURPOSE: To estimate the risk of radiation-induced carcinogenesis based on whole-body dose measurement on adolescent patients undergoing intensity-modulated radiotherapy (IMRT). METHODS AND MATERIALS: Ten adolescent patients with nasopharyngeal cancer were planed and treated to a dose of 70.2 Gy using sliding window IMRT. Peripheral dose (PD) was measured using thermoluminescent dosimeters kept at anterior, lateral and posterior positions of each axial plane at the level of xiphoid process, umbilicus and gonads of every patient. The associated risk of radiation-induced carcinogenesis was estimated based on the measured whole-body dose and using age- and sex-specific ICRP-60 nominal probability coefficient of 7.5% (boys) and 9.5% (girls) per Sv. RESULTS: In all patients, measured PD per monitor unit (MU) decreases almost exponentially with out-of-field distance and varies with gantry angle. Highest whole-body dose equivalent ranged from 0.5318 to 0.9867 Sv (mean=0.8141 Sv, SD=0.138) which was measured posteriorly at the level of xiphoid process. Whole-body dose was represented by the average dose at xiphoid process and all measurement positions ranged from 0.3661 to 0.8766 Sv (mean=0.658 Sv, SD=0.16) and 0.2267 to 0.5277 Sv (mean=0.3859 Sv, SD=0.09), respectively. The associated mean risk of radiation-induced carcinogenesis estimated based on different representation of mean whole-body dose was 6.57%, 5.3% and 3.11%, respectively. Higher mean risk of 7.32% was estimated among girls as compared to 6.25% for boys. CONCLUSIONS: Knowledge of risk of secondary malignancy is particularly important in adolescents and should be considered when choosing the optimal treatment technique and delivery system.

Age related macular degeneration: a study of patients managed with radiotherapy.

INTRODUCTION: Age-related macular degeneration (ARMD) is the leading cause of blindness in the west. Radiotherapy affects the evolution of exudative macular degeneration directly by its effect on the endothelium and inflammation modulation. We conducted a retrospective study to evaluate the improvement in visual acuity and healing of sub retinal neovascular membrane (SRNV) following fractionated radiotherapy. MATERIALS AND METHODS: 47 patients (58 eyes) of ARMD were retrospectively analyzed. One of the following radiotherapy fractionation schedules was employed in all the patients in this study. a) 15 Gy/5 fractions/1 week (five patients) b) 20 Gy/5 fractions/1 week (19 patients) c) 22.5 Gy/5 fractions/1 week (21 patients) d) 25 Gy/5 fractions/1 week (two patients). VA and funduscopy was taken at each follow-up for objective improvement and to assess the healing of SRNV. RESULTS: The median follow-up was 7.23 months. The mean improvement in the VA in the entire group was of 0.44 line. (Median 1, SD 1.04). Overall 75% of the eyes showed either steady vision or an improvement in subjective vision analysis. The deterioration free survival was significantly better in the group that had a relatively short duration of symptoms (P = 0.01). Scarring at presentation was a significant adverse factor for improvement in vision after radiotherapy (P = 0.001). CONCLUSIONS: In patients of ARMD treated with radiotherapy, the initial duration of symptoms and scarring of eyes at presentation were significant prognostic variables for improvement in VA after radiotherapy.

Interstitial brachytherapy for childhood soft tissue sarcoma.

BACKGROUND: To evaluate the efficacy of interstitial brachytherapy (BRT) in children undergoing combined modality treatment for soft tissue sarcomas (STS). PROCEDURE: From September 1984 to December 2003, 50 children (median age 13 years, range 1 to 18) with STS who received BRT as part of loco-regional treatment were included. There were 30 males and 20 females, the majority (68%) had primary lesions, synovial sarcoma (32%) was the most common histological type, and 26% had high-grade lesions. Treatment included wide local excision and BRT with or without external beam radiotherapy (EBRT). Thirty children (60%) received BRT alone. RESULTS: After a median follow-up of 51 months, the local control (LC), disease-free survival, and overall survival were 82%, 68%, and 71%, respectively. LC was superior in patients with tumor size 5 cm (96% vs. 67%, P = 0.04), symptom duration <2 months versus >2 months (100% vs. 73%, P = 0.05), and Grade I versus Grade II versus Grade III tumors (100% vs. 93% vs. 57%, P = 0.03). Children receiving a combination of BRT and EBRT had comparable LC to those receiving BRT alone (78% vs. 84%, P = 0.89). There was no significant difference in LC for patients receiving LDR versus HDR BRT (77% vs. 92%, P = 0.32, for BRT alone; and 67% vs. 100%, P = 0.17, for BRT + EBRT). CONCLUSION: Interstitial BRT with or without EBRT appears to result in satisfactory outcome in children with STS. Radical BRT alone, when used judiciously in select groups of children, results in excellent local control and functional outcome with reduced treatment-related morbidity.

