Radiotherapy in Oral Cancers: Current Perspective and Future Directions

Oral cancers form one of the most common malignancies seen worldwide, with a steady increase in number over time. Surgery with the addition of adjuvant therapy forms the cornerstone of therapeutic management for these cancers. Despite excellent surgical management, loco-regional recurrences have always been of concern. This has expanded the role of radiotherapy, with concomitant therapies, allowing to establish an effective management protocol. Over the last two decades, there have been huge strides taken towards understanding these specific aspects and providing insight into the most fruitful application of radiotherapy in these patients. In this chapter, we have presented the oncologists perspective to dealing with the non-surgical aspects of oral cancer management. We have elaborated on the chronological order with which radiotherapy has evolved and provided the contemporary aspects of decision making, essential for current practice. The evidence-based approach will address all components of radiotherapy workflow from basic understanding of patient’s anatomy, planning & evaluation during therapy to the outcomes & toxicity profiles to be expected in day-to-day clinics. Established guidelines have been incorporated into the graphical representations to ensure scenario-based understanding. Future perspectives, essential for identifying the possible direction of therapy & potential improvements in outcomes, have also been addressed

Epworth Sleepiness Scale- a novel tool to assess somnolence syndrome in patients receiving radiotherapy to the brain

Purpose: Radiation to brain causes early, early-delayed, and delayed side effects. There is paucity of literature regarding early-delayed effects like somnolence syndrome. Existing studies use general symptom assessment and visual analog scales. Epworth Sleepiness Scale (ESS) is a time tested tool to assess daytime sleepiness in various conditions. In this study, the ESS has been used to determine the occurrence of somnolence in patients receiving cranial radiotherapy for primary and metastatic brain tumors. Thus the ESS has been used in a novel setting in our study. The ESS is a simple to administer questionnaire and may be useful in grading the severity of somnolence. To our knowledge, this is the second study to determine post radiation somnolence using ESS. Methods: This prospective study was conducted in 23 patients with primary and metastatic brain tumor. Patient demographics and tumor type and grade was noted. Those with Karnofsky Performance Scale (KPS) less than 70 and with pre-existing sleep disorders were excluded. Radiotherapy regimen included palliative whole brain radiation for brain metastases and conformal adjuvant radiotherapy for primary brain tumors as per standard guidelines. All subjects included were administered ESS at baseline and weekly thereafter during and for 6 weeks after radiation. Results: All 23 patients (median age 50 years) completed the planned questionnaires until 6 weeks post radiation. Twenty (87%) patients had primary brain tumors whereas three (13%) patients had metastatic lesions in brain. Of the 23 patients, 14 patients (60.86%) had abnormal or increased daytime sleepiness; of which 3 had ESS scores greater than 16. Conclusion: Somnolence was noted in 60.86% of the patients, which is in accordance with existing literature. Epworth sleepiness scale is an effective tool to detect and quantify somnolence, However, it does not consider other symptoms of somnolence syndrome and hence should be combined with visual analog scale to get complete information

Equivalent dose in 2 Gy (EQD2) to pelvic lymph nodes using volume based prescription for three brachytherapy applicators — a dosimetric retrospective analysis

BACKGROUND: Pelvic lymph node (PLN) metastasis has been included in the FIGO staging, so there is a need to determine the dose contribution from brachytherapy to ascertain the total delivered dose to the pelvic lymph nodes in cervical cancer. The aim of the study was to calculate the equivalent dose in 2 Gy (EQD2) of the pelvic lymph nodes (PLNs) based on volume prescription using three applicators. Materials and methods: Forty-one patients who had undergone external beam radiotherapy followed by brachytherapy using tandem ovoids (TO), tandem ring (TR) and TO + free hand interstitial needles (TO + FH) applicators were taken for this study. 26 Gy in 4 fractions was prescribed to HRCTV. The external iliac node (ELN), internal iliac node (ILN) and obturator (OBT) were contoured and the median EQD2 of the lymph nodes was calculated. RESULTS: The median bilateral EQD2 values of ELN were 1.55 Gy (TR), 1.75 Gy (TO), 1.9 Gy (TO + FH), of ILN these were 2.57 Gy (TR), 3.27 Gy (TO), 3.04 Gy (TO + FH), and of OBT these were 3.69 Gy (TR), 4.46 Gy (TO), 4.69 Gy (TO + FH), respectively. The total median EQD2 values of TR, TO and TO + FH were 52.71 Gy, 53.03 Gy, and 53.88–62.73 Gy, respectively. CONCLUSION: Our study calculated the median EQD2 to the pelvic lymph nodes using three types of applicators in brachytherapy. This could serve as reference to decide on the EBRT boost dose while treating patients with enlarged pelvic lymph nodes

