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Background: Hematologic toxicity is a critical problem limiting treatment delivery in cancer patients undergoing concurrent chemoradiotherapy. However, the extent to which anatomic variations in radiation dose limit chemotherapy delivery is poorly understood. A unique natural experiment arises in patients with head and neck and cervical cancer, who frequently undergo identical chemotherapy but receive radiation to different regions of the body. Comparing these cohorts can help elucidate to what extent hematologic toxicity is attributable to marrow radiation as opposed to chemotherapy. Methods: In this longitudinal cohort study, we compared hematologic toxicity and bone marrow compensatory response in 148 patients (90 cervix, 58 head/neck) undergoing chemoradiotherapy with concurrent weekly cisplatin 40 mg/m2. We used linear mixed effect models to compare baseline and time-varying peripheral cell counts and hemoglobin levels between cohorts. To assess bone marrow compensatory response, we measured the change in metabolically active bone marrow (ABM) volume on 18F-fluorodeoxyglucose positron emission tomography/computed tomography. Results: We observed greater reductions in log-transformed lymphocyte, platelet, and absolute neutrophil counts (ANC) for cervix compared to head/neck cancer patients (fixed effects for time-cohort interaction [95% CI]: lymphocytes, −0.06 [−0.09, −0.031]; platelets,−0.028 [-0.051, −0.0047]; ANC, −0.043 [−0.075, −0.011]). Mean ANC nadirs were also lower for cervical vs. head/neck cancer cohorts (2.20 vs. 2.85 × 103 per μL, p < 0.01). Both cohorts exhibited reductions in ABM volume within the radiation field, and increases in ABM volume in out-of-field areas, indicating varying compensatory response to radiation injury. Conclusions: Cervical cancer patients had faster decreases in ANC, lymphocyte, and platelet counts, and lower ANC nadirs, indicating a significant effect of pelvic irradiation on acute peripheral blood cell counts. Both cohorts exhibited a compensatory response with increased out-of-field bone marrow activity.

Purpose The study is an audit of reporting dose and volume specifications as per the ICRU 58 for MUPIT-based interstitial brachytherapy in gynecological cancers. Correlation between total reference air kerma (TRAK) and isodose surface was also evaluated to understand the intensity of treatment in interstitial brachytherapy. Methods and Materials Forty-two patients underwent HDR MUPIT-based interstitial brachytherapy 20 Gy in five fractions after EBRT during 2017–2019. Treated volume, high and low-dose regions, mean central dose, Dose Homogeneity Index (DHI), organ at risk doses, and TRAK values were computed. Results High-dose regions V150 mean was 12.4 cc and V200 was 4.58 cc; and low-dose region was 75.92 cc. The mean treated volume was 59.8 cc. The mean central dose was 3.7 Gy. DHI was 79%. The mean D2cm3 bladder and rectum were 2.9 Gy and 2.8 Gy. The mean TRAK was 0.16 cGy per fraction per hour at 1 m. TRAK values showed significant correlation with various isodose volumes (TRAK and V100: r = 0.943 p Conclusions Our study shows compliance with ICRU 58 recommendations along with certain deviations. Local recurrence rate is acceptable. TRAK shows correlation with surface isodose in MUPIT-based brachytherapy and should to be evaluated in future studies.

India has a longstanding tradition in the practice of brachytherapy and has actively contributed to the scientific literature by conducting prospective studies, clinical audits, developing innovative techniques, and performing randomized studies. Indian investigators have also contributed to international collaborative research, education, training programs along with guideline development for brachytherapy in cervix and head and neck cancers. The present article summarizes the key contributions to scientific literature, current infrastructure, skill set for brachytherapy, existing challenges, and strategy to further strengthen brachytherapy practice in the next decade.

Image-guided adaptive brachytherapy (IGABT) has been shown to improve local/regional control and survival for cervix cancer patients while reducing morbidity. However, the technique is complex involving several conceptual, methodological, and technical innovations compared to conventional brachytherapy. The delivery of high-quality IGABT which will translate into improved outcomes is therefore critically dependent on effective education and training of all health professionals involved in the brachytherapy treatment process. This paper reviews the (GEC)-ESTRO/EMBRACE initiatives for education and training to promote the dissemination and implementation of IGABT for cervix cancer worldwide. The new skills required in different health professionals for successful implementation of IGABT are described. The achievements and challenges of current educational strategies for disseminating IGABT are discussed. Innovations to improve the effectiveness of current and future educational strategies are explored.

Primary vaginal cancer is a rare cancer and clinical evidence to support recommendations on its optimal management is insufficient. Because primary vaginal cancer resembles cervical cancer in many aspects, treatment strategies are mainly adopted from evidence in locally advanced cervical cancer. To date, the organ-sparing treatment of choice is definitive radiotherapy, consisting of external beam radiotherapy and brachytherapy, combined with concurrent chemotherapy. Brachytherapy is an important component of the treatment and its steep dose gradient enables the delivery of high doses of radiation to the primary tumour, while simultaneously sparing the surrounding organs at risk. The introduction of volumetric CT or MRI image-guided adaptive brachytherapy in cervical cancer has led to better pelvic control and survival, with decreased morbidity, than brachytherapy based on x-ray radiographs. MRI-based image-guided adaptive brachytherapy with superior soft-tissue contrast has also been adopted sporadically for primary vaginal cancer. This therapy has had promising results and is considered to be the state-of-the-art treatment for primary vaginal cancer in standard practice.

Background: There is paucity of outcome data of patients with cervical cancer presenting with malignant obstructive uropathy. The present retrospective study describes outcomes of patients with cervical cancer who presented with obstructive uropathy at the time of diagnosis and underwent urinary diversion with percutaneous nephrostomy (PCN) before/during treatment. Methods: Patients who underwent PCN from January 2010 to June 2015 were included. Intent of treatment (radical or palliative) was decided within multidisciplinary team depending on disease stage, Karnofsky performance status (KPS), and degree of renal derangement. Treatment and outcome details were retrieved from electronic records. Time to normalization of creatinine, feasibility of delivering planned treatment, and overall survival (OS) were determined. Impact of various prognostic factors on outcomes was determined using univariate or multivariate analysis. Results: After PCN and double-J stenting, 50% were eligible for (chemo) radiation. All radically treated patients (26/52) received brachytherapy. The median EQD2 to point A was 78 Gy (72–84 Gy). The median OS was 10 (0.5–60) months. Patients who completed chemoradiation had median OS of 31 months. Those receiving radical radiation and palliative radiation had median OS of 11 and 6 months, respectively. On univariate analysis, smaller tumor size (p = 0.03), high KPS (P = 0.04), and radical intent of treatment (P = 0.05) predicted for OS. Conclusion: Patients presenting with obstructive uropathy have median OS less than a year despite urinary diversion. Select cohort with good performance status, small tumor size, and serum creatinine of ≤3 mg/dL may be selected for diversion procedures and potential radical treatment.

