Survival and failure outcomes in locally advanced esthesioneuroblastoma: a single centre experience of 15 patients.

Esthesioneuroblastoma (ENB) constitutes 3 % of all malignant intranasal tumors. As the tumor is very rare, the number of patients of ENB treated in individual departments is small. We present our institute's experience in combined modality management of 15 successive patients of ENB treated from 2006 to 2010. Clinical characteristics and treatment modality in form of surgery, radiotherapy and chemotherapy were noted. Kadish stage C was the most common stage (12 patients) followed by stage B (3 patients). Fourteen patients underwent primary surgery, of which nine had total excision and five had subtotal excision. One patient was treated with combination of chemotherapy (CT) and radiotherapy (RT). Median RT dose delivered was 54 Gy. Twelve patients received CT with cisplatin and etoposide. Overall, eight patients had complete response, five had partial response, while one had static disease and progressive disease each. Two patients had distant metastases. Four-year loco-regional control (LRC) was 25 % and 4-year overall survival (OS) was 45 %. Most common presentation in our series was locally advanced tumors. Most of these patients require adjuvant RT, which helps in significant LRC. Systemic CT benefits in inoperable, advanced and high risk tumors. Risk-adapted and multimodality approach is the need of hour to achieve good control rates while minimizing treatment related toxicity.

Paratesticular rhabdomyosarcoma in young adults: A tertiary care institute experience.

INTRODUCTION: Paratesticular rhabdomyosarcoma (RMS) is a rare tumor arising from the mesenchymal tissues of the spermatic cord, epididymis, testis and testicular tunics. It represents only 7% of all patients entered in the Intergroup Rhabdomyosarcoma Study (IRS) and 17% of all malignant intrascrotal tumors in children less than 15 years old. We present our experience in combined modality management of 10 successive patients of paratesticular RMS. MATERIAL AND METHODS: We retrospectively reviewed 10 patients of paratesticular RMS treated in our institute from July 2004 to December 2010. Clinical characteristics and treatment modality in form of surgery and chemotherapy (CCT) were noted. Statistical analysis was done with regards to progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier survival analysis. RESULTS: The median age of the patients was 16.5 years. The median duration of symptoms was 5 months. Five patients had retroperitoneal lymphadenopathy (RPLAP) while three had lung metastases and one had orbital metastases. All patients underwent high inguinal orchidectomy followed by systemic chemotherapy (CCT). Retroperitoneal node dissection was not a required staging procedure. Four patients had partial response to treatment while six had complete response. Mean duration of PFS was 48 months and mean OS was 56 months. CONCLUSIONS: Paratesticular RMS are rare neoplasms with aggressive growth patterns. Cure rates have dramatically improved and 60% of patients in our series had complete response. This success is due to development of multimodality and risk adapted treatment approaches.

Intracranial meningeal hemangiopericytoma: 10 years experience of a tertiary care Institute.

BACKGROUND: Intracranial meningeal hemangiopericytoma (HPC) represents a rare and aggressive intracranial neoplasm located along the dural sinuses. It constitutes less than 1 % of all intracranial tumors and approximately 2-4 % of all meningeal tumors. The authors present our institute's experience in combined modality management of 15 successive patients of HPC. METHODS: We retrospectively reviewed 15 patients of HPC treated in our institute from 2001 to 2011. Clinical characteristics and treatment modality, in the form of surgery and radiotherapy, were noted. Statistical analysis was done with regards to recurrence free survival (RFS) and overall survival (OS) using Kaplan-Meier survival analysis. RESULTS: The median age of the patients was 40.0 years. Nine patients were males and six patients were females. The median duration of symptoms was six months. Headache was the most common presenting symptom followed by vomiting, motor weakness and seizures. Twelve patients underwent total excision while three had subtotal excision. Seven patients had WHO grade II histology tumors and eight patients had grade III histology. Thirteen patients received adjuvant radiotherapy (RT). Median RT dose delivered was 50 Gy. Five patients developed local recurrence. One patient had distant metastases. Median duration of RFS was 68 months. CONCLUSIONS: HPCs are aggressive tumors. The mainstay of therapy is gross total resection at the initial surgery. Postoperative adjuvant RT should be offered to all patients, regardless of the degree of resection achieved. Long-term follow-up is important as local recurrences and distant metastases can develop years after the initial treatment.

