T-Cell Chronic Lymphocytic Leukemia

A case of T-cell chronic lymphocytic leukemia (T-CLL) is reported. The surface receptor for sheep erythrocytes and acid phosphatase staining confirmed the diagnosis of T-CLL. This report provides evidence that T-CLL, a rare variant of CLL, is an aggressive disease with relative resistance to therapy and short survival.

A Clinicopathologic Study of Solitary Myeloma

A retrospective clinicopathologic review of 17 solitary myelomas (SMs) including 13 osseous (solitary plasmacytomas of bone [SPB]) and four extraosseous (extramedullary plasmacytomas [EMP]) tumors in 14 male and three female patients was undertaken. The average age of patients with SPB and EMP was 47.2 years and 48.75 years, respectively, and the most common site was the spine and the head and neck, respectively. The possible utility of histologic and cytologic characteristics of the tumor cells to predict evolution to multiple myeloma (MM) was studied. Follow-up was 63 months (SPB) and 107 months (EMP). No consistent cytohistologic features emerged in patients ultimately evolving either into MM (three patients) or developing recurrences (two patients). Thus, although the correct recognition of SM, as distinct from MM, has clinical relevance, morphology does not help further prognostication.

Radiotherapeutic management of locally advanced head and neck cancer

Head and neck cancer management has undergone several paradigm shifts for several relevant reasons. From the dismal experience with the use of radiotherapy as the sole modality in the treatment of this group of patients with advanced disease, radiotherapy has been evaluated as an adjuvant for the same group of patients who had undergone successful surgery. Although there is no level 1 evidence to support postoperative adjuvant radiation, several studies have demonstrated that adjuvant radiotherapy reduces the local failures and, thereby, improves survival. Predictors of recurrence after surgical resection are: positive margins of resection; extranodal spread in involved nodes; perineural invasion; and presence of two or more involved regional lymph nodes. Realization of the advantages of a combination of chemotherapy with radiotherapy has had a major impact on the management of these cancers. There is emerging evidence for the use of adjuvant concurrent chemoradiotherapy in the group with high-risk features. Multiple organ conservation strategies in the management of locally advanced head and neck cancers have evolved over the years. However, the meta-analyses of impact of chemotherapy in various settings reveal that concomitant chemoradiotherapy is superior to any of the other regimens. Increasing use of computed tomography, magnetic resonance imaging and positron emission tomography scan images has resulted in better visualization of target volumes and critical structures. Delineation of these structures is of paramount importance and has resulted in a profound change in conformal treatment planning. Better understanding of the physical aspects of delivery of radiotherapy and the advent of modern treatment planning systems have led to the development of conformal techniques. Although the benefit of these techniques on survival have yet to be demonstrated, there is evidence to suggest that they reduce treatment-related toxicities significantly and facilitate dose escalation. Increased knowledge of radiobiology has led to the development of various altered fractionation regimens in the management of locally advanced head and neck cancers. Discovery of cell-cycle kinetics and signal transduction pathways has led to the unearthing of several potential targets for targeted therapy. The epidermal growth factor receptor gene has emerged as the most promising target. The role of biological radiation response modifiers is evolving. All of these approaches to improve the therapeutic gain would be incomplete without evaluating their effect on the quality of life of these patients.

Dosimetric evaluation of rectum and bladder using image-based CT planning and orthogonal radiographs with ICRU 38 recommendations in intracavitary brachytherapy

The purpose is to compare CT-based dosimetry with International Commission on Radiation Units and Measurements (ICRU 38) bladder and rectum reference points in patients of carcinoma of uterine cervix treated with intracavitary brachytherapy (ICA). Twenty-two consecutive patients were evaluated. Orthogonal radiographs and CT images were acquired and transferred to PLATO planning system. Bladder and rectal reference points were identified according to ICRU 38 recommendations. Dosimetry was carried out based on Manchester system. Patient treatment was done using ¹⁹²Iridium high dose rate (HDR) remote after-loading machine based on the conventional radiograph-based dosimetry. ICRU rectal and bladder point doses from the radiograph plans were compared with D₂, dose received by 2 cm³ of the organ receiving maximum dose from CT plan. V₂, volume of organ receiving dose more than the ICRU reference point, was evaluated. The mean (±standard deviation) volume of rectum and bladder was 60 (±28) cm³ and 138 (±41) cm³ respectively. The mean reference volume in radiograph and CT plan was 105 (±7) cm³ and 107 (±7) cm³ respectively. It was found that 6 (±4) cm³ of rectum and 16 (±10) cm³ of bladder received dose more than the prescription dose. V₂ of rectum and bladder was 7 (±1.7) cm³ and 20.8 (±6) cm³ respectively. Mean D₂ of rectum and bladder was found to be 1.11 (±0.2) and 1.56 (±0.6) times the mean ICRU reference points respectively. This dosimteric study suggests that comparison of orthogonal X-ray-based and CT-based HDR ICA planning is feasible. ICRU rectal point dose correlates well with maximum rectal dose, while ICRU bladder point underestimates the maximum bladder dose.

Whole-body PET acceptance test in 2D and 3D using NEMA NU 2-2001 protocol

Integrated PET/CT has emerged as an integral component of oncology management because of its unique potential of providing both functional and morphological images in a single imaging session. In this work, performance of the ‘bismuth germinate (BGO) crystal’-based PET of a newly installed Discovery ST PET/CT was evaluated in 2D and 3D mode for whole-body scanning using National Electrical Manufacturers Association (NEMA) NU 2-2001 protocol and the recommended phantoms. During the entire measurements, the system operates with an energy window of 375-650 keV and 11.7 ns coincidence time window. The set of tests performed were spatial resolution, sensitivity, scatter fraction (SF) and counting rate performance. The average transaxial and axial spatial resolution measured as full width at half maximum (FWHM) of the point spread function at 1 cm (and 10 cm) off-axis was 0.632 (0.691) and 0.491 (0.653) cm in 2D and 0.646 (0.682) and 0.54 (0.601) cm in 3D respectively. The average sensitivity for the two radial positions (R = 0 cm and R = 10 cm) was 2.56 (2.63) cps/kBq in 2D and 11.85 (12.14) cps/kBq in 3D. The average scatter fraction was 19.79% in 2D and 46.19% in 3D. The peak noise equivalent counting rate (NECR) evaluated with single random subtraction was 89.41 kcps at 49 kBq/cc in 2D and 60 kcps at 12 kBq/cc in 3D acquisition mode. The NECR with delayed random subtraction was 61.47 kcps at 40.67 kBq/cc in 2D and 45.57 kcps at 16.45 kBq/cc in 3D. The performance of the PET scanner was satisfactory within the manufacturer-specified limits. The test result of PET shows excellent system sensitivity with relatively uniform resolution throughout the FOV, making this scanner highly suitable for whole-body studies.