Aim: The aim of this study is to compare disease-free survival (DFS) and overall survival (OS) in patients with stage I cervical cancer (≤ 4cms, lymph node-negative) undergoing open radical hysterectomy (ORH) vs. minimally invasive radical hysterectomy (MIRH). Methods: All patients undergoing radical hysterectomy between January 2012-December 2018 from the largest tertiary referral cancer centre were included. A 1:1 propensity matching was done based on four independent prognostic factors to compare DFS and OS with the route of surgery. Results: One hundred and ninety-nine patients were included during the study period. The median age of the cohort was 50 years. The median follow-up of patients was 47 months. Following 1:1 propensity matching, a total of 174 patients were analysed for DFS and OS in ORH (n = 87) and MIRH (n = 87) groups. Protective measure was used in two-thirds of the patients during MIRH. Twenty-nine patients (16.7%) had recurrences. For the matched cohort (n = 174), the DFS at 36 and 60 months was 84.8% (78.1%-89.6%) and 81% (73.4%-86.6%) respectively and the OS was 96.5% (91.7%-98.5%) and 95.6% (90.3%-98%) respectively. There was no statistically significant difference in DFS or OS between ORH and MIRH. Conclusion: The present study showed no difference in oncological outcomes in MIRH compared to ORH. Retrospective audits on patient characteristics such as screening/vaccination history along with surgical technique/load and matching for crucial risk factors should be factored in future studies to eliminate the possible methodological errors.

Cervical cancer is still a major cause of morbidity and mortality among women worldwide. Surgery and chemoradiation are widely utilized treatments for cervical cancer. Despite the available standard treatment of choice, outcome is suboptimal among patients with LACC. It is vital to integrate the evidence generated from high-quality research work for effective management of these cases. This review intends to critically evaluate the latest evidence supporting the available treatment modalities and to provide a comprehensive overview of recent advances and ongoing research in the management of LACC.Research advances in imaging and radiotherapy technologies, incorporating imaging into brachytherapy planning, use of newer targeted agents, chemotherapy intensification and immunotherapy are some of the new therapeutic options that have been in the forefront of research to improve the outcome of patients with LACC.Advanced imaging modalities are increasingly being utilized to tailor treatments. Neoadjuvant chemotherapy followed by surgery does not improve outcomes in FIGO Stage IB2-IIB. Although cisplatin-based concurrent chemoradiation is the standard of care, more aggressive systemic therapies (neoadjuvant or adjuvant chemotherapy and chemoradiation) and use of newer agents, still remains investigational.

Purpose To prospectively compare survival between human immunodeficiency virus (HIV)-infected versus HIV-uninfected cervical cancer patients who initiated curative chemoradiation therapy (CRT) in a limited-resource setting. Methods and Materials Women with locally advanced cervical cancer with or without HIV infection initiating radical CRT in Botswana were enrolled in a prospective, observational, cohort study from July 2013 through January 2015. Results Of 182 women treated for cervical cancer during the study period, 143 women initiating curative CRT were included in the study. Eighty-five percent of the participants (122 of 143) had stage II/III cervical cancer, and 67% (96 of 143) were HIV-infected. All HIV-infected patients were receiving antiretroviral therapy (ART) at the time of curative cervical cancer treatment initiation. We found no difference in toxicities between HIV-infected and HIV-uninfected women. The 2-year overall survival (OS) rates were 65% for HIV-infected women (95% confidence interval [CI] 54%-74%) and 66% for HIV-uninfected women (95% CI 49%-79%) (P = .70). Factors associated with better 2-year OS on multivariate analyses included baseline hemoglobin >10 g/dL (hazard ratio [HR] 0.37, 95% CI 0.19-0.72, P = .003), total radiation dose ≥75 Gy (HR 0.52, 95% CI 0.27-0.97, P = .04), and age Conclusions Human immunodeficiency virus status had no effect on 2-year OS or on acute toxicities in women with well-managed HIV infection who initiated curative CRT in Botswana. In our cohort, we found that baseline hemoglobin levels, total radiation dose, and age were associated with survival, regardless of HIV status.

Purpose To determine the clinical impact of magnetic resonance image guided adaptive brachytherapy (IGABT) for locally advanced cervical cancer (LACC) (stages II and III) in a tertiary care cancer hospital in a low and middle income countries setting. Methods and Materials Ninety-four LACC patients enrolled in a prospective EMBRACE (An International Study on MRI-Guided Brachytherapy in Locally Advanced Cervical Cancer) protocol treated with external radiation therapy (45 Gy in 25 fractions) with or without weekly cisplatin, followed by magnetic resonance IGABT (4 fractions of 7 Gy), were analyzed in detail for dosimetric and clinical outcomes including late toxicities. Results The mean (± standard deviation) high-risk clinical target volume (HR-CTV) at the first session of brachytherapy and at the second session of brachytherapy for the current study cohort was 46.94 ± 24.6 cm 3 and 42.7 ± 22.5 cm 3 , respectively, with mean minimum dose received by 90% volume (D 90 ) of 88.3 ± 4.4 equivalent 2-Gy fractionation (Gy EQD2 ). At median follow-up (39 months), the local control rate (LCR) and overall progression-free survival rate were 90.1% ± 3.4% and 72.1% ± 4.8%, respectively, with grade 3 bladder toxicity in 3% of patients and rectum toxicity in 9%. The LCR at 39 months was significantly better in patients with stage IIB and IVA disease versus stage IIIB disease (100% vs 85%, P =.013). Local failures were limited to stage IIIB only and were associated with significantly larger HR-CTVs at brachytherapy (70 ± 25.7 cm 3 vs 44.3 ± 21.9 cm 3 , P =.01) but not with HR-CTV D 90 doses (which were similar for patients who had local failures vs those who did not: 86.3 ± 3.9 α/β equal to 10 Gy (Gy 10 ) vs 88.5 ± 5 α/β equal to 10 Gy, P =.987). Conclusions IGABT leads to a significant improvement in LCR and overall progression-free survival in LACC and should be considered for wider implementation in developing countries to improve outcomes.

Purpose To investigate dose-response relationship between vaginal doses and long-term morbidity. Methods and Materials Patients receiving adjuvant pelvic (chemo) radiation and brachytherapy for cervical cancer from January 2011 to December 2014 were included. Baseline vaginal length was determined clinically and from imaging at BT planning. Dose points were defined along mucosa and at 5 mm depth at 12, 3, 6, and 9 ‘o’ clock positions at every 2 cm from apex to introitus. Cumulative equivalent doses in 2 Gy were calculated. Vaginal stenosis was reported in reference to baseline length according to CTCAE version 3.0. Receiver operator characteristics curve was used to identify dose thresholds for univariate and multivariate analysis. Results Overall, 78 women with median age of 49 (32–71) years were included. The median dose at vaginal apex mucosa and 5 mm depth was 118 Gy3 (78–198) and 81 Gy3 (70–149) respectively. At median follow-up of 36 (18–60) months, vaginal stenosis ≥25%, and grade ≥ II telangiectasia was observed in 33.3% and 45.7%, respectively. On receiver operator characteristics analysis, apical mucosal dose >142 Gy3 and recto-vaginal point dose >86 Gy3 predicted for stenosis on univariate (p = 0.02, p = 0.06) and multivariate analysis (p = 0.04). The probability of stenosis increased from 32% at 70 Gy3, 38% at 80 Gy3, and 45% at 90 Gy3 rectovaginal point dose. No correlation was observed between vaginal doses and telangiectasia and vaginal stenosis and sexual quality of life. Conclusion Vaginal apex mucosal dose >142 Gy3 independently predicts for vaginal stenosis.

