Dose to swallowing structures and dysphagia in head and neck Intensity Modulated Radiation Therapy – A long term prospective analysis

AimTo analyse the long term swallowing function in head and neck cancer patients and correlate with the dose to midline swallowing structures.BackgroundThe use of concurrent chemo radiation (CRT) as the present standard of care resulted in high rates of early and late toxicities. Dysphagia, aspiration, and xerostomia are early as well as late effects of radiation. Not many studies on the dysphagia scores during radiation and follow-up period have correlated dose to the swallowing structures, hence this study.Materials and MethodsHistologically proven head and neck cancer patients treated with intensity modulated radiation therapy were accrued in this study. The pharyngeal constrictors, larynx and cervical oesophagus were contoured and labelled as midline swallowing structures. The volume of the midline swallowing structures which were outside the PTV was delineated separately and was given a mean dose constraint of 45Gy. Dysphagia was assessed at baseline, weekly intervals during irradiation and follow-up at six years. The dose to the structures for swallowing was correlated with degree of dysphagia.ResultsThere was a gradual increase in the dysphagia grade during the course of radiation. There was a significant recovery of late dysphagia compared to dysphagia during the completion of radiation therapy in patients who receive

Magnitude of fatigue in cancer patients receiving radiotherapy and its short term effect on quality of life

Background : Fatigue is one of the most common, ongoing symptoms reported by patients undergoing radiotherapy and has profound effects on the quality of life. Aims : This study attempts to identify the magnitude of fatigue and its implication on the quality of life during radiotherapy. Methods and Materials : A prospective study was conducted from March 2004 to September 2005, on 90 patients with histologically proven cancer, receiving radiotherapy. Pretreatment and weekly assessment of fatigue and QOL was done during radiation treatment using Brief Fatigue Inventory Scale and EORTC QLQ C30 respectively and repeated one month after completion of radiotherapy. All the scores were measured in the 0 to 100 scale. Statistical Methods Used : Trimean, SPSS 11.0 and Sysstat 8.0 were used for statistical analysis. Results : Fatigue was present in 87.8% of patients initially and increased gradually over the course of radiotherapy and peaked in the last week. However at follow up it was nearing the pretreatment level. There was significant reduction in the functional scores ( P < 0.001) of QOL (physical, role and emotional function), which returned to pretreatment level at follow up. In the seventh week impairment of cognitive function (P=0.059) was noted. Significant reduction of social function (P < 0.001) at second week and global health status (P < 0.001) at fifth week was noted while financial difficulty was seen from second week onwards. Conclusion : Fatigue is transiently increased by radiotherapy before reaching pretreatment level after few weeks of completion of radiotherapy. QOL is also affected by fatigue which follows the same pattern

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

Primary cerebello-pontine angle melanoma: a case report

Intra-cranial melanomas are commonly metastatic from primary melanoma elsewhere in the body. The primary occurrence of a melanoma in the brain parenchyma is rare. We report a case of 38 year aged woman who presented with deviation of left eye and headache. On imaging, a space occupying lesion was found in the left Cerebello-pontine angle and a preoperative diagnosis of meningioma was made. She underwent left retro-mastoid sub-occipital craniectomy and excision of a black vascular tumor. Histopathological examination revealed a melanoma which was confirmed with Immunohistochemical assay. Search for dermal, mucous and ocular lesions were negative. She received adjuvant radiation to the post- operative tumor bed to 5400cGy in 30 fractions using Intensity Modulated Radiation Therapy technique along with concurrent Temozolomide. She tolerated the treatment well and is symptom free 12 months after treatment. Primary Melanomas are rare lesions of the Cerebello-pontine angle and its radiological features, evaluation and management have been discussed.-------------------Cite this article as: Ponni A, Jagannatha A, Gururajachar J, Harjani R, Koushik K, Subramanian N, Sowmya R, Varma R. Primary cerebello-pontine angle melanoma: a case report. Int J Cancer Ther Oncol 2014; 2(3):020315. DOI: 10.14319/ijcto.0203.1

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

A case of endometrial carcinoma with age related hyperkyphosis treated with definitive radiotherapy

This report describes a simple brachytherapy procedure in a patient with endometrial cancer with age related hyperkyphosis.  Sixty-eight year-old postmenopausal woman with age related hyperkyphosis presented with endometrial carcinoma, and the patient was not operated on due to associated pelvic deformity. The patient received whole pelvic radiation followed by uterovaginal brachytherapy. Patient was supported with soft pillows to support her exaggerated anterior concavity during brachytherapy procedure and execution. The brachytherapy dose was 6 Gy per fraction per week for 3 weeks using image guidance. This is probably the first reported case of endometrial cancer with age related hyperkyphosis. In spite of the associated skeletal problems, a simple brachytherapy procedure is possible and provides good result.

