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Brain metastases constitute one of the most common distant metastases of cancer and are increasingly being detected with better diagnostic tools. The standard of care for solitary brain metastases with the primary disease under control is surgery followed by radiotherapy. Radiotherapy is also the primary modality for the treatment of multiple brain metastases, and improves both the quality of life and survival of patient. Unfortunately, more than half of these treated patients eventually progress leading to a therapeutic dilemma. Another course of radiotherapy is a viable but underutilized option. Reirradiation resolves distressing symptoms and has shown to improve survival with minimal late neurotoxicity. Reirradiation has conventionally been done with whole brain radiotherapy, but now studies with stereotactic radiosurgery have also shown promising results. In this review, we focus on reirradiation as a treatment modality in such patients. We performed a literature search in MEDLINE (www.pubmed.org) with key words brain metastases, reirradiation, whole brain radiotherapy, stereotactic radiosurgery, interstial brachytherapy, and brain. The search was limited to the English literature and human subjects. [ABSTRACT FROM AUTHOR]

Aim: The main objective of this study was to analyze the radiobiological effect of different treatment strategies on high-risk prostate adenocarcinoma. Materials and Methods: Ten cases of high-risk prostate adenocarcinoma were selected for this dosimetric study. Four different treatment strategies used for treating prostate cancer were compared. Conventional four-field box technique covering prostate and nodal volumes followed by three-field conformal boost (3D + 3DCRT), four-field box technique followed by intensity-modulated radiotherapy (IMRT) boost (3D + IMRT), IMRT followed by IMRT boost (IMRT + IMRT), and simultaneous integrated boost IMRT (SIBIMRT) were compared in terms of tumor control probability (TCP) and normal tissue complication probability (NTCP). The dose prescription except for SIBIMRT was 45 Gy in 25 fractions for the prostate and nodal volumes in the initial phase and 27 Gy in 15 fractions for the prostate in the boost phase. For SIBIMRT, equivalent doses were calculated using biologically equivalent dose assuming the α/β ratio of 1.5 Gy with a dose prescription of 60.75 Gy for the gross tumor volume (GTV) and 45 Gy for the clinical target volume in 25 fractions. IMRT plans were made with 15-MV equispaced seven coplanar fields. NTCP was calculated using the Lyman-Kutcher-Burman (LKB) model. Results: An NTCP of 10.7 ± 0.99%, 8.36 ± 0.66%, 6.72 ± 0.85%, and 1.45 ± 0.11% for the bladder and 14.9 ± 0.99%, 14.04 ± 0.66%, 11.38 ± 0.85%, 5.12 ± 0.11% for the rectum was seen with 3D + 3DCRT, 3D + IMRT, IMRT + IMRT, and SIBIMRT respectively. Conclusions: SIBIMRT had the least NTCP over all other strategies with a reduced treatment time (3 weeks less). It should be the technique of choice for dose escalation in prostate carcinoma. [ABSTRACT FROM AUTHOR]

Background: In upper abdominal malignancies (UAM), due to the presence of multiple inhomogeneous tissues, a wedge-based conformal treatment planning results in high-dose regions inside the target volume. Aim: This study was designed to explore the feasibility of using a field-in-field (FIF) technique in different UAM and its efficacy in reducing the high-dose regions. Materials and Methods: Twelve patients of UAM (which included malignancies of the gastroesophageal junction, stomach, gall bladder, and pancreas) were selected for this study. Computed tomography (CT) scans were performed and three-dimensional conformal wedge plans were generated for all the cases. The same plan was copied with the wedges removed and a FIF plan was generated. The two plans were compared for mean, maximum, and median doses; dose received by 2% (D2) and 98% (D98) of the target volume; volume receiving >107% (V > 107%) and <95% (V < 95%) of the prescribed dose; conformality index (CI); and total monitor units. The doses to critical structures such as liver, kidneys, and spinal cord were also compared. Statistical Analysis: Statistical analysis was performed with SPSS, version 10.0. Results: For all the cases, the FIF technique was better than wedge-based planning in terms of maximum dose, D2, V > 107%, and CI; there was a statistically significant reduction in monitor units. With regard to doses to critical structures, there was marginal dose reduction for the kidneys and spinal cord with FIF as compared to wedge-based planning. Conclusion: The FIF technique can be employed for UAM in place of wedge-based conformal treatment plans. [ABSTRACT FROM AUTHOR]