Background To test the hypothesis that atlas-based active bone marrow (ABM)-sparing intensity modulated radiation therapy (IMRT) yields similar dosimetric results compared to custom ABM-sparing IMRT for cervical cancer patients. Methods We sampled 62 cervical cancer patients with pre-treatment FDG-PET/CT in training ( n =32) or test ( n =30) sets. ABM was defined as the subvolume of the pelvic bone marrow (PBM) with standardized uptake value (SUV) above the mean on the average FDG-PET image (ABM Atlas ) vs. the individual's PET (ABM Custom ). Both were deformed to the planning CT. Overlap between the two subvolumes was measured using the Dice coefficient. Three IMRT plans designed to spare PBM, ABM Atlas , or ABM Custom were compared for 30 test patients. Dosimetric parameters were used to evaluate plan quality. Results ABM Atlas and ABM Custom volumes were not significantly different ( p =0.90), with a mean Dice coefficient of 0.75, indicating good agreement. Compared to IMRT plans designed to spare PBM and ABM Custom , ABM Atlas -sparing IMRT plans achieved excellent target coverage and normal tissue sparing, without reducing dose to ABM Custom (mean ABM Custom dose 29.4Gy vs. 27.1Gyvs. 26.9Gy, respectively; p =0.10); however, PTV coverage and bowel sparing were slightly reduced. Conclusions Atlas-based ABM sparing IMRT is clinically feasible and may obviate the need for customized ABM-sparing as a strategy to reduce hematologic toxicity.

Rising cancer incidence and mortality in India emphasize the need to address the increasing burden of this disease and the stark inequities in access to radiotherapy and other essential medical treatments. State-of-the-art technology is available within the private sector and a few hospitals in the public sector, but 75% of patients in the public sector in India do not have access to timely radiotherapy. This inequity in access to radiotherapy in the public sector is amplified in rural areas, where most of India׳s population lives. A long-term government commitment to machine purchase and human resource development in the public sector is needed to improve access. A number of innovative initiatives to improve cancer treatment and access have emerged that could support such an investment. These include local production of equipment, twinning programs between institutions in high- and low-income countries to exchange knowledge and expertise, and nongovernmental and state-sponsored schemes to sponsor and support patients in their cancer journey. Strengthening of cancer registries and regulatory bodies with authority to enforce minimum standards is also required to improve care. The more uniform and frequent availability of high-quality radiotherapy can improve cancer outcomes and may be regarded as a marker of a comprehensive and equitable system of health care delivery.

Purpose To test the hypothesis that intensity modulated radiation therapy (IMRT) reduces acute hematologic and gastrointestinal (GI) toxicity for patients with locoregionally advanced cervical cancer. Methods and Materials We enrolled patients with stage IB-IVA cervical carcinoma in a single-arm phase II trial involving 8 centers internationally. All patients received weekly cisplatin concurrently with once-daily IMRT, followed by intracavitary brachytherapy, as indicated. The primary endpoint was the occurrence of either acute grade ≥3 neutropenia or clinically significant GI toxicity within 30 days of completing chemoradiation therapy. A preplanned subgroup analysis tested the hypothesis that positron emission tomography-based image-guided IMRT (IG-IMRT) would lower the risk of acute neutropenia. We also longitudinally assessed patients' changes in quality of life. Results From October 2011 to April 2015, 83 patients met the eligibility criteria and initiated protocol therapy. The median follow-up was 26.0 months. The incidence of any primary event was 26.5% (95% confidence interval [CI] 18.2%-36.9%), significantly lower than the 40% incidence hypothesized a priori from historical data ( P =.012). The incidence of grade ≥3 neutropenia and clinically significant GI toxicity was 19.3% (95% CI 12.2%-29.0%) and 12.0% (95% CI 6.7%-20.8%), respectively. Compared with patients treated without IG-IMRT (n=48), those treated with IG-IMRT (n=35) had a significantly lower incidence of grade ≥3 neutropenia (8.6% vs 27.1%; 2-sided χ 2 P =.035) and nonsignificantly lower incidence of grade ≥3 leukopenia (25.7% vs 41.7%; P =.13) and any grade ≥3 hematologic toxicity (31.4% vs 43.8%; P =.25). Conclusions IMRT reduces acute hematologic and GI toxicity compared with standard treatment, with promising therapeutic outcomes. Positron emission tomography IG-IMRT reduces the incidence of acute neutropenia.