Cancer survival in Barshi, India, 1993-2000

The rural cancer registry of Barshi, Paranda and Bhum, was the first of its kind in India and was established in 1987. Registration of cases is carried out entirely by active methods. Data on survival from 15 cancer sites or types registered during 1993-2000 are reported in this study. Follow-up has been carried out predominantly by active methods, with median follow-up time ranging between 2-49 months for different cancers. The proportion of histologically verified diagnosis for various cancers ranged between 73-98%; death certificates only (DCOs) comprised 0-2%; 98-100% of total registered cases were included for survival analysis. Complete follow-up at five years ranged between 96-100% for different cancers. The 5-year age-standardized relative survival rates for selected cancers were non-melanoma skin (86%), penis (63%), breast (61%), cervix (32%), mouth (23%), hypopharynx (11%) and oesophagus (4%). The 5-year relative survival by age group did not display any particular pattern. Five-year relative survival trend between 1988-1992 and 1993-2000 showed a marked decrease for cancers of the tongue, hypopharynx, stomach, rectum, larynx, lung and penis; but a notable increase for breast and non-Hodgkin lymphoma.

Intraoral adenoid cystic carcinoma: prognostic factors and outcome

Intraoral (oral cavity and oropharynx) adenoid cystic carcinomas are uncommon cancers characterized by slow evolution, protracted clinical course, multiple and/or delayed recurrences, and late distant metastases. The molecular biology behind this enigmatic disease remains poorly characterized. To analyze and correlate prognostic factors with outcome in intraoral adenoid cystic carcinoma. Medical records of 76 patients with intraoral adenoid cystic carcinoma treated with definitive loco-regional therapy at the institute between 1992 and 2004 were retrospectively reviewed and analyzed.Majority (85.5%) of the patients had advanced stage disease. Seventy-four patients underwent surgery, of which 51 (68.9%) received adjuvant radiotherapy. The median dose of radiation was 56 Gy (range 44-66 Gy). Two patients with medical co-morbidities received radical radiotherapy. Perineural invasion, margin positivity and nodal positivity were present in 24 (32.4%); 27 (36.4%); and 15 (19.7%) patients, respectively. Ten (13.1%) patients developed local recurrence and 6 (7.8%) distant metastases. With a median follow-up of 20 months (range 1-137 months), the 5-year Kaplan-Meier estimates of local control and disease-free survival were 57.9% and 47.1%, respectively. On uni-variate analysis, perineural invasion (p=0.003), oropharyngeal primary (p=0.033), and advanced T-stage (p=0.047) were associated with increased local recurrences. Perineural invasion (p=0.05) and primary site (p=0.042) also predicted disease-free survival. On multivariate analysis, both perineural invasion and primary site retained significance for local control (p=0.007, p=0.011) and disease-free survival (p=0.018, p=0.014), respectively. Intraoral adenoid cystic carcinoma is an uncommon disease with an enigmatic clinical course. Perineural invasion, site of primary, and T-stage significantly impact upon local control and disease-free survival. The role of adjuvant radiotherapy remains controversial. Larger prospective studies with mature follow-up are needed to define the optimal treatment of intraoral adenoid cystic carcinoma.

Cosmesis, Late Sequelae and Local Control after Breast-Conserving Therapy: Influence of Type of Tumour Bed Boost and Adjuvant Chemotherapy

AIMS

To study the influence of various factors affecting cosmetic outcome and late sequelae in a large cohort of women treated with breast-conserving therapy.

MATERIALS AND METHODS

Between 1980 and 2000, 1022 pathological stage I/II breast cancer patients underwent breast-conserving therapy. On the basis of the type of tumour bed boost they received after whole breast radiotherapy, these women were assigned to three groups: (A) low dose rate (LDR) brachytherapy of 15-20 Gy (n=383); (B) high dose rate (HDR) brachytherapy of 10 Gy (optimised) in a single fraction (n=153); (C) electron beam 15 Gy/six fractions (n=460). Systemic adjuvant therapy was given to 757 women, of whom 570 received adjuvant chemotherapy.

RESULTS

Cosmesis at the last follow-up was good or excellent in 77% of women. Post-radiation worsening of cosmesis was observed in 11.5% of women and was similar in the three boost groups. Moderate to severe late breast sequelae were observed in 22% of women in group B, which was significantly higher than the 12% in group A (P=0.002) and 9% in group C (P=0.0001). The actuarial 5-year local control rate was 91% and was 90, 92 and 93% in groups A, B and C, respectively. Tumour size (P=0.049) and adjuvant chemotherapy (P=0.04) were the significant factors affecting cosmetic outcome on univariate analysis. On multivariate analysis, adjuvant chemotherapy was the only factor leading to worsening in the cosmetic outcome, with P=0.03 (hazard ratio 1.65 [95% confidence interval 1.05-2.59]).

CONCLUSION

The type of tumour bed boost did not have a significant effect on the worsening of cosmetic outcome. However, there were significantly more late breast sequelae in women treated with single fraction HDR implants. Chemotherapy had an adverse effect on the cosmetic outcome, but the late breast sequelae and local control rates were comparable.

Commissioning of motorized wedge for the first equinox-80 telecobalt unit and implementation in the Eclipse 3D treatment planning system

A new model of the telecobalt unit (TCU), Theratron Equinox-80, (MDS Nordion, Canada) equipped with a single 60 degree motorized wedge (MW), four universal wedges (UW) for 15 degrees, 30 degrees, 45 degrees and 60 degrees have been evaluated. MW was commissioned in Eclipse (Varian, Palo Alto, USA) 3D treatment planning system (TPS). The profiles and central axis depth doses (CADD) were measured with Wellhofer blue water phantom for MW and the measured data was commissioned in Eclipse. These profiles and CADD for MW were compared with UW in a homogeneous phantom generated in Eclipse for various field sizes. The dose was also calculated in the same phantom at 10 cm depth. For the particular MW angle and the respective open and MW beam weights, the dose was measured for a field size of 10 cm x 10 cm in a MEDTEC water phantom at 10 cm depth with a 0.13 cc thimble ion chamber (Scanditronix Wellhofer, Uppsala, Sweden) and a NE electrometer (Nuclear Enterprises, UK). Measured dose with ion chamber was compared with the TPS calculated dose. MW angle verification was also done on the Equinox for four angles (15 degrees, 30 degrees, 45 degrees and 60 degrees). The variation in measured and calculated dose at 10 cm depth was within 2%. The measured and the calculated wedge angles were in good agreement within 2 degrees. The motorized wedges were successfully commissioned in Eclipse for four wedge angles.