Aims: Radiotherapy forms an integral part of breast-conserving treatment in early-stage breast cancer. Subcutaneous fibrosis of the treated breast is an important late effect in whole-breast irradiation. The aim of this study was to compare the normal tissue complication probability (NTCP) for radiation-induced fibrosis in treated breast using accelerated partial-breast irradiation (APBI) vs conventional treatment.Materials and Methods: Ten postoperative early-stage breast cancer patients (T1N0M0) were included in this dosimetric analysis. APBI treatment was planned using conformal radiotherapy technique and conventional treatment plans included two tangential portals. All the APBI treatment plans were made with five non-coplanar beams with 6 MV photons. The prescription dose was 38 Gy in 10 fractions for the APBI treatments and 50 Gy in 25 fractions, followed by a boost dose of 16 Gy in 8 fractions, for the conventional treatments. We used Lyman's relative-seriality model and the breast fibrosis NTCP model fitting parameters for the study.Results: The equivalent uniform dose (EUD) was 30.09 Gy and 50.79 Gy in APBI and conventional treatment, respectively. The mean NTCP values for ipsilateral breast fibrosis in APBI and conventional treatment were 0.51 and 25.66%, respectively. Using the paired t-test, a statistically significant difference was seen in the breast fibrosis NTCP values for APBI vs conventional treatment (P < 0.001).Conclusions: APBI reduces the ipsilateral breast fibrosis compared to conventional whole-breast treatment in early-stage breast cancer. [ABSTRACT FROM AUTHOR]

Aims: Radiotherapy forms an integral part of breast-conserving treatment in early-stage breast cancer. Subcutaneous fibrosis of the treated breast is an important late effect in whole-breast irradiation. The aim of this study was to compare the normal tissue complication probability (NTCP) for radiation-induced fibrosis in treated breast using accelerated partial-breast irradiation (APBI) vs conventional treatment. Materials and Methods: Ten postoperative early-stage breast cancer patients (T1N0M0) were included in this dosimetric analysis. APBI treatment was planned using conformal radiotherapy technique and conventional treatment plans included two tangential portals. All the APBI treatment plans were made with five non-coplanar beams with 6 MV photons. The prescription dose was 38 Gy in 10 fractions for the APBI treatments and 50 Gy in 25 fractions, followed by a boost dose of 16 Gy in 8 fractions, for the conventional treatments. We used Lyman's relative-seriality model and the breast fibrosis NTCP model fitting parameters for the study. Results: The equivalent uniform dose (EUD) was 30.09 Gy and 50.79 Gy in APBI and conventional treatment, respectively. The mean NTCP values for ipsilateral breast fibrosis in APBI and conventional treatment were 0.51 and 25.66%, respectively. Using the paired t-test, a statistically significant difference was seen in the breast fibrosis NTCP values for APBI vs conventional treatment (P<0.001). Conclusions: APBI reduces the ipsilateral breast fibrosis compared to conventional whole-breast treatment in early-stage breast cancer. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the local control of hepatic metastasis with radiofrequency ablation treatment. Materials and Methods: We did a retrospective analysis in 40 patients treated with radiofrequency ablation for hepatic metastasis. The tumors ablated included up to two metastatic liver lesions, with primaries in breast, gastrointestinal tract, cervix, etc. Radiofrequency ablation was performed under general anesthesia in all cases, using ultrasound guidance. Radionics Cool-Tip RF System was used to deliver the treatment. Results: The median age of patients treated was 49 years. There were 13 female and 27 male patients. The median tumor size ablated was 1.5 cm (0.75-4.0 cm). A total of 52 radiofrequency ablation cycles were delivered. Successful ablation was achieved in all patients with hepatic metastasis less than 3 cm in size. Pain was the most common complication seen (75%). One patients developed skin burns. At 2-year follow-up 7.5% of patients had locally recurrent disease. Conclusions: Radiofrequency ablation is a minimally invasive treatment modality. It can be useful in a select group of patients with solitary liver metastasis of less than 3 cm size. [ABSTRACT FROM AUTHOR]