Solitary plasmacytoma of the proximal tibia in an adolescent.

This is the case report of a 14-year young female who was diagnosed with solitary bone plasmacytoma (SBP) of proximal tibia and was treated by local involved field radiotherapy. We present the clinical, radiological and pathological findings of the case and review of the available treatment options and prognosis of this rare site presentation of plasmacytoma in an adolescent female.

Primary Bone Lymphoma: An Experience of a Regional Cancer Center from India.

Background Primary bone lymphoma (PBL) is a rare disease, representing <5% of all extranodal non-Hodgkin's lymphomas (NHLs). The optimal treatment strategy is still unclear. Here, we report our institutional outcome analysis of patients diagnosed with PBL. Materials and Methods From 2007 to 2014, the medical records of 22 patients with PBL were reviewed. Analysis was done for symptom-, patient-, disease-, and treatment-related characteristics. All patients were treated with chemotherapy with or without radiotherapy. Treatment response and impact of different prognostic factors on clinical outcome were analyzed. Results The median age of presentation was 44 years (range: 18-70 years). A total of 19 (86.4%) patients were ≤60 years of age and 3 (13.6%) patients were >60 years. Out of all, 18 were males and 4 were females. Ann Arbor clinical staging at diagnosis was Stage I in 13 (59.1%), Stage II in 3 (13.6%), Stage III in 2 (9.1%), and Stage IV in 4 (18.2%) patients. Spine was the most common site of involvement seen in 12 (54.5%) patients. Diffuse large B cell lymphoma histology was seen in 8 (36.4%) patients and 8 (36.4%) had high-grade NHL. Chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone was given to 20 (90.9%) patients, whereas 2 (9.1%) patients received cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab. Radiotherapy (30-40 Gy) was delivered to 19 (86.4%) patients. The median follow-up period was 40 months (range: 8-105 months). The overall response rate was 86.3% with complete response (CR) in 15 (68.1%) and partial response in 4 (18.2%) patients. Relapses were seen in three (13.5%) patients: two nodal, and one in the bone. Disease-free survival (DFS) and overall survival (OS) at 5 years were 56.6 and 72.7%, respectively. CR after initial treatment was associated with a significant better OS, 80 and 25%, respectively ( p < 0.0001). Age, sex, stage, International Prognostic Index, histologic subtype, and number of sites had no significant influence on OS. Combining radiation therapy with chemotherapy (with or without rituximab) also did not improve the OS or DFS of patients. Conclusion In spite of small number of patients reported in this study, conventional chemotherapy remains an effective treatment option for patients with PBL. OS was found to be affected by the initial response to treatment.

Male breast cancer: Outcome with adjuvant treatment.

INTRODUCTION: Male breast cancer (MBC) incidence is <1%, but it is increasing. MBC incidence increases with age. There are no randomized trials on MBC because of low number of patients seen in any institution and hence its management is derived from breast cancer (BC) in women. In this study, we analyzed outcome in MBC patients with adjuvant treatment. MATERIALS AND METHODS: From 1991 to 2014, 81 men with BC were retrospectively analyzed for demographic, clinicopathological, and treatment outcomes. Disease-free survival (DFS) was defined as time duration from diagnosis to first recurrence. Overall survival (OS) was defined as time duration from pathologic diagnosis to death or last follow-up with any death defined as an event. DFS and OS were estimated using Kaplan-Meier method and compared between patients receiving and not receiving adjuvant treatment using log-rank test. RESULTS: The median age was 57 years (range 30-86 years). Right, left, and bilateral BCs were seen in 41 (51%), 38 (47%), and 2 (2%) men, respectively. The mean duration of symptoms was 25 months (range 1-240 months). Comorbidity and family history was present in 31 (38%) and 3 (4%) men, respectively. The mean tumor size was 5 cm × 5 cm (range, 1 cm × 1 cm to 10 cm × 10 cm). Nipple was involved in 46 (57%) men. Early, locally advanced, and metastatic disease were seen in ??30 (37%), 34 (42%), and 17 (21%) men, respectively. Majority (71, 88%) of men had invasive ductal carcinoma histology. In radically treated 64 men, neoadjuvant chemotherapy was given to 12 (19%) patients (fluorouracil, adriamycin, and cyclophosphamide [FAC] to 9 and FAC + taxanes to 3), with CR in 4 (33.3%) and partial response (PR) in 8 (66.7%) patients. Mastectomy was done in 55 (86%) and wide local excision in 9 (14%) men. Margins and nodes were positive in 17 (27%) and 38 (59%) men, respectively. Estrogen receptor, PR, and human epidermal growth factor receptor 2/neu positive were seen in 27 (42%), 17 (26.5%), and 2 (3%) patients, respectively. Adjuvant hypofractionated radiotherapy, chemotherapy, and tamoxifen were received by 51 (80%), 35 (55%), and 45 (70%) men, respectively. Median follow-up was 60 months (range 4-278 months). Locoregional recurrence occurred in 8 (12.5%) and distant metastasis in 22 (34%) men, respectively. DFS and OS at 10 years were 42% and 53%, respectively. DFS and OS were significantly better in men with adjuvant radiation (54% vs. 24%, P = 0.007 and 57% vs. 35%, P = 0.022, respectively) and hormonal therapy (57% vs. 14.5%, P = 0.004 and 62% vs. 39%, P = 0.045, respectively). Chemotherapy had no impact on DFS and OS. CONCLUSION: Adjuvant hypofractionated radiotherapy and hormonal therapy significantly improved DFS and OS in MBC patients. Chemotherapy had no impact on DFS and OS.