A prospective dosimetric and clinical comparison of acute hematological toxicities in three-dimensional conformal radiation therapy and intensity modulated radiation therapy with concurrent chemotherapy in carcinoma cervix

Background and Objectives: Acute hematological toxicities are an important cause of morbidity in patients receiving concurrent chemoradiation to pelvis in carcinoma cervix. The objective of this study was to evaluate the role of intensity-modulated radiotherapy (IMRT) in reducing the dose to the bone marrow as compared with three-dimensional conformal radiotherapy (3DCRT) and hence its impact on reducing the acute hematological toxicities. Materials and Methods: Eleven consecutive patients treated with IMRT and 12 patients treated with 3DCRT to the whole pelvis along with concurrent chemotherapy were selected. Bone marrow was delineated. V10 Gy, V20 Gy, V95%, and Dmean of bone marrow were recorded. Weekly blood counts were recorded and graded as per Common Terminology Criteria version 4.0 for all the patients. Results: The dose to the bone marrow V20 Gy was 206.78 ± 57.10 cc (75%) and 251.70 ± 40.45 cc (91%) for IMRT and 3DCRT, respectively (P = 0.04) and V95% was 23.30 ± 8.34% and 46.76 ± 6.71% for IMRT and 3DCRT, respectively (P = 0.001). The grade of toxicities during each week did not show the difference in either arm. However, the total count and Neutrophil counts during the 2nd week showed statistical significance between IMRT and 3DCRT. Conclusion: IMRT significantly reduces the dose to the bone marrow as compared to 3DCRT. The reduction of the dose did not translate into a decrease in acute hematological toxicities. Concurrent platinum-based chemotherapy is the probable cause for the hematological toxicities

Positional variation of applicators during low dose rate intracavitary brachytherapy for cervical cancer: a prospective study

Purpose: In order to know the effect of variation in position of applicators to the dose received by the tumor volume, critical organs such as rectum and bladder and the correlation of variation on the clinical outcome.Material and methods: 36 patients with histologically proven cervical cancer, undergoing intracavitary brachythe - rapy (ICBT) from October 2005 to December 2006 were the subjects of the study. Two pairs of orthogonal X-ray films were taken: one prior to loading of sources and the other after removal of sources. These patients were followed up as per the RTOG criteria.Results: The median duration of insertion was 25 hours with a median follow up period of 6.7 months. The translational variation of the applicator position for all patients was 3 mm and 1 mm (2 SD), respectively, in the patient’s lateral and antero-posterior direction. The rotational variation was 3 and 4 degrees (2 SD) in the patient’s transverse and sagittal planes. Detailed analysis of source movement showed following changes in median dose: point A: 14%, point B: 2%, point P: 1%, Rectum 1: 3.5%, Rectum 2: 4% and Bladder: 9.1%. The incidence of rectal toxicity was 6/36(16.7%) and that of bladder was 1/36 (2.8%). When the variables were grouped to evaluate the relationship, our study showed statistically significant relationship between: R2 and rectal toxicity (p value: 0.002), point A and rectal toxicity (Pearson: 0.792), lateral displacement/anteroposterior displacement and rectal toxicity (p value: 0.012/0.003), beta angle and R2 (p value: 0.002).Conclusions: The geometric relationships between the ICBT applicators and the critical structures vary during the course of low dose rate brachytherapy. Source movement does result in significant dose alterations in terms of increased rate of complications, but its impact on cure rates needs to be studied in the future

Role of Palliative Radiotherapy in Brain Metastases

Background: Brain metastases are a common manifestation of systemic cancer and exceed primary brain tumors in number and are a significant cause of neurologic problems. They affect 20-40% of all cancer patients. Aggressive management of brain metastases is effective in both symptom palliation and prolonging the life. Radiotherapy has a major role to play in the management of brain metastases. AIM: The aim of the study was to know the outcome of palliative radiotherapy in symptomatic brain metastases in terms of improvement in their performance status. Materials and Methods: This is a retrospective study of 63 patients diagnosed to have brain metastases and treated with palliative whole brain radiotherapy to a dose of 30 Gy in 10 fractions over two weeks between June 1998 and June 2007. Diagnosis was done in most of the cases with computed tomography scan and in a few with magnetic resonance imaging. Improvement in presenting symptoms has been assessed in terms of improvement in their performance status by using the ECOG scale. Results: Fifty-four patients completed the planned treatment. Eight patients received concurrent Temozolamide; 88% of patients had symptom relief at one month follow-up; 39/54 patients had a follow-up of just one to three months. Hence survival could not be assessed in this study. Conclusion: External beam radiotherapy in the dose of 30 Gy over two weeks achieved good palliation in terms improvement in their performance status in 88% of patients. Addition of concurrent and adjuvant Timozolamide may improve the results