Non-Hodgkin lymphoma of the Waldeyer's ring: Is a higher radiotherapy dose required?

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Background: To evaluate the prognostic factors and treatment outcome of Indian patients with primary Non-Hodgkins Lymphoma (NHL) of the Waldeyer's Ring (WR) region treated at a single institute. Methods: 269 patients with NHL of the WR treated at Tata Memorial Hospital, Mumbai from January 1990 to December 2002 were included. The median age was 45 years and majority of the patients (67%) were males. Systemic symptoms were present in only 16% of patients, primary site was the tonsil in 58%, nasopharynx in 42% and base tongue in 5% of patients. Majority had Diffuse Large B-Cell Lymphoma (85%); 26% patients presented with stage I disease and 66% had stage II disease. Treatment comprised of a combination of chemotherapy (CTh) and radiotherapy (RT) in majority of the patients (71%). Among these patients, 63% received an RT dose of =45Gy. Results: The complete response rate was 68%. After a median follow-up of 57 months, the 5 year DFS & OS for the whole group were 62.2% and 70.1% respectively. Multivariate analysis showed that; age >30 years (HR=4.05, 95%CI=1.53–10.7, p=0.005), WHO performance score =2 (HR=2.36, 95%CI=1.12–4.95, p=0.023), T-cell lymphomas (HR=5.55, 95%CI=2.43–12.7, p<0.001), bulky tumors (HR=2.08, 95%CI=1.02–4.257, p=0.045), and nasopharyngeal primary (HR=3.26, 95%CI=1.51–7.02, p=0.003), had a negative influence on survival. Patients treated with a combination of CTh & RT had a significantly better outcome than those treated with CTh alone (OS: 78.9% vs. 48.1%, p<0.00001). The hazard ratio for death (HR) in the chemotherapy alone group was 3.50 (95% CI=2.17–5.65). The CR (p=0.01), DFS (p<0.0001) and OS (p=0.002) rates were significantly better for patients receiving a RT dose of =45Gy. The HR in the subgroup that received a RT dose of < 45Gy was 5.09 (95% CI=2.39–10.86). Conclusions: Age at diagnosis, WHO performance score, T-cell histological type, size and site of the tumor significantly influence outcome in patients with primary NHL of the Waldeyer's Ring. Combined modality treatment, comprising of CTh & RT (with an RT dose of =45Gy), results in satisfactory outcome in patients with this rare neoplasm.

No significant financial relationships to disclose.

Breast movement during normal and deep breathing, respiratory training and set up errors: implications for external beam partial breast irradiation

This study was designed to evaluate interfraction and intrafraction breast movement and to study the effect of respiratory training on respiratory indices. Five patients were immobilized in supine position in a vacuum bag and three-dimensional set up errors, respiratory movement of the breast during normal and deep breathing, tidal volume and breath hold time were recorded. All patients underwent respiratory training and all the respiratory indices were re-evaluated at the end of training. Cumulative maximum movement error (CMME) was calculated by adding directional maximum set up error and maximum post training movement during normal breathing. The mean set up deviation was 1.3 mm (SD +/- 0.5 mm), 1.3 mm (SD +/- 0.3 mm) and 4.4 mm (SD +/- 2.6 mm) in the mediolateral, superoinferior and anteroposterior dimensions. Pre-training mean of the maximum marker movement during normal breathing was 1.07 mm, 1.94 mm and 1.86 mm in the mediolateral, superoinferior and anteroposterior dimensions. During deep breathing these values were 2 mm, 5.5 mm and 4.8 mm. While respiratory training had negligible effect on breast movement during normal breathing, it resulted in a modest reduction during deep breathing (p = 0.2). The mean CMME recorded for these patients was 3.4 mm, 4.5 mm and 7.1 mm in the mediolateral, superoinferior and anteroposterior dimension. Respiratory training also resulted in an increase in breath hold time from a mean of 31 s to 44 s (p = 0.04) and tidal volume from a mean of 560 cm(3) to 1160 cm(3) (p = 0.04). With patients immobilized in the vacuum bag the CMMEs are relatively less. Individualized directional margins may aid in reduction of planning target volume (PTV).

Peripheral dose from uniform dynamic multileaf collimation fields: implications for sliding window intensity-modulated radiotherapy

The increase in the number of monitor units in sliding window intensity-modulated radiotherapy, compared with conventional techniques for the same target dose, may lead to an increase in peripheral dose (PD). PD from a linear accelerator was measured for 6 MV X-ray using 0.6 cm3 ionization chamber inserted at 5 cm depth into a 35 cm x 35 cm x 105 cm plastic water phantom. Measurements were made for field sizes of 6 cm x 6 cm, 10 cm x 10 cm and 14 cm x 14 cm, shaped in both static and dynamic multileaf collimation (DMLC) mode, employing strip fields of fixed width 0.5 cm, 1.0 cm, 1.5 cm, and 2.0 cm, respectively. The effect of collimator rotation and depth of measurement on peripheral dose was investigated for 10 cm x 10 cm field. Dynamic fields require 2 to 14 times the number of monitor units than does a static open field for the same dose at the isocentre, depending on strip field width and field size. Peripheral dose resulting from dynamic fields manifests two distinct regions showing a crest and trough within 30 cm from the field edge and a steady exponential fall beyond 30 cm. All dynamic fields were found to deliver a higher PD compared with the corresponding static open fields, being highest for smallest strip field width and largest field size; also, the percentage increase observed was highest at the largest out-of-field distance. For 6 cm x 6 cm field, dynamic fields with 0.5 cm and 2 cm strip field width deliver PDs 8 and 2 times higher than that of the static open field. The corresponding factors for 14 cm x 14 cm field were 15 and 6, respectively. The factors by which PD for DMLC fields increase, relative to jaws-shaped static fields for out-of-field distance beyond 30 cm, are almost the same as the corresponding increases in the number of monitor units. Reductions of 20% and 40% in PD were observed when the measurements were done at a depth of 10 cm and 15 cm, respectively. When the multileaf collimator executes in-plane (collimator 90 degrees) motion, peripheral dose decreases by as much as a factor of 3 compared with cross-plane data. The knowledge of PD from DMLC field is necessary to estimate the increase in whole-body dose and the likelihood of radiation induced secondary malignancy.

Radical Radiotherapy in Head and Neck Squamous Cell Carcinoma: An Analysis of Prognostic and Therapeutic Factors

AIMS

Head and neck squamous cell carcinoma (HNSCC) continues to be a leading cancer in developing countries. Definitive radiation therapy either primary or as postoperative adjuvant is offered to most patients. We aimed to identify prognostic and therapeutic factors that affect locoregional control and survival in patients undergoing radical radiotherapy for head and neck squamous cell cancers.