Prognostic significance of micropapillary pattern in pure mucinous carcinoma of the breast.

Breast carcinoma with micropapillary architecture is associated with aggressive behavior. Similar micropapillary pattern in pure mucinous carcinoma has been noticed and has been shown to convey poor prognosis. In this study 17 cases of pure mucinous carcinoma of the breast seen during a 10-year period have been reviewed, with special reference to micropapillary pattern. Diffuse micropapillary pattern was seen in 6 of 17 cases of mucinous carcinoma of the breast and demonstrated reverse polarity immunostaining pattern with "Epithelial Membrane Antigen." In all cases, the tumor cells showed grade I morphology, and no lymph node metastases were noticed. All the tumors except 1 expressed strong estrogen and progesterone receptor expression, however, all the cases were negative for Her-2/neu expression. In this present study, mucinous carcinomas with micropapillary pattern showed a low nuclear grade, higher incidence of hormone receptor positivity, and lower incidence of Her-2/neu similar to mucinous carcinomas without micropapillary pattern, thus explaining their indolent behavior.

Outcome of adult acute lymphoblastic leukemia with BFM protocol in a resource-constrained setting.

Cure rates for adult acute lymphoblastic leukemia (ALL) in developing countries are significantly lower because of problems unique to these countries. We assessed some of the problems in adult ALL patients (>12 years of age) in a tertiary care hospital of northwest India with modified BFM regimen. The diagnosis of ALL was made according to FAB criteria. The protocol consisted of Phase I & II induction, consolidation, reinduction and maintenance phases. CNS prophylaxis was administered with 24 Gy radiation and intrathecal methotrexate. One hundred and eighteen patients (72.9% males), aged 12-68 years (median 23 years) were treated from January 1997 till December 2003. Follow-up of patients was done till December 2005. Complete remission (CR) was achieved in 85.6% patients after induction therapy and 40% patient relapsed. Most patients (23.7%) relapsed during the maintenance phase or after completion of chemotherapy. At least 15% of patients (15/101) after successful induction abandoned the treatment because of financial constraints, prolonged travel time to treatment facility and switching over to alternative medicines. Fatal infectious complications occurred in 19.5% of patients. The 3-year and 5-year event free survival rates were 29.8% and 21.6% respectively. In conclusion, modified BFM regimen resulted in high induction rates but relatively poor 5-year event free survival. Infections related death and post induction abandonment of treatment were the main reasons for poor overall results.

Whole body exposure to low-dose gamma radiation promotes kidney antioxidant status in Balb/c mice.