Purpose To evaluate and compare response and toxicities in patients treated with chemoradiation alone and chemoradiation with high dose rate intraluminal brachytherapy in carcinoma of the esophagus. Material and methods A total of 60 patients were included in the study and were divided randomly into 1 arms – CT RT arm and ILBT arm with 30 patients each. CT RT received definitive chemoradiation 54 Gy in 27 fractions with concurrent weekly cisplatin and ILBT received definitive chemoradiation 50 Gy in 25 fractions with concurrent weekly cisplatin followed by two sessions of intraluminal brachytherapy of 4 Gy each. Evaluation of early response was done 1 and 6 months after completion of chemoradiation on a clinical basis and by upper GI endoscopy. Dysphagia scores were recorded before, on completion of treatment and in the 1st and 6th month of follow-up. Acute gastro-intestinal toxicities (fistula, stricture, ulcer, esophagitis) were evaluated. Results The patient characteristics were comparable in both the arms. Dysphagia to solids was more frequent in the chemoradiation alone arm compared to the ILBT arm at the end of 1 month and 6 months. 80% had a complete clinical response in the CT-RT arm compared to 86.7.3% in the ILBT arm. Grade 3 stricture was more frequent in arm 2. Grade 2 ulceration was seen only in arm 2. None of the patients developed fistula or pneumonitis. There was improvement in dysphagia in both the arms with 50% in arm 1 and 67% in arm 2 tolerating a normal solid diet at the end of 6 months. Conclusions Chemoradiation with ILBT for carcinoma of the esophagus provides excellent local control of the disease with acceptable toxicities when compared with chemoradiation alone., Purpose To analyse the outcomes of MR based IGBT in our hospital. Material and methods 151 biopsy proven cervical cancer patients with stage IB2-IVA were recruited at Vydehi Hospital, Bangalore. MRI scans were acquired as a routine investigation for all the patients before the start of whole pelvic EBRT. All the patients had undergone EBRT to a dose of 45-50 Gy in conventional fractionation or VMAT with concurrent weekly chemotherapy. Radiologically if there was presence of pelvic LN ≥ 1 cm in the greatest dimension, then the node was boosted to 55 Gy by EBRT. Brachytherapy was undertaken under spinal anaesthesia after the 3rd week of EBRT if the patients were suitable. IC OR IC-ISBT was done. After assessing the extent of residual disease under anaesthesia, appropriate MR-compatible intracavitary applicators (tandem-ovoids/tandem-ring/tandem with ring and interstitial needles/tandem with cylinder and interstitial needles) were used for the procedure. The 1st fraction of BT in all patients was planned on MRI and the subsequent fractions on CT simulated images. Results Local control Percentage p Stage IB2 100 .00224 IIA 100 IIB 92.68 IIIA 84.61 IIIB 80.64 IVA 42.85 Dose (Gy) < 85 85.45 .0626 ≥ 85 94.73 Size (cc) < 5 92.98 .004 ≥ 5 84.61 HRCTV (cc) < 35 94.23 .0611 ≥ 35 84.31 LN + 78.57 .043 – 93.47 Histo SQCC 88.48 .657 Adeno 71.42 OTT (d) ≤ 49 87.95 .98 > 49 87.69 Conclusions MRI-based image-guided brachytherapy for cervical cancer, following the recommendations by GEC-ESTRO, has been a feasible technique at our institution. Excellent local control rates with minimal toxicity have been achieved. Stage-wise EQD2 has been sufficiently achieved for the majority of the cases. With further experience, we might be able to escalate the tumour doses in all our cases without compromising the OARs., Purpose To dosimetrically compare multicatheter interstitial brachytherapy (MIBT) and intensity modulated radiotherapy (VMAT) for accelerated partial breast irradiation (APBI) with the focus on dose to organs at risk. Material and methods Twenty-one patients with early stage breast cancer treated in the Department of Radiotherapy and Oncology, Shirdi Sai baba Cancer Hospital, KMC Manipal during 2016-2019 with MIBT were selected for the study. For each patient an additional VMAT treatment plan was created using the same CT data and contours as used in MIBT plans. OARs included ipsilateral and contralateral breast, lung of both sides, skin, and heart. The CTV was created from the outlined lumpectomy cavity. The PTV in VMAT plans was generated from CTV with the addition of an isotropic 5 mm margin. The prescribed dose was 34 Gy in 10 fractions for both techniques. From dose-volume histograms, quality parameters, tumour coverage, homogeneity including volumes receiving a given dose (e.g. V105, D95) and doses to specified volumes (e.g. V5, D0.01, D0.1, D1) were calculated and compared. Results Mean ipsilateral lung dose was lower in MIBT, with D0.01, D0.1, D2 and V10 being statistically significant with D0.01, D0.1, D2, V10 being 63%, 59%, 47%, 24% in MIBT compared to 84.1%, 81%, 74%, 45% in the VMAT plan. Heart doses were also lower in MIBT compared to VMAT, with D0.1, D2, V10 showing statistical significance. D0.1, D2, V10 for heart were 19.5%, 16.3% and 10% in MI B T respectively whereas they were 29.6%, 25.2% and 22% respectively with the VMAT plan. Maximum dose received to skin was 93% in MIBT versus 81% in VMAT. Conclusions The target volume can be appropriately irradiated by both techniques, but MIBT generally spares normal tissues and organs at risk better than VMAT. Whether this dosimetric benefit translates into clinical benefit needs to be ascertained., Purpose Stated as the most mobile part of the LGI tract and within clinical and dosimetric preview of ICBT in cancer cervix, sigmoid colon dosimetry and toxicity is less studied with respect to its rectal counterpart. With endoscopic data suggesting a proportional increase of ICBT related LGI toxicity to RSJ, our study aimed at estimation of sigmoid movements with respect to interfractional imaging and its dosimetric impact. Material and methods 7 patients (FIGO IB3-IIIB) were treated with EBRT (50 Gy/25 #) using 3D-CRT and ICBT (7 Gy/3 #) ± nodal boost. During ICBT, sigmoid contouring was done from the RSJ to the superior aperture of the lesser pelvis. A standard bowel and bladder protocol was followed. Sigmoid movement was measured in 2 axes (anterosuperior, posteroinferior) based on a line from the top of the symphysis pubis to the S1-2 junction in sagittal section (Rt and left lateral) based on the AP line from the symphysis pubis to the coccyx (axial section). Interfractional differences in volumes (cc) in each quadrant were correlated with D2cc of that quadrant and the sigmoid. A 2 cm radius sphere was contoured from the central tandem with cranial extent of 1 cm and caudally up to cervical os. The impact of rectal volume, arching/crossing of sigmoid over the uterus was estimated. Results Most interfractional movement was observed in the anterosuperior quadrant (range, 4-38 cc). Ratio of total volume/D2cc was lower in the posteroinferior quadrant (mean 4.08, range, 1.43-11.5). Dosimetric data of 21# analysed suggest that minimal rectal volume (12 cc) is needed below which sigmoid D2cc increases. Posteroinferior volume (p = 0.08) and D2cc (p = 0.08) correlated with Sphere D2cc. Sigmoid colon arching over uterus was more associated with higher D2cc (p = 0.06) than crossing of the sigmoid (p = 0.1). Conclusions The anterosuperior part has more interfractional motion but does not effect OAR dose. Increase of volume in the posteroinferior part leads to overall D2cc increase. Minimal rectal filling is needed below which posteroinferior volume increases lead to a higher sigmoid dose. Arching of the sigmoid over the uterus needed optimisation in terms of dwell positions., Purpose To compare intracavitary brachytherapy planning methods for cervical cancer, based on X-ray films (conventional plan) and CT sections (CT plan). The comparison focused on target volume coverage (CTV) and dose received by the organs at risk (OARs), by representing point doses as per International Commission