MATERIALS AND METHODS

A retrospective analysis of 568 previously untreated patients with squamous head and neck cancers, who received radical radiotherapy between 1990 and 1996, using local control, locoregional control and disease-free survival (DFS) as outcome measures.

RESULTS

With a median follow-up of 18 months for living patients, the 5-year local control, locoregional control and DFS for all 568 patients were 53%, 45% and 41%, respectively, for all stages combined. The 5-year local control, locoregional control and DFS as per the American Joint Committee on Cancer stage grouping were 78%, 70% and 70%; 64%, 59% and 57%; 51%, 42% and 37%; and 40%, 27% and 22% from stages I to IV, respectively, with highly significant P values. Patients receiving higher doses (> or = 66 Gy) had a significantly better outcome compared with lower doses. The 5-year local control (59% vs 48%, P = 0.0015), locoregional control (47% vs 41%; P = 0.0043) and DFS (44% vs 37%; P = 0.0099) were significantly better in patients receiving > or = 66 Gy. Site of primary also affected outcome significantly, with oral cavity lesions faring badly.

CONCLUSION

Tumour stage remains the most important factor affecting outcome in radical radiotherapy of HNSCC. A definite dose-response relationship exists with higher total doses, leading to better local control, locoregional control and DFS in all stages. Site of primary affects outcome too, with laryngeal primaries doing well and oral cavity cancers faring the worst.

Breast conservation treatment in women with locally advanced breast cancer - experience from a single centre

INTRODUCTION

In absence of randomized evidence to support safety of conservative surgery (BCT) in locally advanced breast cancer (LABC), we analyzed a cohort of 664 women with LABC treated during January 1998 to December 2002 at Tata Memorial Hospital, Mumbai, India.

MATERIALS AND METHODS

All were treated with a multimodality regimen comprising of neoadjuvant chemotherapy (NACT) followed by surgery (modified radical mastectomy or BCT) and adjuvant radiotherapy and hormone therapy. The outcome was evaluated to assess safety of BCT.

RESULTS

71% (469/664) women responded to NACT (22% clinical CR and 49% PR) and 28.3% (188/664) underwent BCT. Positive lumpectomy margins were reported in 8.5%, with gross presence of tumor at the margins in 2.3% requiring a revision surgery. At a median follow-up of 30months, local relapse rate was 8% after BCT and 10.7% after mastectomy. The 3-year local DFS was better post-conservation than after mastectomy (87% vs 78%, P=0.02). The disease-free survival (DFS) was also superior after BCT, 72% vs 52% (P<0.001) at 3years and 62% vs 37% (P<0.001) at 5years respectively. On multivariate analysis, presence of lymphatic vascular emboli (LVE) was the major significant predictor of local recurrence (P<0.001, HR 2.52, 95% CI 1.52-4.18). DFS was better after BCT [(P<0.001, HR 2.0 (95% CI 1.38-2.91)]; shorter DFS was noted in LVE positive (HR 1.54, P=0.007) and larger residual disease after NACT (HR 1.13, P=0.001).

CONCLUSION

BCT is technically feasible and safe post neo-adjuvant chemotherapy in women with LABC with no detriment in outcome.

Ultrasonographic changes in malignant neck nodes during radiotherapy in head and neck squamous carcinoma

Limited information is available about the sonomorphological changes in metastatic neck nodes during radiotherapy. The aim of this study was to evaluate the pattern of sonomorphological changes in metastatic neck nodes with radiotherapy. The study population consisted of 16 consecutive patients planned for radical radiotherapy to the head and neck. All patients were subjected to four ultrasound examinations: before therapy, at 46 Gy, at the conclusion of radiation and at first follow up. A total of 59 ultrasound examinations were performed on 16 patients. The difference between the mean number of nodes detected per patient before (10.6) and after (7.8) radiation was significant (P = 0.05). Sixteen nodes were categorized as malignant at first sonography, half of which reverted back to normal by the end of radiation. Changes in the sonomorphology of malignant cervical lymph nodes occur with radiotherapy with more that half demonstrating reversion to normal pattern. Future studies correlating this with histopathology should be considered.

Split therapy: Planned neck dissection followed by definitive radiotherapy for a T1, T2 pharyngolaryngeal primary cancer with operable N2, N3 nodal metastases—A prospective study

BACKGROUND

The management of patients with a small pharyngolaryngeal cancer (T1 and T2) with large nodal metastases is a subject of debate. We present data on the feasibility and outcome of treating these patients with surgery for the nodal metastases followed by definitive radiotherapy.

METHODS

Prospective study of 59 patients of small pharyngolaryngeal primary squamous carcinomas with operable (N2/N3) nodal metastasis treated with neck dissection followed by radiotherapy.

RESULTS

Complete nodal clearance was achieved in 54 (90%). The mean nodal size was 4 cm and extranodal extension was seen in 88% of patients in the study group. There were no significant postoperative complications. Median interval between surgery and radiotherapy was 23 days. Forty-nine patients (83%) started their RT within 6 weeks of surgery. With a median follow-up of 25 months, the disease free and overall survival was 54% and 60% (5 years).

CONCLUSION

The management of patients with a radiocurable pharyngolaryngeal primary with large nodes by this approach is a feasible option with adequate control and survival.

Primary malignant tumors of the trachea - the Tata Memorial Hospital experience

OBJECTIVE

Primary tumors of the trachea are extremely rare. Treatment methods vary considerably and few studies have sought to provide adequate guidelines. This study reviews the records of patients treated for tracheal cancer at the Tata Memorial Hospital (TMH), Mumbai, India.

SUBJECTS AND METHODS

Fifteen patients with primary tracheal malignancies were identified in the TMH database during the period from 1983 to 2000. They were predominantly males (87%) belonging to an older age-group (67% above 40 years). Common presenting symptoms were cough, hoarseness, hemoptysis and indications of airway obstruction. Squamous cell carcinoma was the commonest histologic subtype (40%) followed by adenoid cystic carcinoma (27%). Ten patients received radical treatment. One patient underwent surgery (resection and anastomosis) and received postoperative radiotherapy. Another was explored but was found to be unresectable and was 1 of 2 patients treated with chemotherapy and radiotherapy. Laser resections and radiotherapy were used in 2 patients while 4 patients were managed with radiotherapy alone. One patient was treated elsewhere. The majority of patients (8/9) were treated with locoregional fields and doses ranging from 40 to 60 Gy (median 50 Gy). Two patients also received intraluminal brachytherapy, 1 as part of initial treatment and another for recurrence.