Perioperative interstitial brachytherapy for soft tissue sarcomas: prognostic factors and long-term results of 155 patients.

BACKGROUND: The goal of this study was to evaluate the efficacy of temporary interstitial brachytherapy (BRT) for patients undergoing combined modality management of soft tissue sarcomas (STS). METHODS: From January 1990 to December 2003, 155 adults 18-88 years of age (median = 42 years) with STS who had received BRT as part of locoregional treatment were included in this review. Sixty-four percent were males. Sixty-nine percent had primary lesions. Sixty percent had lesions involving the lower extremities. Spindle cell sarcoma (28%) and synovial sarcoma (16%) were the most common histologic types and 51% had grade III lesions. Treatment included wide local excision of primary tumor with BRT with or without external beam radiotherapy (EBRT). RESULTS: After a median followup of 45 months, the local control (LC), disease-free survival (DFS), and overall survival (OS) for the entire cohort was 71%, 57%, and 73%, respectively. DFS was superior for superficial tumors compared with that for deep tumors (96% vs. 54%, P =.02). Patients with a tumor less than 5 cm had superior OS (88% vs. 63%, P =.05). Cumulative radiotherapy dose greater than 60 Gy had a significant positive impact on LC (P = .003), DFS (P =.003), and OS (P =.048). Subcutaneous fibrosis (21%) was the major complication. CONCLUSIONS: Temporary perioperative iridium-192 interstitial BRT with or without EBRT after function-preserving surgery results in satisfactory outcome in patients with STS. Both low dose rate and high dose rate BRT are equivalent in terms of disease control and complications when used alone or in combination with EBRT. BRT results in fewer complications compared with the combination of BRT and EBRT.

Safety and feasibility of breast conserving therapy in Indian women: two decades of experience at Tata Memorial Hospital.

PURPOSE: The NIH consensus statement on the management of breast cancer has highlighted the paucity of outcome data in non-Caucasian women. Treatment outcome and factors determining it in a large cohort of ethnic Indian women treated with breast conserving therapy (BCT) at Tata Memorial Hospital are reported here. MATERIALS AND METHODS: During 1980-2000, 1,022 pathological Stage I/II breast cancer patients (median age 43 years) underwent BCT (wide excision, complete axillary clearance, whole breast radiotherapy with 6 MV photons plus tumor bed boost, +/-systemic therapy). Median pathological tumor size was 3 cm (1-5 cm). Axillary node metastases were found in 39% women. Of the 938 patients with IDC, 70% were Grade III and in patients where receptor status was known, 209/625 (33%) were ER positive and 245/591 (41%) were PR positive. RESULTS: The 5- and 10-year actuarial overall survival was 87% and 77% and disease-free survival was 76% and 68%, respectively. Actuarial 5-year local and locoregional control rates were 91% and 87%, respectively. Cosmesis was good or excellent in 78% women. Independent adverse prognostic factors for local recurrence were, age<40 years, axillary node metastasis, lymphovascular invasion (LVI), and adjuvant systemic therapy; for locoregional recurrence-inner quadrant tumor, axillary node metastasis, and LVI; for survival-LVI and axillary node metastasis. CONCLUSION: Compared to Caucasians, these Indian women undergoing BCT were younger, had larger, higher grade, and receptor negative tumors. Comparable local control and survival was obtained by using stringent quality assurance in the diagnostic and therapeutic protocol. BCT, a resource intense treatment is safe for selected and motivated patients undergoing treatment at centers with adequate facilities and expertise even in countries with limited resources.