on Radiation Units and Measurement (ICRU) 38 and dose volume histograms (DVHs) from 3D planning (Gynaecological GEC ESTRO recommendations). Material and methods Patients with carcinoma of the uterine cervix treated between May 2017 and December 2018 with radical chemoradiation and high dose rate (HDR) ICBT were included. All the patients were treated with a standard dose of external beam radiotherapy (46-50 Gy) with weekly 40 mg/m2 inj. cisplatin, followed by HDR ICBT to a dose of 7.5 Gy in 3 sessions. Each application underwent both X-ray and CT simulation and the dosimetric data for 74 conventional and CT-based ICBT plans were analyzed. Point A and ICRU 38 rectal and bladder points were defined on the conventional plan and CT plan. The doses to bladder and rectum were compared in both the plans. The gross tumor volume (GTV), clinical target volume (CTV) and organs at risk (OAR)s were contoured on the CT plan according to GEC-ESTRO guidelines. With the same source configuration, the dose was prescribed to point A and CTV and respective volume coverage, D1cc,2cc bladder and rectum volumes were compared. Results The mean of ICRU bladder point and rectal point in the conventional plan (X-ray) were 44.4% (3.33 Gy) with SD of ±19.84% (1.48 Gy) and 48.10% (3.6 Gy) ±13.71% (1.02 Gy). The mean of ICRU bladder and rectal point in the CT plan was 62.95% (4.72 Gy) ±22.71% (1.70 Gy) and 59.66% (4.47 Gy) ±17.16% (1.28 Gy). In the current study when the dose was prescribed to point A in CT, the bladder D1cc was 78.83% (5.9 Gy) with SD of ±17.83% (1.33 Gy), bladder D2cc was 68.58% (5.14 Gy) ±14.71% (1.10 Gy) and rectum D1cc was 67.14% (5.03 Gy) ±20.15% (1.51 Gy), rectum D2cc was 59.57% (4.46 Gy) ±17.9% (1.34 Gy). When the dose is prescribed to CTV the bladder D1cc was 60.85% (4.56 Gy) with SD of ±19.82% (1.48 Gy), bladder D2cc was 51.49% (3.86 Gy) ±15.70% (1.17 Gy) and rectum D1cc was 41.57% (3.11 Gy) ±22.78% (1.7 Gy), rectum D2cc was 36.53% (2.73 Gy) ±19.5% (1.46 Gy). The CTV coverage in the point A based plan was 91.67% ±7.09 and in the volume based plan was 96.58% ±3.44. Conclusions Comparison of orthogonal X-ray-based and CT-based HDR ICBT planning is feasible. The ICRU bladder and rectal point doses in 2D planning were lower compared to the ICRU bladder and rectal point doses in 3D planning. But D1cc, D2cc of bladder and rectal doses were lower in 3D planning compared to 2D planning due to normalization in 2D planning and optimization in 3D planning and also it was observed that the tumor coverage was better in 3D volume based planning compared to 2D point A based BT planning., Purpose The aim of this study is to find an optimum bladder volume and central tandem length to minimize the dose to pelvic OARs. Material and methods This study was done in 2017-2018 among 40 patients who received concurrent chemoradiation of dose 50 Gy in 25#, 2 Gy per fraction over 5 weeks along with weekly inj.cisplatin of dose 40 mg/m2 followed by 3 sessions of HDR intracavitary brachytherapy with dose 7.5 Gy per session once weekly from the Department of Radiation Oncology, Father Muller Medical College with histologically proven squamous cell carcinoma of cervix. The bladder, rectum, and sigmoid DVH parameters such as D0.1cm3, D2cm3 and D10, D30, D50 were recorded in terms of percentages of the planning aim dose after each treatment plan. Results Bladder: High-dose parameters of bladder are increased by increasing the bladder volume. Tandems longer than 4 cm increase the dose to the bladder up to about 4% (of the planning aim dose) more, compared to the shorter tandems; Rectum: Rectum dose reaches its minimum and maximum levels for < 70 cc and 110-170 cm3 bladders, respectively. Choosing a longer tandem leads to about 5% higher dose to the rectum. Rectum volume does not have any drastic influence on the dose to rectum for patients whose tandems are ≤ 4 cm. Sigmoid: When the bladder volume is 70-75 cm3, the sigmoid dose will be minimum. Tandem lengths have a direct relationship with sigmoid dose. Conclusions In conclusion, choosing a bladder with a volume of about 70 cm3 or less and tandem length of < 4 cm is recommended when taking into account the high dose volume parameters for bladder, rectum, and sigmoid., Purpose To evaluate response in locally advanced carcinoma cervix patients who could not be adequately treated with intracavitary brachytherapy. Material and methods 40 patients from January 2014 to July 2019 received HDR interstitial brachytherapy using the MUPIT applicator under transabdominal USG guidance under spinal/epidural anaesthesia. The dose of 12 Gy to 22.5 Gy was delivered in 3 to 6 fractions. Total no. of patients 40 Median age 50 Histology: SCC 36 Histology: adenocarcinoma 4 Stage IIB 8 Stage IIIA 2 Stage IIIB 17 Stage IVA 5 Ca vaginal vault/stump 8 EBRT 50 Gy/25# 28 EBRT 46 Gy/23# 8 Chemotherapy: Cisplatin 30 Chemotherapy: Paclitaxel + Cis 5 Chemotherapy: Carboplatin 5 An invasive procedure was performed under spinal and epidural anesthesia. EUA – external genitalia, vaginal length, tumor dimension, parametrial and paravaginal tissue involvement, and relationship of the tumor to the uterus and other pelvic organs as well as a thorough per-rectal examination is done. Foley’s catheterization is done with the balloon filled with 7 ml of contrast. Bladder filling with 200 cc of normal saline and clamp the Foley catheter. The uterine sounding is done to assess the uterine length. The uterine tandem is placed into the uterine cavity. The vaginal length is determined and the vaginal obturator is inserted over the tandem until its tip abuts the cervical os. The base plate is fixed to the obturator with screws and to the perineum by stitches at 4 corners. A guide needle is inserted 3-4 cm beyond the clinically palpable disease, starting with the needles near the rectum, with one finger inside the rectum to avoid rectal perforation. The number and position of the needles are according to the extent of the disease. All the needle insertions are done under transabdominal USG guidance and the position is checked. The cover plate is placed over the template to prevent the needles’ displacement. Results 20 patients had a complete response. 10 patients had a partial response and 10 patients had disease progression. Conclusions In conclusion, HDR-ISBT gives better results in locally advanced carcinoma cervix not suitable for intra cavitary brachytherapy., Purpose This study aims to compare dosimetry and skin toxicity of patients treated with local tumour bed dose escalation (boost) with photon beams (external beam radiation therapy – EBRT) vs high-dose-rate interstitial brachytherapy (HDR-BT) after breast-conserving treatment in women with early-stage breast cancer. Material and methods Eligibility criteria: Age ≥ 18 years. Histologically confirmed carcinoma of breast, unilateral early breast cancer. Undergone breast conservation surgery followed by whole breast radiation therapy. Three dimensional conformal radiotherapy was planned as per conventional methods. The whole breast was treated to a total dose of 40 Gy in 15 consecutive daily fractions, 2.67 Gy per fraction. An additional boost dose was delivered either by ISBT or EBRT. Skin contouring was defined as a thick layer of 5 mm underneath the skin surface (Nandi M et al.). All patients underwent clinical examination before irradiation, weekly during the treatment course and every three months for the first year. Acute skin toxicity was assessed during and at the completion of RT and after 1 month, 3 months, and 6 months. Late effects and cosmetic outcome were evaluated at each clinical visit. Results Skin toxicities during the end of radiation: grade 1 toxicity in 6 (1/5), grade 2 toxicity in 11 (6/5), grade 3 toxicity in 3 (6/0), grade 4 toxicity: nil. Observed in 1 patient in arm that received tumour bed boost by EBRT. Recurrence occurred within 1 cm from the surgical