RESULTS

Only 5 patients treated at TMH (5/9) achieved local control of their disease. Follow-up times ranged from 1 month to 134 months, median of 38 months. Distant metastases were identified in 4 patients (bone n = 1 and lung n = 3). Median survival was 38 months. Overall survival at 5 years was 37% by Kaplan-Meier method, but this figure should be treated with caution since only 6 patients had a follow-up of more than 2 years.

CONCLUSION

Tracheal cancer is a rare malignancy. Radiation therapy is a reasonably effective modality for unresectable disease.

Consolidation radiation after complete remission in Hodgkin's disease following six cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy: is there a need?

PURPOSE

Combined modality treatment using multidrug chemotherapy (CTh) and radiotherapy (RT) is currently considered the standard of care in early stage Hodgkin's disease. Its role in advanced stages, however, continues to be debated. This study was aimed at evaluating the role of consolidation radiation in patients achieving a complete remission after six cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy using event-free survival (EFS) and overall survival (OS) as primary end points.

PATIENTS AND METHODS

Two hundred and fifty-one patients with Hodgkin's disease attending the lymphoma clinic at the Tata Memorial Hospital (Mumbai, India) from 1993 to 1996 received induction chemotherapy with six cycles of ABVD after initial staging evaluation. A total of 179 of 251 patients (71%) achieved a complete remission after six cycles of ABVD chemotherapy and constituted the randomized population. Patients were randomly assigned to receive either consolidation radiation or no further therapy.

RESULTS

With a median follow-up of 63 months, the 8-year EFS and OS in the CTh-alone arm were 76% and 89%, respectively, as compared with 88% and 100% in the CTh+RT arm (P =.01; P =.002). Addition of RT improved EFS and OS in patients with age < 15 years (P =.02; P =.04), B symptoms (P =.03; P =.006), advanced stage (P =.03; P =.006), and bulky disease (P =.04; P =.19).

CONCLUSION

Our study suggests that the addition of consolidation radiation helps improve the EFS and OS in patients achieving a complete remission after six cycles of ABVD chemotherapy, particularly in the younger age group and in patients with B symptoms and bulky and advanced disease.

Experience with telepathology at a tertiary cancer centre and a rural cancer hospital

BACKGROUND

Telepathology allows quick and timely access to an expert opinion, no matter where the patient is located. We analysed the experience with the use of telepathology between a tertiary cancer centre and a rural cancer hospital.

METHODS

Ninety-three cases were analysed in which static telepathology was used to obtain a consultation between Tata Memorial Centre and Nargis Dutt Memorial Cancer Hospital at Barshi, a rural area.

RESULTS

Successful teleconsultation was achieved in all cases. A diagnosis was offered in 92 cases (98.9%) and was deferred in 1 case (1.1%). Complete concordance, clinically unimportant minor discrepancy and hedged diagnosis were obtained in 83 cases (90.2%). Major discrepancies were encountered in 9 cases (9.7%). The number of images per case ranged from 3 to 27 (average: 7 images). Images were of diagnosable quality in 89.2% of cases. Most of the cases (77.4%) were reported within 3 days; 32.2% were reported within 8 hours (a single working day) and 45.1% within 1-3 days.

CONCLUSION

Telemedicine can be effectively used to bridge the gap between medically underprivileged, geographically distant rural areas and advanced centres using the static store and forward methodology.

Hypofractionated radiotherapy in carcinoma cervix IIIB: Tata Memorial Hospital experience

PURPOSE OF THE STUDY

To analyze the role of hypofractionated radiotherapy in advanced carcinoma of cervix.

BASIC PROCEDURE

Medical records of 62 women with advanced carcinoma cervix III3 treated during 1994-1996 were reviewed. Patients were treated with standard pelvic portals to a total dose of 39Gy in 13 fractions over 17 days followed by intracavitary brachytherapy. Forty-eight patients completed the planned treatment and were considered suitable for analysis of late reactions and survival.

MAIN FINDINGS

The 5-year disease free survival was 59% and the overall survival was 50% at the mean follow up of 40 months. Twenty-one (44%) patients developed acute gastrointestinal toxicity of which 5 patients had grade III and one patient had grade IV reaction. Ten patients (21%) developed acute genitourinary complications, 13 patients (27%) had late rectal reactions and 10 patients (20%) had late bladder complications. Three patients had grade I, five had grade II and five had grade III late rectal toxicity.

CONCLUSION

Survival in patients treated hypofractionated radiotherapy appears comparable to that of standard fractionation. The acute gastrointestinal and skin reactions were mainly grade I or grade II. Hypofractionated radiotherapy can certainly be considered in a select group of patients where the local disease is extensive and is unsuitable for conventional treatment.

Transperineal low-dose rate iridium-192 interstitial brachytherapy in cervical carcinoma stage IIB

PURPOSE

To assess local control, survival and complications in patients with cervical carcinoma Stage IIB treated radically with transperineal Iridium-192 low-dose rate interstitial brachytherapy following external beam radiotherapy.

PATIENTS AND METHODS

65 women (age 25-70 years, mean 47 years) with cervical carcinoma Stage IIB were initially treated with external beam radiotherapy on a telecobalt or 6 MV linear accelerator to a dose of 50 Gy delivered in 5-6 weeks. After 2-3 weeks of completing external radiation, patients received interstitial brachytherapy with Iridium-192 (activity 0.5-1 mCi/cm) using a Syed-Neblett perineal template. The median dose delivered to the implant volume was 24 Gy (range 20-32 Gy) delivered at an average dose rate of 0.70 Gy/h (range 0.40-1.20 Gy/h). A point defined at 1.5 cm lateral to the central uterine tandem at the level of os was taken as a representative for assessing the dose to the cervix. Mean doses delivered by interstitial brachytherapy to point A, cervix, point B and rectum were 38 Gy, 34 Gy, 16 Gy and 16 Gy, respectively.

RESULTS

At a median follow-up of 53 months, the actuarial disease free survival and overall survival for 65 patients at both 5 and 10 years was 64% and 44%, respectively. Response to radiotherapy was a strong predictor of local control with 82% of patients continuing to have pelvic control after initial complete response. Overall, nine (14%) patients had persistent disease, ten (15%) developed a central recurrence after initial control and three patients developed distant metastasis on follow-up. No patient had any immediate treatment-related complication. Late toxicity included grade I-II rectal reactions in five patients and grade IV bladder complication (vesico-vaginal fistula) in two patients. 5 years after treatment, one patient developed intestinal obstruction, which was relieved after conservative management. Two patients developed vaginal stenosis. The 5- and 10-year disease free survival was 48% in patients aged less than 45 years as compared to 80% in patients of more than 45 years (p = 0.009). Dose to the cervical point was a prognostic indicator with 5- and 10-year disease free survival of 47% in patients who received < 35 Gy in comparison to 80% in patients who had > 35 Gy (p = 0.03). There was no difference in local control and survival in patients with minimal and moderate parametrial involvement. Bulky disease (> 4 cm) at presentation and a longer gap between external radiation and brachytherapy showed a trend towards inferior local control.