We examined the effect of whole body low-dose gamma-irradiation on the status of the antioxidant defense system in the rodent kidneys at different time intervals. Young male Balb/c mice were exposed to whole body radiation from a (60)Co source at doses of 10, 25 and 50 cGy (48.78 cGy/min). Antioxidant status and lipid peroxidation were estimated in the kidneys at 4, 12 and 24 h after irradiation. Lipid peroxidation increased between 33% and 49% and reduced glutathione between 12% and 47% at 12 h at different radiation doses. Reduced glutathione level remained significantly (p < 0.05) elevated even at 24 h after irradiation to 25 cGy. Superoxide dismutase activity also increased by 37% at 12 h on exposure of animals to all the doses up to 50 cGy. Catalase activity increased significantly at 12 h on exposure to 10 cGy and 50 cGy. Interestingly, glutathione peroxidase activity increased by 31% at 4 h and subsequently returned to control levels at 24 h after exposure to 50 cGy. Glutathione reductase activity increased by 10-12% at 12 h after exposure to 25 cGy and 50 cGy. The results suggest that the whole body exposure of animals to gamma radiation stimulates the antioxidant defense system in the kidneys within 4 to 24 h after irradiation, at doses of 25 cGy and 50 cGy.

High-dose-rate interstitial brachytherapy in early stage oral tongue cancer - 15 year experience from a tertiary care institute.

PURPOSE: To determine outcomes of interstitial high-dose-rate brachytherapy (HDR-BT) in patients with early stage oral tongue cancer. MATERIAL AND METHODS: Ninety-two patients with stage I and II oral tongue cancer were treated with HDR-BT between 1999 and 2014: brachytherapy alone = 62 (67.4%), and combination of external beam radiotherapy (EBRT) and brachytherapy = 30 (32.6%). Median follow-up was 53.5 months. Patterns of failure, overall survival (OS), disease-free survival (DFS), local control rates (LCR), and nodal control rates (NCR) were determined. RESULTS: 5-year OS, DFS, LCR, and NCR were 73.2%, 58.2%, 64.2%, and 83.8%, respectively. In total, 43 patients (46.7%) failed treatment: isolated local failures = 28 (30.4%), isolated nodal failures = 8 (8.7%), both local and regional failures = 7 (7.6%). While in T1 stage, 5 year LCR were significantly higher in brachytherapy alone group compared to combined EBRT and brachytherapy group (81.7% vs. 62.5%, p = 0.04), the isolated nodal failure rates were not significantly different among the two groups. For T2 stage, NCR were higher in combined EBRT and brachytherapy group compared to brachytherapy alone (92.9% vs. 74.3%). Acute mucositis (grade ≥ 2) was seen more in brachytherapy alone group compared to the combined modality group (87% vs. 66%), and this correlated significantly with the higher biological equivalent dose (BED) in the brachytherapy alone group. CONCLUSIONS: Our study recommends treating patients with brachytherapy alone in T1 stage, and demonstrates the need for addressing nodal region either by neck dissection or nodal irradiation in T2 stage patients. Also, the study highlights the need for dose escalation (from the doses used in the study) in both T1 and T2 stage tumors when using interstitial brachytherapy either as sole modality or as a boost.

Radiotherapy for ovarian cancers - redefining the role.

Radiation therapy in ovarian cancers has been considered an outdated concept for many years, mainly due to toxicity and failure to show benefit in terms of survival. Chemotherapy has been extensively used after surgery for these cancers and it has almost replaced radiation therapy as an adjuvant treatment. Nevertheless, failures in ovarian cancers continue to occur even with the use of newer and effective chemotherapy regimens. About 70% patients demonstrate recurrence in the abdomen or pelvis after first line chemotherapy in ovarian cancers. With advances in technology and sophistication of radiation techniques, along with the molecular and biological knowledge of distinct histological subtypes, there is a need to redefine the role of radiation therapy. This review article focuses on the literature on use of radiation in ovarian cancers and its rationale and indications in the present day. For this, a literature pub med/medline search was performed from January 1975 to March 2014 to redefine the role of radiotherapy in ovarian cancers.

Clinical and cosmetic results of breast boost radiotherapy in early breast cancer: a randomized study between electron and photon.