scar. Conclusions Tumour bed boost by interstitial brachytherapy has shown better tumour control with lower grades of skin toxicity., Purpose Soft tissue sarcomas (STS) are a comparatively rare heterogeneous group of tumours with different distinct histopathological subtypes. It accounts for less than 1% of all adult solid neoplasms. Due to rarity of the occurrence and heterogeneous pathological varieties, STS have aggressive biological behaviour and high potential for local recurrence after surgery. Adjuvant radiation therapy, either preoperative or post-operative, improves local control rates after local resection or limb sparing surgery, eliminating the need for amputation in case of limb sarcoma. Case details A 45-year-old woman was diagnosed with fibroid uterus and underwent total abdominal hysterectomy after which she developed a swelling on the anterior abdominal wall. Wide local excision was done. IHC showed features suggestive of myofibroblastic proliferation reactive for vimentin, CD99, SMA, and CD34; Ki-67 labelling index is 20%. The patient developed recurrent swelling at the same site twice and was excised. She received adjuvant radiation therapy 66 Gy with 33 fractions completed. She was on regular followup when she noticed a swelling in the right scapular region which was increasing in size. On examination, right shoulder – 7 × 6 cm swelling present over the right scapular region. Skin over the swelling normal. Firm to hard in consistency. Fixed to underlying structure. MRI: mass lesion measuring 11 × 10.5 × 5.3 cm noted in the right infraspinatus muscle. Inferiorly fat planes with teres minor were maintained. Anterior portion of infraspinatus muscle was normal. She underwent wide local excision under GA with per op insertion of 8 ISBT catheters. HPE showed malignant soft tissue neoplasm – epithelioid malignant peripheral nerve sheath tumor. The external contours of the CTV were delineated on each CT slice in the 3D treatment planning system (Oncentra Brachytherapy Mode). HDR brachytherapy was performed using an 192Ir remote after loading the system with the treatment device Nucleotron micro-Selectron using the prescription point at 1 cm from the catheters and a total prescription dose of 15 Gy in 5 sessions, 3 Gy per session, delivered through 8 ISBT catheters. Brachytherapy was started on POD 6. The patient is on regular follow-up and presently has no complaints and is planned for EBRT. Results For function preservation in the management of STS, a wide margin resection is the common surgical procedure. Local recurrence rates after conservative surgery alone have been unacceptably high (30-75%). Combination of surgery and ISBT with/without EBRT improves local and distant control with acceptable late toxicities. Conclusions In this case report we noted that local recurrence rate had significant control with ISBT. Long term follow-up is necessary to comment regarding late recurrences., Purpose Sebaceous carcinoma of the eyelid is a rare malignant tumor of the sebaceous gland. The general principles of radiation to skin cancer also apply to sebaceous carcinoma of the eyelid. We report the use of surface mould brachytherapy for adjuvant radiotherapy in eyelid tumors. Case details A 73-year-old man presented with a small, progressively increasing painless papule of 2 × 1.5 cm exuberant vegetative nodule with central crusting over the margin of the left upper eyelid. After detailed evaluation and review, left upper eyelid tumor excision and reconstruction was done. Histopathology revealed sebaceous carcinoma grade II with intraepithelial pagetoid spread and positive medial and lateral margin. Therefore, adjuvant RT was planned. Surface-mold technique was considered. With the help of a thermoplastic mold (to hold the catheter in place) and a wax spacer (as a separator), a single catheter was placed each time along the surgical scar and fixed to it with adhesive plaster. A corneal shield was used to further increase the distance between the catheter and the cornea. The patient received 40 Gy/9# over 5 days, with ≥ 6 hour inter-fraction interval. Results He tolerated the treatment well, with grade I skin reaction following treatment completion. At one-year follow-up, the patient has no recurrence, and has no long-term sequelae of brachytherapy. Conclusions Surface-mold brachytherapy could be considered in selected patients with eyelid tumors., Purpose The aim of this study is to analyse treatment outcomes of perioperative interstitial brachytherapy in keloids. Material and methods From 2014 to 2016, 20 patients who underwent keloid excision and were referred for adjuvant RT were analysed retrospectively. After excision of keloid, brachytherapy tubes were placed subcutaneously before closing the wound and radiation to a total dose of 15 Gy in 3 divided doses was delivered on day 1, 2, 3 of surgical excision. Results The median age was 29 years (range: 18-71); 50% of patients were male and 50% female. The most common site of keloid was ear lobe (40%) followed by sternum (20%) and forearm (15%). The most common presenting complaints were cosmesis, itching and pain. 30% of patients had received a previous treatment, either surgery or corticosteroid injection, and had recurrence in the same region. The median size of keloid before brachytherapy was 80 mm3. The median followup was 3.8 years. 5 patients had local recurrence (26%) and median time to recur was 8 months. 1 patient had recurrence outside the treated region. No treatment-related complications (infection) were seen in any patients. All patients reported symptomatic and cosmetic improvement at 1-year follow-up. Conclusions Peri-operative radiation therapy can reduce the risk of keloid recurrence. Our study shows good local control of 73%, hence suggesting that HDR brachytherapy with 3 fractions of 5 Gy each is a safe and effective dosage schedule for postoperative adjuvant radiotherapy in management of keloids., Purpose According to FIGO staging of cervical cancer, involvement of the lower third of the vagina is considered as IIIA. There are limited studies of treatment outcomes in these patients. Narrowing of the vagina from invasion of tumor may cause improper intracavitary brachytherapy (ICBT) leading to an insufficient radiation dose delivered. Therefore, these patients have higher risk of persistent or local recurrence (LR). The usual tandem and ovoids application does not provide a sufficient dose to the lower third of the vagina. So either tandem and cylinder or interstitial brachytherapy is done in these patients. The study aims to observe the response to radiotherapy. Material and methods Patients with confirmed pathological results of squamous cell carcinoma cervix and who received complete radiation therapy. Results The total number of patients included in this study was 56, of whom 5 patients were lost to follow up, so 51 patients were included. Median followup of these patients is 36 months (12-72 months). 11.7% (6) patients developed grade 2 proctitis, 1.9% (1) developed grade 3 proctitis. 