Aim: The aim of our study was to compare the two standard treatment approaches in muscle invasive carcinoma of urinary bladder--radical cystectomy and chemo radiation.Materials and Methods: Transitional cell carcinoma (TCC) of bladder of stages, T2 to T4, N0/N1/N2 and M0 were included in the study. Patients were allotted to two arms of the study. Arm A consisted of radical cystectomy. Adjuvant CMV chemotherapy was given for T3/T4 or Node positive disease only. Arm B received 2 cycles of neoadjuvant CMV chemo therapy followed by concurrent chemo radiation.Results: Forty-four patients were recruited into the study. Thirty patients in the surgical arm and 13 patients in the chemo radiation arm. The actuarial two-year survival rate in surgical arm is 56% while in chemo radiation arm it is 54%. There was no statistically significant difference in disease-free survival also between the two groups.Conclusion: Chemo radiation yielded equivalent survival results with radical cystectomy. So it is worth giving preference to chemo radiation that will give a better quality of life for the patient. [ABSTRACT FROM AUTHOR]

Primary spinal glioblastoma multiforme (GBM) is a rare entity, which is invariably associated with poor outcome. Standard treatment is surgery followed by post-operative radiotherapy. Due to paucity of cases role of chemotherapy is investigational. We intend to report two cases of primary spinal GBM treated with radiation and adjuvant temozolomide. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the integral dose to carotid vessels in extended field intensity modulated radiotherapy (IMRT) (including the lower neck nodes in IMRT field) and split field IMRT (using separate single anterior field to treat lower neck nodes) in cancer nasopharynx. Materials and Methods: Dosimetric data from 10 patients of carcinoma nasopharynx, undergoing IMRT, were evaluated in this prospective study. The carotid vessels were contoured from sternoclavicular joints upto the base of skull. IMRT plans were generated for all patients with extended field and split field IMRT techniques using nine coplanar beams with 6 MV photons. A dose of 70 Gy to planning target volume (PTV)70Gy, 59.4 Gy to PTV59.4Gy and 54 Gy to PTV54Gy was delivered in 33 fractions. The dose constraints were similar for both the techniques. The integral dose to the carotid arteries was calculated as the mean dose times the volume (mean dose × volume) in units of liter-gray. Results: The mean dose to the carotid vessels in the extended field IMRT was 63.88 ± 0.97 Gy (mean dose ± SD) and it was 64.43 ± 0.73 Gy for the split field technique. The integral dose in the extended field versus split field technique was 0.29 ± 0.0207 and 0.32 ± 0.0213 liter-gray, respectively. The difference was statistically significant (P < 0.013). Conclusions: Extended field IMRT delivers a slightly lower integral dose to carotid arteries in treatment of cancer nasopharynx while maintaining good dose homogeneity to the PTV54Gy and can be preferred over split field radiotherapy. [ABSTRACT FROM AUTHOR]

Purpose: Field matching poses challenges in craniospinal irradiation (CSI) as it leads either to underdosage or overdosage in the junctional area. A simple technique for CSI in pediatric patients is proposed. Materials and Methods: Computed tomography scans were performed in the prone position. Two lateral cranial fields and a direct posterior spinal field were planned with a common central axis. Half-beam-blocked cranial fields with zero collimator rotation were used for treating the cranium. A half-beam-blocked field defined with jaws was used to treat the spinal column at an extended sourceto-surface distance. Before treating the patient, matching of the cranial and spinal field junction along the central axis was verified with an extended dose range film. Results and Conclusion: The technique described is simple and easy to implement and can be applied to pediatric patients undergoing CSI. This method has the potential to reduce daily setup time and setup errors. This technique is ideally suitable for patients with spinal fields less than 30 cm. [ABSTRACT FROM AUTHOR]