INTRODUCTION: Breast-conserving surgery followed by radiation therapy (RT) to the intact breast is now clearly established as the most acceptable strategy for women with early-stage invasive breast cancer. Recommended techniques for radiotherapy is whole breast irradiation (WBI) followed by boost to the tumor bed. AIMS: The aim of this study is to compare the modalities of three-dimensional conformal RT (3DCRT) and electron beam therapy as boost in post-lumpectomy patients of early stage breast cancer, following WBI. MATERIALS AND METHODS: The study comprised of selecting 50 patients of early-stage post-lumpectomy breast cancer. Each patient was initially treated by WBI (40 Gy in 16 fractions) and then followed by tumor bed boost (16 Gy in 8 fractions) with either electron beam therapy or with photon (3DCRT), 25 patients in each arm. Patients were evaluated regularly for acute and chronic radiation toxicities, cosmesis, and pattern of failure. Dosimetric comparison of the plans was also done. RESULTS: Median age of the patients was 42 years with 66% being premenopausal. Median duration of follow-up was 23 months. In arm A (electrons), two patients had grade III-IV reactions at treatment completion with one patient required RT interruption. Whereas, in arm B (3DCRT), five patients had grade III-IV reactions at treatment completion with three patients required RT interruption. At 6 months and 2 years follow-up, both the arms had almost similar skin, subcutaneous toxicity, and cosmetic score. At the end of 2 years, there were totally four failures among 50 patients, with one locoregional failure in both arms (4%). Dosimetric analysis revealed that conformality (radiation conformity index (RCI)), dose homogeneity index (DHI) and planning target volume (PTV) coverage was significantly better in 3DCRT boost plans. Organs at risk (OAR) dosimetry also revealed significant decrease in ipsilateral lung and heart doses with 3DCRT plans in which tangential or oblique fields were used; and whereas in electron beam, only single direct fields were used. CONCLUSIONS: Both electrons and 3DCRT can be used for boost planning to the tumor bed in post-lumpectomy patients. Though there was slightly increased acute skin toxicity with 3DCRT photon which led to interruption of therapy, overall cosmesis at 2 years is similar in both modalities. 3DCRT boost is a better option than electrons dosimetrically, considering the fact that conformality; PTV coverage and OAR dosimetry were superior with photons. Thus in centers where electron beam therapy is not available, 3DCRT photon can be used effectively for tumor bed boost.

Evaluation of intrafraction motion of the organs at risk in image-based brachytherapy of cervical cancer.

PURPOSE/INTRODUCTION: To assess the variation in the doses received by the organs at risk (OARs) that can occur during treatment planning of cervical cancer by image-based brachytherapy. METHODS AND MATERIALS: After intracavitary application, two sets of images-CT and MRI-were obtained. The two sets of images were fused together with respect to the applicator. Contouring was done separately on CT and MR images. Dose received by the OARs on CT images with respect to the plans made on the MR images was estimated and compared with those on the MR images. RESULTS: Although there was always a difference between the dose received by the OARs based on the CT and MRI contours, it was not significant for the bladder and rectum; 2 cc doses differed by 0.49 Gy (±0.44) p = 0.28 for the bladder and 0.30 Gy (±0.29) p = 0.16 for the rectum. The 1 cc and 0.1 cc differences were also not significant. However for the sigmoid colon, there was significant intrafraction variation in the 2 cc doses 0.61 (±0.6) p = 0.001, 1 cc doses 0.73 (±0.67) Gy p = 0.00, and 0.1 cc dose 0.97 (±0.93) Gy p = 0.009. CONCLUSIONS: The variation in the doses to the OARs must be considered while weighing target coverage against overdose to the OARs. Although not significant for the bladder and rectum, it was significant for the sigmoid colon. Estimated doses to OARs on the planning system may not be the same dose delivered at the time of treatment.

Survival and failure outcomes in primary thyroid lymphomas: a single centre experience of combined modality approach.

Primary thyroid lymphoma (PTL) is a rare malignancy and represents 2%-5% of all thyroid malignancies and 1%-2.5% of all malignant lymphomas. We present our institute's experience in combined modality management of 16 successive patients of PTL treated from 2005 to 2010. The median age of the patients was 56.0 years. Five patients were males, and 11 patients were females. An enlarging thyroid mass was the most common presenting symptom. 14 patients had diffuse large B-cell lymphoma, and 2 patients had follicular lymphoma. The most common stage of presentation was stage II comprising 6 (37.5%) patients. All patients received CCT, and only 12 patients received involved field RT with a median dose of 36.0 Gy. 10 patients (62.5%) had CR, and 6 patients (27.5%) had PR. Eight patients had disease progression in subsequent followup and this included the initial 6 patients with PR. The 5-year DFS was 40.0%, and median DFS was 47 months. The 5-year OS was 41.0%, and median OS was 51 months. Most common presentation in our series was locally advanced tumors. Most of these patients require combined modality management. Risk-adapted and multimodality approach is the need of the hour to achieve good control rates while minimizing treatment related toxicity.