CONCLUSIONS

Interstitial brachytherapy after external beam irradiation in patients with cervical carcinoma Stage IIB results in acceptable local control, survival and complication rates. Increased dose to the cervical disease results in improved local control and survival and should therefore be considered while optimizing brachytherapy treatment plans. Comparison of the results with those of standard intracavitary therapy remains to be proven in a randomized trial.

Primary extranodal mucosa associated lymphoid tissue (MALT) lymphoma of the prostate

Low-grade B-cell mucosa associated lymphoid tissue (MALT) lymphoma can rarely present primarily in extranodal sites other than stomach, which is the most common site for it. Until now only four cases of primary prostatic MALTomas have been described in the literature and we report the fifth. We describe a case of primary prostatic MALToma in a 67-year-old man and the diagnosis was made on the trans-urethral resection specimen of the prostate. As the disease was limited to prostate (stage IEA), the patient was treated with external beam radiation therapy to a total dose of 4400cGy in 22 fractions. The patient achieved completed remission and has remained free of disease in the following 36 months.

Radiation therapy in T1-T2 glottic carcinoma: influence of various treatment parameters on local control/complications

PURPOSE

To evaluate the influence of various treatment parameters on local control as well as complications in T1 and T2 glottic carcinomas.

METHODS AND MATERIALS

Between 1975 and 1989, 676 patients with early glottic carcinoma (460 T1 and 216 T2) received curative radiation with three different treatment regimens, as follows: Regimen 1-50 Gy/15 Fr/3 weeks (3.33 Gy/daily) for 192 patients; Regimen 2-60-62.5 Gy/24-25 Fr/5 weeks (2.5 Gy/daily) for 352 patients; and Regimen 3-55-60 Gy/25-30 Fr/5-6 weeks (2-2.25 Gy/daily) for 132 patients.

RESULTS

The local control at 10 years was 82% and 57% for T1 and T2 lesions respectively (p = 0.0). For the T1N0M0 group, field size had significant impact on local control with both univariate (p = 0.05) and multivariate (p = 0.03) analysis. For T2N0M0, group field size (p = 0.03) as well as registration year (p = 0.016) were significant in univariate analysis whereas only field size remained significant on multivariate analysis. Persistent radiation edema was noted in 146 (22%) patients and was significantly worse with larger field size (p = 0.000) but not related to different treatment regimens.

CONCLUSION

The shorter fractionation schedule had comparable local control, without increased complications in comparison to the protracted schedule and is best suited for a busy department.

Discrepancies in Epstein-Barr virus association at presentation and relapse of classical Hodgkin's disease: impact on pathogenesis

BACKGROUND

Though Epstein-Barr virus (EBV) has been linked to classical Hodgkin's disease (cHD), only a proportion of cHD cases show EBV-association. While there has been evidence to suggest a crucial role for EBV in the early phase of cHD evolution, we are unclear whether continued presence of EBV is essential for the maintenance of the neoplasm. We have addressed this issue by investigating the EBV-association in paired samples of cHD obtained at presentation and relapse.

MATERIALS AND METHODS

We have analysed lymph node biopsy samples from 23 cases of cHD at presentation and relapse. In situ hybridization with EBER-1 probe and immunostaining with anti latent membrane protein-1 (LMP-1) antibody was performed on the paraffin sections. PCR for EBNA 3C gene was performed for EBV subtype analysis on the DNA extracted from paraffin sections.

RESULTS

EBV-association was documented in both the presentation and relapse samples of 14 cases. One case showed loss of EBV-association at relapse. PCR analysable DNA was obtained from both presentation and relapse samples in four of the EBV-associated cases. The EBNA 3C amplimer corresponded to type A strain of EBV in all the samples.

CONCLUSION

Loss of EBV-association between presentation and relapse seen in one case implies a hit and run mechanism in EBV-induced lymphomagenesis. Though EBV may be essential early in the evolution of cHD, it may not be required for maintenance of the neoplastic clone. Our study also brings out a speculation that a proportion of EBV-negative cHD could represent loss of EBV in the tumour prior to clinical presentation. Alternatively, an unidentified lymphotropic virus other than EBV might play a pathogenetic role in EBV-negative cHD.

Primary carcinoma of the vagina: Tata Memorial Hospital experience

PURPOSE

Carcinoma of the vagina is a rare gynecological malignancy comprising approximately 2% of all the gynecological malignancies. We have analyzed the treatment outcome of the patients treated at the Tata Memorial Hospital from January 1984 to December 1993.

METHODS AND MATERIALS

In this 10-year period, 134 patients of primary vaginal cancers were registered at our hospital. Of these, 75 patients received complete treatment and are analyzed.

RESULTS

Disease-free survival (DFS) for the whole group is 50%, and overall survival (OAS) is 60%. Most locoregional recurrences and distant failures are noted in the 2 years following treatment. DFS at 5 years is as follows: Stage I (5 patients), Stage IIA (37 patients), Stage IIB (15 patients), Stage III (14 patients), and Stage IV (4 patients); are 40%, 55%, 60%, 50%, and 25%, respectively. The DFS for patients with complete response (42 patients) to external radiation at 5 years is 68%, with partial response (25 patients) is 35%, and with poor or no response (6 patients) is 18% (p = 0.0000). We observed that brachytherapy was an important part of the treatment, and patients who received brachytherapy (59 patients), either with a vaginal intracavitary applicator (30 patients) or interstitial implant (29 patients) had a DFS of 53% and 56%, respectively, while 15 patients who received external radiation alone had a DFS of 30%. Patients receiving brachytherapy within 4 weeks of external radiation had a DFS of 60% as compared to 30% when the interval was more than 4 weeks.

CONCLUSION

The factors indicating prognosis are: site and extent of involvement, presence of lymph nodes at presentation, technique of brachytherapy, and interval between external radiation and brachytherapy.

Epstein-Barr virus association in classical Hodgkin's disease provides survival advantage to patients and correlates with higher expression of proliferation markers in Reed-Sternberg cells

BACKGROUND

Most Epstein-Barr virus (EBV) associated lymphoproliferative disorders have high proliferation indices. However, classical Hodgkin's disease (cHD) is heterogeneous, with respect to proliferation index of the Reed-Sternberg cell (RS cell), and EBV association. Hence, we investigated whether cHD with and without EBV-association differ with respect to the proliferation index of the RS cells. Further we investigated whether this would have a bearing on patients survival.