Cylindric cell carcinomas (transitional cell carcinomas) are a rare and distinct histopathological entity presenting in the head and neck region. They have been known by myriads of nomenclature like cylindric carcinomas, nonkeratinizing sinonasal carcinoma, papillary carcinoma, cylindrical or columnar cell carcinoma, intermediate cell carcinoma, Schneiderian carcinoma, and Ringertz carcinoma. They are considered a variant of nonkeratinizing squamous cell carcinoma. Cylindric carcinomas are usually described in the sinus and nasal cavity and rarely said to involve nasopharynx and larynx. Only passing references have been made for its presentation in oropharynx including tonsils and the base of the tongue. We report here a rare case of transitional cell carcinoma presenting in the base of the tongue. There are no separate treatment recommendations in the literature, and the management is on the lines of treatment of squamous cell carcinoma. We report here a case of cylindric cell carcinoma presenting in the base of the tongue. The patient was staged as having cT2 N3 M0 (Stage IV B) disease. The patient received palliative radiotherapy of 20 Gy in five fractions followed by chemotherapy with injection paclitaxel and carboplatin. A partial response to treatment was achieved at the time of writing this report. [ABSTRACT FROM AUTHOR]

Purpose: This study was mainly framed to study the difference in tumor volumes as seen on computed tomography (CT) and magnetic resonance (MR) and their significance in planning.Materials and Methods: Twenty-five patients with brain tumor of different diagnoses who underwent stereotactic radiotherapy were included in this study. CT and MR imaging was done for all the patients with 2.5 mm slice thickness. The CT tumor volume and MR tumor volume were measured and compared with each other. The center of mass (CM) of the tumor volume delineated on CT and MR were computed and the shift between the two CMs was determined.Results: The mean and median volume of the tumor as measured from MR scans was 19.67 cc +/- 13.73 and 16.13 cc (range: 3.25 cc-50.37 cc). Similarly, the mean and median volume of the tumor as measured from CT scans was 15.05 cc +/- 10.13 and 11.63 cc (range: 3.0 cc-36.25 cc) respectively. The mean and median CM shift between CT and MR was 5.47 mm and 5.21 mm respectively.Conclusion: The study demonstrates that MR is an indispensable imaging modality in radiotherapy for planning brain tumors. [ABSTRACT FROM AUTHOR]

Sweat gland carcinoma is a rare skin tumor. The tumor has propensity to spread to lymph nodes and distant metastases has been reported. Their exact incidence in the Indian setting is not known. Aspects related to treatment are also not clearly defined. Though surgery forms the initial treatment approach, adjuvant treatment has not been properly explored. We report here a case of sweat gland carcinoma with bilateral lung metastases. [ABSTRACT FROM AUTHOR]

Background: For inoperable non-small cell lung cancer combined chemotherapy and radiotherapy plays an important role as a therapeutic modality. The aim of the present study was to analyze neoadjuvant chemotherapy related acute toxicity in locally advanced lung cancer (stage IIIA and IIIB) in Indian patients using Cisplatin and Etoposide combination chemotherapy.Material and Methods: Forty patients of locally advanced Non small cell lung cancer received three cycles neoadjuvant chemotherapy using Injection Cisplatin and Etoposide. The patients were taken for Radical radiotherapy to a dose of 60 Gray over 30 fractions in conventional fractionation after completing chemotherapy. Chemotherapy associated toxicity was assessed using common toxicity criteria (CTC v2.0)Results: Forty patients were available for final evaluation. Median age of presentation of patients was fifty-six years. Thirteen patients had Non small cell lung cancer stage IIIA while twenty-seven patients had Stage IIIB disease. Anemia was the most common hematological toxicity observed (seen in 81% of patients). Nausea and vomiting were the most common non-hematological toxicity seen. Sensory neuropathy was seen in 38% of patients. 88% patients developed alopecia. Seven patients developed febrile neutropenias.Conclusion: Neo-adjuvant chemotherapy using Cisplatin and Etoposide continues to be a basic regimen in the Indian set up despite availability of higher molecules, since it is cost effective, well tolerated and therapeutically effective. Blood transfusions, growth factors and supportive care can be used effectively to over come toxicity associated with this regimen. [ABSTRACT FROM AUTHOR]

A response by G. K. Rath to a letter to the editor about their article "Radiofrequency ablation in liver metastasis" in the previous issue is presented.