Evaluation of outcome and prognostic factors in patients of glioblastoma multiforme: A single institution experience.

AIMS: We present retrospective analysis of patients of glioblastoma multiforme (GBM) and discuss clinical characteristics, various treatment protocols, survival outcomes, and prognostic factors influencing survival. MATERIALS AND METHODS: From January 2002 to June 2009, 439 patients of GBM were registered in our department. The median age of patients was 50 years, 66.1% were males, and 75% underwent complete or near-total excision. We evaluated those 360 patients who received radiotherapy (RT). Radiotherapy schedule was selected depending upon pre-RT Karnofsky Performance Status (KPS). Patients with KPS < 70 (Group I, n = 48) were planned for RT dose of 30-35 Gy in 10-15 fractions, and patients with KPS ≥ 70 (Group II, n = 312) were planned for 60 Gy in 30 fractions. In group I, six patients and in group II, 89 patients received some form of chemotherapy (lomustine or temozolomide). STATISTICAL ANALYSIS USED: Statistical analysis was done using Statistical Package for Social Sciences, version 12.0. Overall survival (OS) was calculated using Kaplan-Meier method, and prognostic factors were determined by log rank test. The Cox proportional hazards model was used for multivariate analysis. RESULTS: The median follow-up was 7.53 months. The median and 2-year survival rates were 6.33 months and 2.24% for group I and 7.97 months and 8.21% for group II patients, respectively (P = 0.001). In multivariate analysis, site of tumor (central vs. others; P = 0.006), location of tumor (parietal lobe vs. others; P = 0.003), RT dose (<60 Gy vs. 60 Gy; P = 0.0001), and use of some form of chemotherapy (P = 0.0001) were independent prognostic factors for survival. CONCLUSIONS: In patients with GBM, OS and prognosis remains dismal. Whenever possible, we should use concurrent and/or adjuvant chemotherapy to maximize the benefits of post-operative radiotherapy. Patients with poor performance status may be considered for hypofractionated RT schedules, which have similar median survival rates as conventional RT.

Thymoma: clinical experience from a tertiary care institute from North India.

BACKGROUND: Thymomas are the most common tumors of the mediastinum. They have varied presentation ranging from asymptomatic incidental mediastinal masses to locally extensive tumor with compressive symptoms and distant metastases. The authors present our institute's experience in combined modality management of thymomas. MATERIALS AND METHODS: We retrospectively reviewed 36 patients of thymoma treated in our institute from January 2004 to December 2010. Clinical characteristics and treatment modality in form of surgery, radiotherapy (RT) and chemotherapy (CCT) were noted. Statistical analysis was done with regard to progression free survival (PFS) and overall survival (OS) using Kaplan-Meier survival analysis. RESULTS: A total of 17 patients had associated Myasthenia gravis and 3 patients had associated Cushing syndrome. Masaoka Stage 4a was the most common stage (13 patients) followed by stage 3 (10 patients), stage 2 (9 patients) and stage 1 (4 patients). Twenty seven patients underwent primary surgery, out of which 20 received adjuvant RT and five received both RT and CCT. Of nine non-surgical cases, four received only palliative RT whereas 5 received systemic CCT followed by local mediastinal RT. Overall, 23 patients had complete response while 13 had partial response. 1 patient had local recurrence. Three year PFS was 60% and 3 year OS was 83%. CONCLUSIONS: Most common presentation in our series was locally advanced tumors. Most of these patients require adjuvant mediastinal radiation, which helps in significant loco-regional control. Systemic CCT benefits in inoperable, advanced and high-risk tumors. Risk-adapted and multimodality approach is the need of the hour to achieve good control rates while minimizing treatment related toxicity.

Dosimetric evaluation of 3Dconformal acceleratedpartial-breast irradiation vs. whole-breast irradiation: A comparative study.