Comparison of manual and inverse optimisation techniques in high dose rate intracavitary brachytherapy of cervical cancer: A dosimetric study

Aims and objectivesTo compare dosimetrically the manual optimisation with IPSA using dose volume histograms (DVH) among patients treated for carcinoma of cervix with intracavitary brachytherapy.BackgroundWith the advent of advanced imaging modalities, there has been a shift from conventional X-ray based planning to three-dimensional planning. Manual optimisation is widely used across various institutions but it is time consuming and operator dependant. Inverse planning simulated annealing (IPSA) is now available in various brachytherapy planning systems. But there is a paucity of studies comparing manual optimisation and IPSA in treatment of carcinoma cervix with intracavitary brachytherapy and hence this study.Materials and methodsFifteen consecutive patients treated between December 2013 and March 2014 with intracavitary brachytherapy for carcinoma of cervix were selected for this study. All patients were initially treated with external beam radiotherapy followed by intracavitary brachytherapy. The DVH was evaluated and compared between manually optimised plans and IPSA in the same set of patients.ResultsThere was a significant improvement in the HRCTV coverage, mean V100 of 87.75% and 82.37% (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.001) and conformity index 0.67 and 0.6 (p[[ce:hsp sp="0.25"/]]=[[ce:hsp sp="0.25"/]]0.007) for plans generated using IPSA and manual optimisation, respectively. Homogeneity index and dose to the OARs remained similar between the two groups.ConclusionThe use of inverse planning in intracavitary brachytherapy of cervix has shown a significant improvement in the target volume coverage when compared with manual planning

Epworth Sleepiness Scale- a novel tool to assess somnolence syndrome in patients receiving radiotherapy to the brain

Purpose: Radiation to brain causes early, early-delayed, and delayed side effects. There is paucity of literature regarding early-delayed effects like somnolence syndrome. Existing studies use general symptom assessment and visual analog scales. Epworth Sleepiness Scale (ESS) is a time tested tool to assess daytime sleepiness in various conditions. In this study, the ESS has been used to determine the occurrence of somnolence in patients receiving cranial radiotherapy for primary and metastatic brain tumors. Thus the ESS has been used in a novel setting in our study. The ESS is a simple to administer questionnaire and may be useful in grading the severity of somnolence. To our knowledge, this is the second study to determine post radiation somnolence using ESS. Methods: This prospective study was conducted in 23 patients with primary and metastatic brain tumor. Patient demographics and tumor type and grade was noted. Those with Karnofsky Performance Scale (KPS) less than 70 and with pre-existing sleep disorders were excluded. Radiotherapy regimen included palliative whole brain radiation for brain metastases and conformal adjuvant radiotherapy for primary brain tumors as per standard guidelines. All subjects included were administered ESS at baseline and weekly thereafter during and for 6 weeks after radiation. Results: All 23 patients (median age 50 years) completed the planned questionnaires until 6 weeks post radiation. Twenty (87%) patients had primary brain tumors whereas three (13%) patients had metastatic lesions in brain. Of the 23 patients, 14 patients (60.86%) had abnormal or increased daytime sleepiness; of which 3 had ESS scores greater than 16. Conclusion: Somnolence was noted in 60.86% of the patients, which is in accordance with existing literature. Epworth sleepiness scale is an effective tool to detect and quantify somnolence, However, it does not consider other symptoms of somnolence syndrome and hence should be combined with visual analog scale to get complete information.</p