3.9% (2) patients developed grade 3 small bowel toxicities. No urinary bladder toxicities were noted. All the toxicities are observed in the patients treated with tandem and cylinder. Conclusions There is a smaller amount of data regarding stage IIIA carcinoma cervix. In our study we provided the results attained in our institute. The toxicity of radiotherapy is less when interstitial brachytherapy is done than tandem cylinder., Purpose Despite advances in treatment of patients with locally advanced cervical cancer, failure and recurrence seem to be greatly increasing. The aim was to analyse factors affecting recurrence, failure and pattern of care in carcinoma cervix patients undergoing treatment in our institution. Material and methods We retrospectively investigated the treatment charts of 230 patients with carcinoma cervix in the Department of Radiation Oncology in Madras Medical College who completed treatment during February 2009 and January 2014 with minimum follow-up of 6 months. Results Out of 230 patients, 68 (29.5%) patients presented with failure and recurrence. Among those, 68.21% of patients did not complete radiation, 32% of patients did not receive radiation in an adjuvant setting. The most common sites of distant failure were paraaortic node (42%), lung (31%), bones (15%), liver (12%). Treatment time, EBRT and ICBT gap and mean EQD2 point A were found to be associated with a better outcome in terms of DFS. Conclusions Both failure and recurrence depend upon age and stage at presentation, point A cumulative dose and treatment gap. The failure can be reduced if the patients are educated about the importance of completing both EBRT and brachytherapy without defaulting the treatment. An interesting result was that follow-up pattern had a significant impact on DFS period., Purpose Intracavitary vaginal brachytherapy is a common adjuvant treatment for superficial vaginal cancer invading a depth up to 0.5 cm (3,4). Custom applicators are required when standardized applicators do not conform or adapt to the patient’s specific anatomy. For patients with a small vaginal cavity, standard applicators to achieve conformity at the vaginal apex may be impossible. Case details This case study describes a custom surface mould applicator designed to deliver adjuvant HDR vaginal brachytherapy to a patient with long standing procidentia with vaginal cancer, post-surgery and post EBRT. A custom surface mould applicator was created to deliver intra-vaginal brachytherapy to a postvaginectomy patient with a vaginal cavity of 1 cm in length. Results The patient tolerated the treatment with grade 1 skin toxicity and clinically no recurrence after 3 months of followup. Conclusions The custom applicator was a viable and safe solution that resulted in an acceptable dose distribution and was well tolerated by the patient., Purpose Interstitial brachytherapy is the most effective way of delivering radiation therapy in the case of boost to the tumour bed or in APBI in treatment of breast carcinoma. Strict dosimetric and volumetric parameters are to be maintained during treatment planning in order to obtain a good coverage and to reduce the dose to OARs. Here we report the parameters used in dosimetric and volumetric evaluation during treatment planning of breast ISBT. Material and methods 8 patients who underwent multi-catheter breast ISBT were included in the study. All patients were treated by a MicroSelectron HDR Brachytherapy unit; treatment was planned in the Oncentra planning system with graphical optimization. The dosimetric and volumetric parameters evaluated were as follows: Dosimetric parameters Definition/calculation DNR – dose non-uniformity ratio V1.5 × PD/VPD DHI – dose homogeneity index (VPD – V1.5 × PD)/VPD OI – overdose volume index V2 × PD/VPTV CI – coverage index V100/100 COIN – conformal index PTVPD/VPTV × PTVPD/VPD Volumetric parameters VPD volume irradiated by prescribed dose V150 volume receiving 150% of the dose V90 and V50 of ipsilateral non-target breast Results The DNR value was 0.626. The DHI was 0.3736. The coverage index was 0.67. The OI was 0.339 and COIN was 0.526. The dose to OAR was well under the normal constraints. Conclusions DNR, DHI, OI, CI, COIN, V150, VPD should be routinely used in all treatment planning of breast ISBT., Purpose Oesophageal cancer is the sixth leading cause of cancer-related mortality worldwide because of its high malignant potential. It accounts for approximately 6% of all gastrointestinal malignancies. Most commonly it presents as locally advanced disease or as advanced or metastatic disease with 5-year survival approximately 5-10%. The prognosis is poor with median survival of 9 months. Surgery is the preferred primary treatment for operable patients. However, a substantial number of patients are unfit for surgery. In locally advanced oesophageal cancers definitive chemoradiation therapy has been shown to improve survival rates. Case details A 63-year-old man presented with dysphagia to semisolids and solids since 2 months and severe dyspnoea since 5 days. Dyspnoea increased on exertion with KPS-20. Clinically there were reduced breath sounds on the left side of the lung. UGI-scopy showed a 11 cm lesion in the mid oesophagus and biopsy showed squamous cell carcinoma. CT scan showed irregular circumferential wall thickening of the mid oesophagus noted from T5-T8 level approximately 9 cm, with proximal dilatation of the oesophagus with infiltration of the left main bronchus noted with collapse of the left lingula, lower lobe and reduced volume of the left upper lobe. Due to the poor general condition of the patient, he was planned for palliative radiotherapy with endobronchial and oesophageal intraluminal brachytherapy, bronchoscopy showing proliferative growth in the left main bronchus. A bronchoscopy guided endobronchial 6F catheter was placed. He received 8 Gy in a single fraction through 2 catheters – 1 endobronchial and 1 oesophageal by HDR brachy-therapy. Results Post brachytherapy he had a good response to treatment was able to tolerate solids. UGIscopy suggested no evidence of disease in the oesophagus and chest X-ray showed re-expansion of the collapsed left lung and also improvement of his general condition with KPS-80. Due to good clinical and radiological response, he was planned for radical treatment. He received 9 cycles of weekly paclitaxel and carboplatin. Post-chemotherapy UGI-scopy revealed residual disease, a 6 cm lesion in the mid-esophagus and he also had complaints of dysphagia to solids. In view of the above he was treated concurrently with CTRT 50 Gy in 25 fractions with weekly dual agent chemotherapy carboplatin and paclitaxel. The patient tolerated the treatment well and is able to tolerate a solid diet. Currently he is on follow-up. Conclusions HDR endobronchial brachytherapy is an effective method to relieve airway obstruction and oesophageal brachytherapy for relief of severe dysphagia promptly for patients and may be considered as a boost for obstructive lesions before chemotherapy and external beam radiation therapy., Purpose To report the early disease and toxicity outcomes of image guided adaptive brachytherapy for carcinoma cervix treated with definitive radiotherapy. Material and methods This retrospective study considered patients with carcinoma cervix treated with curative radiotherapy at our institute. Patients who received image guided brachytherapy using cross-sectional imaging after completion of external-beam radiotherapy were selected. Patients not completing the planned treatment, partially treated with simulator based planning and those receiving palliative RT were excluded. The disease status of the patients at the last follow-up and the toxicities experienced were recorded. Results Between April 2017 and December 2018, 34 patients were treated with image guided brachytherapy. Mean age of the patients was 60.7 years (range, 39-78 years). The majority (22; 59.5%) of the patients had stage IIB disease. The average HR-CTV volume at the time of brachytherapy was 19.6 cc (range, 5.7-99 cc). The D2cc to bladder and rectum were 3.4 (range, 1.2-6.2) Gy and 4.4 (range, 1.4-9.9) Gy, respectively. Mean dose to PIBS was 2.1 Gy (range, 0.5-11.2). Among the 24 patients with a mean followup of 9.7 months (range, 2.1-19.2 months), residual/recurrent disease was noted in two (8.3%). Rectal and bladder toxicities were mild (≤ grade 2) and noted in two patients each. However, vaginal stenosis was frequent (41.7%), with 3 patients (12.5%) experiencing total stenosis. Conclusions Early results of implementing image guided brachytherapy in carcinoma cervix at our institute have been promising, with good locoregional control and low gastrointestinal and genitourinary toxicity, excepting a high incidence of vaginal stenosis., Purpose The mean age of the general population has been prolonged and incidence of cancer in elderly patients has increased. The purpose is to evaluate outcome of brachytherapy as an integrated part of treatment of elderly patients with cervical cancer. Material and methods This is a retrospective analysis of 69 patients of 70 years of age diagnosed with cervical cancer with stage 2B-4A (FIGO) from Jan 2012 to Jan 2016 presented at Radiation Oncology OPD, MMC. They were treated by HDR brachytherapy as part of their treatment. Results The median age was 75 years (range 70-80 years). 