BACKGROUND: Conventional early breast cancer treatment consists of lumpectomy followed by whole-breast irradiation (WBI) therapy. Accelerated partial-breast irradiation (APBI) is also an approach to post-lumpectomy radiation for early breast cancer. AIM: The purpose of this study is to compare two different external-beam APBI techniques using three-dimensional (3D) conformal radiation therapy (3DCRT), with conventional whole-breast irradiation based on the radiation conformity index, dose homogeneity index, and dose to organs at risk. MATERIALS AND METHODS: WBI treatment plans were compared with two different 3DCRT APBI plans for each of 15 patients (8 with right sided lesions, 7 with left sided lesions). The first APBI plan (APBI 1) used two small coplanar fields conformed to the planning target volume (PTV) using multileaf collimators (MLCs) and wedges, while the other APBI plan (APBI 2) used three non-coplanar fields conformed to the PTV using MLCs and wedges. RESULTS: Both the APBI techniques improved the conformity index significantly over whole-breast tangents while maintaining dose homogeneity and not causing significant increase in dose to organs at risk. CONCLUSION: Both the 3DCRT APBI techniques are technically feasible and dosimetrically appealing,with better target coverage and relative sparing of normal critical organs.

Guidelines for locoregional therapy in primary breast cancer in developing countries: The results of an expert panel at the 8(th) Annual Women's Cancer Initiative - Tata Memorial Hospital (WCI-TMH) Conference.

BACKGROUND: Limited guidelines exist for breast cancer management in developing countries. In this context, the Women's Cancer Initiative - Tata Memorial Hospital (WCI-TMH) organised its 8(th) Annual Conference to update guidelines in breast cancer. MATERIALS AND METHODS: Appropriately formulated guideline questions on each topic and subtopic in the surgical, radiation and systemic management of primary breast cancer were developed by the scientific committee and shared with the guest faculty of the Conference. Majority of the questions had multiple choice answers. The opinion of the audience, comprising academic and community oncologists, was electronically cumulated, followed by focussed presentations by eminent national and international experts on each topic. The guidelines were finally developed through an expert panel that voted on each guideline question after all talks had been delivered and audience opinion elicited. Separate panels were constituted for locoregional and systemic therapy in primary breast cancer. RESULTS: Based on the voting results of the expert panel, guidelines for locoregional therapy of breast cancer have been formulated. Voting patterns for each question are reported. CONCLUSIONS: The updated guidelines on locoregional management of primary breast cancer in the context of developing countries are presented in this article. These recommendations have been designed to allow centers in the developing world to improve the quality of care for breast cancer patients.

Optimization of high-dose-rate intracavitary brachytherapy schedule in the treatment of carcinoma of the cervix.

PURPOSE: At our institute, we use high-dose-rate (HDR) intracavitary brachytherapy (ICBT) schedule of 9 Gy per fraction for two fractions after external beam radiotherapy (EBRT) in patients with advanced carcinoma of the cervix. But American Brachytherapy Society recommends that individual fraction size should be less than 7 Gy per fraction in such patients. We present the results of comparison of our institution standard schedule with biologically equivalent dose of 6.8 Gy per fraction for three fractions in terms of local control, disease-free survival, and late toxicity. METHODS AND MATERIALS: Between October 2003 and August 2007, 104 patients with carcinoma of the uterine cervix (Stages IIB and IIIB) were treated with EBRT and HDR ICBT. After EBRT, patients were randomized to one of the treatment arms. ICBT dose in Control Arm A (n=52) was 9 Gy per fraction in two fractions, 1 week apart, and in Study Arm B (n=52), it was 6.8 Gy per fraction in 3 fractions, 1 week apart. RESULTS: The median followup was 31.48 months. The 3-year actuarial local control was 81.35% in Arm A and 65.18% in Arm B (p=0.0423), and the 3-year actuarial disease-free survival was 64.97% in Arm A and 49.47% in Arm B (p=0.0393). The 3-year actuarial risk of developing any Grade 3 or worse late toxicity was 7.47% in Arm A and 3.57% in Arm B (p=0.2907). CONCLUSION: In our setup, HDR brachytherapy at 9 Gy per fraction in two fractions is safe and effective with good local control, survival, and manageable normal tissue toxicity.