PATIENTS AND METHODS

We investigated 110 cases of cHD for: a) EBV association by immunohistochemical demonstration of EBV-latent membrane protein-1 and EBV encoded nuclear RNA 1 by mRNA in situ hybridisation; b) Proliferating cell nuclear antigen (PCNA) expression in the RS cells.

RESULTS

EBV association was noted in 86 of 110 cases (78%). Higher PCNA expression (P = 0.004) and younger age (P = 0.001) correlated independently with EBV association. The 10 year relapse free survival (RFS) of EBV+ and EBV- patients were 60% and 44%, respectively (P = 0.03). The 10 year overall survival (OS) of EBV+ and EBV- patients were 85% and 64%, respectively (P = 0.03). EBV association maintained its significant impact on RFS and OS within Cox proportional hazard model.

CONCLUSIONS

Our study suggests that EBV is likely to confer a higher PCNA expression and also contribute towards maintaining the RS cells of cHD in cell cycle. Hence, RS cells in EBV associated cHD would be more responsive to chemotherapy and radiotherapy associated DNA damage. Thus, EBV-association provides survival advantage to cHD patients treated with standard chemotherapy and radiotherapy protocols.

The quality of swallowing for patients with operable esophageal carcinoma: a randomized trial comparing surgery with radiotherapy

BACKGROUND

Surgery is considered the standard treatment for operable esophageal carcinoma, although there is no compelling evidence that surgery can achieve better results than radiotherapy. There has previously been no direct randomized comparison of these two modalities with survival or disease specific outcome end points.

METHODS

Ninety-nine patients with operable squamous cell carcinoma of the esophagus were randomly allocated to surgery or radiotherapy after stratification for tumor length (< or = or >5 cm). Those randomized to surgery underwent transthoracic esophagectomy with limited lymphadenectomy, whereas those in the radiotherapy arm received 50 gray in 28 fractions followed by a 15-gray boost to the primary tumor. Disease specific outcome was assessed for 4 subgroups: 1) disease specific symptoms, 2) physical symptoms, 3) ability to work, and 4) social/family interaction and global perception of disease specific outcome. The questionnaire was given prior to treatment and posttreatment at 3-month intervals for 1 year. Death was a secondary end point.

RESULTS

There was an overall improvement in the quality of swallowing in both treatment arms after treatment and with the passage of time. The swallowing status was better in the surgery arm than in the radiotherapy arm at 6 months after treatment (P = 0.03, Fisher's exact test). Logistic regression analysis showed randomization arm (P = 0.035), time since treatment (P = 0.003), and pretreatment swallowing status to be significant determinants of posttreatment swallowing status. Surgery was twice as likely to result in improvement in swallowing than radiotherapy after correction for time and pretreatment swallowing status. Overall survival was better in the surgery arm than in the radiotherapy arm (P = 0.002, log rank test) (OR = 2.74 with 95% confidence intervals 1.51-4.98; P < 0.009, Cox proportional hazards model).

CONCLUSIONS

Both surgery and radiotherapy can improve the quality of swallowing significantly for patients with operable esophageal carcinoma. Surgery is marginally superior to radiotherapy in improving the quality of swallowing. In this trial, survival in the surgery arm was significantly better than in the radiotherapy arm, although the small number of patients is a limitation.

Survival analysis of 5595 head and neck cancers--results of conventional treatment in a high-risk population

This is a study of 5595 head and neck cancer patients treated during 1987-89 at TMH, Mumbai. The study included 1970 oral cancers (ICD 140-145), 1495 oropharyngeal cancers (ICD 1410, 1453, 146), 1255 hypopharyngeal cancers (ICD 148), 125 nasopharyngeal cancers (ICD 147) and 750 laryngeal cancers (ICD 161). The clinical extent of disease at presentation was based on TNM group staging (UICC 1978). For the majority of sites, patients attended the hospital during stage III and stage IV of the disease; the only exception was for cancers of the lower lip, anterior tongue and vocal cord when between 46.2% and 56.5% of patients with localized cancer (stage I and II) were seen. Generally, surgery either alone or with radiation has been administered for oral cancer patients whereas radiation either alone or in combination with chemotherapy was administered for other head and neck sites. The overall 5-year survival rate was in the range of 20-43% for oral cancer, 8-25% for pharyngeal cancers and 25-62% for laryngeal cancer. The 5-year relative survival rates were more or less in agreement with the results published by the Eurocare study for head and neck cancers. The importance of primary prevention in head and neck cancer is stressed.

Dosimetry of intracavitary applications in carcinoma of the cervix: rectal dose analysis

The International Commission on Radiation Units and Measurements (ICRU), in its Report-38, has given certain recommendations regarding the specifications of bladder and rectal reference points in the intracavitary treatment of carcinoma of the cervix. Conforming to this report, 182 intracavitary applications performed in stage I and II cervix cases were analyzed. In 113 applications, the maximum rectal dose was found to be in a point on the anteroposterior line drawn through the centre of colpostat sources. However, for our type of applications, the point on the anteroposterior line drawn through the lower end of the uterine tube seldom gets maximum dose. In addition, it was observed that there are other dose points than the ICRU reference point receiving doses close to maximum dose. It was concluded that doses to multiple rectal reference points should be recorded, in addition to the ICRU-defined rectal reference point.

Design and comparison of wedge shaped midline block with rectangular block used in early stage cervical cancers

PURPOSE

Design of an universal wedge shaped midline block for early stage cervical cancers to get uniform dose distribution around the target volume.

MATERIAL AND METHODS

The method of fabrication of wedge shaped midline block is discussed for treatment of early stage cervical cancers based on the configuration of 137Cs pellets used in intracavitary applications and along with external photon beams obtained by using 60Co teletherapy machine and 6 and 10 MV linear accelerators.

RESULTS

The dosimetric measurements are carried out to confirm the adequacy of thickness and shape of the block using radiation field analyzer for all the 3 energies.

DISCUSSION

The dose distribution comparison has been made with wedge shaped midline block and conventional rectangular shields to show its superiority in getting homogeneous dose distribution around target volume. The shift in 184 intracavitary applications is analyzed in actual clinical applications with respect to central axis of external beams and its comparison is made with both types of blocks. With the shift of 1 cm towards lateral from midline an overdose can occur upto 12 Gy at certain points with rectangular block compared to wedge shaped midline block.

CONCLUSION

Since the preparation of individual wedge shaped midline block for every application will be a difficult process for busy centers, the single wedge shaped midline block for each energy is more convenient to handle for busy centers instead of individualized compensating blocks for every intracavitary application.

Geometrical considerations in dose volume analysis in intracavitary treatment

PURPOSE

The present work was aimed at to study the relationship between the volume enclosed by reference isodose surface and various geometrical parameters of the intracavitary applicator in treatment of carcinoma of cervix.

MATERIAL AND METHODS

Pearshape volume of the reference isodose derived from the Total Reference Air Kerma (TRAK) and the product of its dimensions, height H, width W and thickness T which is dependent on the applicator geometry, were estimated for 100 intracavitary applications treated by Selectron LDR machine. Orthogonal radiographs taken for each patient were used for measurement of actual geometric dimensions of the applicator and carrying out the dosimetry on TP-11 treatment planning system. The dimensions H, W and T of reference isodose surface (60 Gy) were also noted.

RESULTS

Ratio of the product HWT and the pearshape volume was found mainly to be a function of colpostat separation and not of other geometrical parameters like maximum vertical and anterio-posterior dimension of the applicator. The ratio remained almost constant for a particular combination of uterine tandem and colpostat. Variation in the ratios were attributed to the non-standard geometry.

CONCLUSION

The ratio of the volume of reference isodose surface to the product of its dimensions in the applicator depends upon the colpostat separation.

Hodgkin's disease relapse presenting as Pancoast's syndrome

Among the various infrequent causes of Pancoast's syndrome, Hodgkin's disease is one. A 26 year old man was diagnosed as Hodgkin's disease. Five years later the disease relapsed producing Pancoast's syndrome. The importance of precise aetiological diagnosis before treatment of such cases with similar presentation is emphasized.

Treatment results of Hodgkin's disease in Indian children

This is a retrospective study of Hodgkin's disease in children less than 15 years of age who were registered at Tata Memorial Hospital in India from January 1985 through December 1990. Clinicopathologic characteristics and response were evaluated in 147 patients and survival was calculated in 187. There were 126 boys and 21 girls (6:1). All patients were treated with combination chemotherapy and involved field radiotherapy. The COPP schedule was given to 108 patients. COPP/ABVD to 33, and ABVD to 6. Ninety-three patients (63%) had stage I or II disease and 54 (37%) had stage III or IV disease. B symptoms were observed in 65 patients (56%) and bulky disease in 40 (27%). Histologically, the most common subtype was mixed cellularity, seen in 95 patients (65%). Complete response was observed in 136 (89%), partial response in 6 (4%), and there were 4 treatment-related deaths. Relapse has been observed in 11%. Seven-year actuarial survival was 73% and event-free survival was 64%. Median survival has not yet been reached, with a median follow-up of 36 months.

Modified MACOP-B chemotherapy for intermediate and high grade non Hodgkins lymphomas

Combination chemotherapy consisting of methotrexate with leucovorin rescue, doxorubicin, cyclophosphamide, vincristine, prednisolone and bleomycin (MACOP-B) has been extensively used for the treatment of Non Hodgkins Lymphoma. However, different results have been reported. The aim of this study was to assess the feasibility of administration of this regimen on an out patient basis and to confirm the efficacy of MACOP-B. 51 patients with intermediate--and high--grade lymphoma were treated with this regimen in a single institute study. Numerous clinical features predictive of response and disease free survival were analysed. The Median age was 48 years (range 14-77). Diffuse large cell lymphoma was seen in 65%, diffuse small cleaved in 10% and diffuse mixed in 15%. Eight patients (15%) had Stage I disease, 18 (35%) Stage II, 12 (23%) Stage III and 13 (25%) Stage IV. Complete remission was achieved in 65% of the patients. With a median follow up of 18 months, 40% of the patients are alive at 40 months. Sixty percent of the complete responders are disease free at 40 months. Response rates did not differ significantly for age, sex, stage, histology, bone marrow involvement and extranodal disease. However patients with absence of B' symptoms, non bulky disease at presentation and diffuse large cell histology had a higher percentage of complete remission. Hematological toxicity occurred in 90% and was grade IV in 14% patients. Three patients died of sepsis. Severe mucositis occurred in 40% of the patients. In conclusion, while it is possible to give aggressive chemotherapy at the out patient basis in India we failed to confirm the high response rates as originally reported.

Dilation of esophageal strictures induced by radiation therapy for cancer of the esophagus

During a 2-year period, 103 consecutive patients undergoing dilation of esophageal strictures induced by radiation therapy for cancer of the esophagus were prospectively studied. The length of the strictures ranged from 0.5 to 13.5 cm (median, 5 cm) and the luminal diameter from 1 to 11 mm (median, 6 mm). Patients were referred for dilation from 2 weeks to 5 years (median, 2 months) after completion of radiation therapy. The guide wire was placed using fluoroscopy in 21 patients, endoscopy in 61, and a combination of endoscopy and fluoroscopy in 21. At least one dilator larger than the stricture could be passed in 101 (98%) patients. Five strictures were dilated to 16 mm, 29 to 15 mm, 28 to 14 mm, 16 to 12.8 mm, and 23 to 12 mm or less during the initial procedure. Development of complications and severe resistance were the limiting factors for optimal dilation. Relief of dysphagia was adequate in 66% of patients. The duration of dysphagia relief was 3 to 84 weeks (median, 16 weeks). Complications included persistent pain in 7 patients, unexplained fever in 2, perforation in 2, and delayed tracheo-esophageal fistula in 1. Two patients died of treatment-related complications. Repeated dilation was required in 32 of the 75 patients on long-term follow-up. We conclude that adequate palliation of dysphagia can be achieved by dilation in two-thirds of patients with radiation therapy-induced strictures of the esophagus. Dilation of these strictures is relatively simple and safe if performed with care.

Treatment volume from total reference air kerma (TRAK) in intracavitory applications and its comparison with ICRU reference volume

PURPOSE

A systematic dosimetry study conforming to International Commission on Radiation Units and Measurements Report Number 38, was carried out for, cancer of Cervix Stage I and II cases at Tata Memorial Hospital.

METHODS AND MATERIALS

The reference Volume dimension were noted for each applicator. Also 3-D dosimetry was performed for selected cases, and actual geometric volume enclosed by various isodose surfaces were obtained. A relation was derived, which gave the volume enclosed by any isodose surface as a function of total reference air kerma of the sources in the applicator. The volume enclosed by reference isodose surface was compared with the product of its dimensions height, width, and thickness.

RESULTS

The volume enclosed by any isodose surface of an intracavitary application can be easily derived from total reference air kerma of the sources within the applicator.

CONCLUSION

Ratio of the volume enclosed by reference isodose surface with the product of its dimensions (HWT) could be a predictive parameter for clinical outcome, besides the reference volume specified by the report.