91% of patients presented with squamous cell carcinoma. The mean point A EQD2 dose was 82 Gy (range: 80-85). The mean bladder and rectal point doses were 78 Gy and 67 Gy respectively. Rectal, small bowel and urinary tract complications were observed in 15 (21.7%), 3 (4.3%) and 9 patients (13.04%) respectively. Rectal complications grade 1, grade 2, grade 3 incidences were 8 (11.5%), 5 (7.2%) and 2 (2.8%) respectively. Urinary complications grade 1 and grade 2 incidences were 5 (7.2%) and 4 (5.7%) respectively. With a median follow-up of 3 years, 10 patients developed distant metastases and 9 others presented local relapses. The 3-year specific overall survival rate was 86.9% and the corresponding disease-free survival rate was 72.5%. Conclusions Elderly women with cervical cancer tolerated brachytherapy well and had excellent local disease-free survival and specific survival rates. Age did not influence the effectiveness of brachytherapy in elderly patients and brachytherapy should be considered whenever possible, even in elderly patients presenting with cervix cancer., Purpose High-dose-rate intracavitary brachytherapy has been widely used in the treatment of cervical cancer. In the analysis of RT outcome it is important to assess not only local tumor control, but also the incidence of late sequelae caused by treatment. The risk factors of late sequelae include age, stage, EBRT dose, no. of HDRICB treatments, point A dose and rectal and bladder reference doses. Material and methods Between January 2016 and December 2017, 50 patients who survived more than 12 months after treatment were studied. Initially, they were treated with EBRT 50 Gy-50.4 Gy using a telecobalt 60 machine in 25-28 fractions to the whole pelvis along with weekly chemo inj. cisplatin 40 mg/m2 after which HDR ICB was performed using a 60Co remote afterloading device after CT simulation with tandem-ovoid applicators. Point A standard dose prescribed was 6-8 Gy/#. Patient and treatment related factors were evaluated for rectal complications and bladder complications along with local control, progression-free survival, and overall survival. Results The probability of rectal and bladder complications showed better correlation of dose response with increasing total ICRU rectal and bladder dose. Mean point A dose was 76.6 Gy by EQD2. Mean bladder and rectal doses were 70.2 Gy and 60.6 Gy. The mean follow-up period was 30 months. 2-year LC, PFS, OS rates were 90.86 and 82% respectively. PFS for patients with FIGO stage 2B-3B was 91.8% vs. 33.3%. OS at 2 years was 86.4% vs. 50%. Late grade 3-4 toxicities, mainly gastrointestinal and urinary complications, were observed in 11 patients (22%). Conclusions This study demonstrated the values of ICRU rectal and bladder mean doses achieved in HDR ICB. Patients who had a rectal dose and bladder dose greater than 68 Gy and 73.5 Gy EQD2 were at risk of late sequelae., Brachytherapy is a treatment modality as old as the history of radiotherapy in cancer treatment. The word brachytherapy is derived from the word brachy, which means “short” in Greek. Following the discovery of X-rays by Wilhelm Konrad Roentgen in 1895, the French physicist Henri Becquerel discovered that uranium spontaneously emitted rays similar to Roentgen rays. Shortly after the discovery of radioactivity, Pierre Curie recommended the use of radioactive isotopes for cancer treatment in the early 1900s. In 1903, the first gynecological brachytherapy was described by Margaret A. Cleaves in New York. Treatment of prostatic disease with radium was first reported in Paris, at a meeting of the Association Françoise d’Urologie in October 1909. In New York, Robert Abbe from St. Luke Memorial Hospital performed the first radium implant following the excision of a tumor in 1905. After October 1910, Marie Curie started dose calculations of radioisotopes and dose calculations in brachytherapy applications based on the mg-radium equivalent (mgRaEq). After the First World War, radium treatment of carcinoma of the cervix was started by Gösta Forssell in 1910. The Nobel Prize in Chemistry in 1911 was awarded to Marie Curie for the discovery of the elements radium and polonium, by the isolation of radium. Methods of intracavitary brachytherapy were described by the schools of Stockholm and Paris in 1914 and 1919, respectively. In 1960, Henschke described afterloading technique for tumors of the uterus and cervix, which reduced exposure to staff. In 1952, the MD Anderson technique was presented by Gilbert Fletcher and the Fletcher applicator, which was used in vaginal colpostate in the United States, was identified in 1953. Prof. Dr. Reha Uzel and Ulrich Henschke pioneered gynecological tumors and brachytherapy in Turkey and performed the intracavitary application with Manchester type rubber ovoid and intrauterine applicators in 1955 with Seyfet tin Kuter. In 1957, eye tumors were treated with Sr-90 eye applicators. In the 1960s, Drs Scardino and Carlton at Baylor College of Medicine in Houston, TX, performed permanent prostate brachytherapy using Au-198 interstitial implantation or 125I. In 1969, the 60Co remote controlled Cathetron device was established at the radiotherapy department at Istanbul Faculty of Medicine. Thus, HDR brachytherapy was started. In the 1970s, the dosimetry rules of the Paris system were determined by Chassagne, Pierquin, and Dutreix in interstitial treatment. In 1983, Hans Henrik Holm introduced the use of trans-rectal ultrasound to visualize the permanent placement of 125I seeds via needles inserted through the perineum directly into the prostate. In the 1990s, interstitial applications were started with low-dose 192Ir wires in the Department of Radiotherapy in the Istanbul Medical Faculty of Istanbul University. In 1985, Blasko and Ragde began the first transperineal, ultrasound-guided approach in the United States. Since 2000, permanent prostate brachytherapy has been performed under the guidance of transperineal ultrasound with LDR 125I sources at the Oncology Institute of Istanbul. As a result, brachytherapy, with its 120-year long history, preserved its importance., Purpose Hidradenocarcinoma is a rare malignant adnexal tumor which arises from the intradermal duct of eccrine sweat glands. Head and neck are common sites. It can rarely occur on the extremities. It is an aggressive tumor with spread to region lymph nodes and distant visceral metastasis. Case details An 80-year-old woman was evaluated for complaints of painless swelling over left ear pinna, starting in April 2018; excision was done in April 2018. A similar lesion reappeared below the previous site; excisional biopsy was done in October 2018, suggestive of spindle cell tumour, grade 3. [Margins uninvolved, LVI negative, mitotic activity = 3-4/HPF] Feb 2019, the patient again developed a swelling in the infra-auricular and parotid region, along with matting of submandibular and upper jugular lymph nodes. USG done shows hyperechoic lesion, 3.5 × 2.7 cm with compressible internal echoes. Incision and drainage was done. Biopsy s/o recurrent spindle cell carcinoma of vascular origin. CT neck shows nodular enhancing lesion measuring 2 × 1.2 cm in the helix of the pinna along with multiple enlarged cervical lymph nodes at level 2 and 3, the largest measuring 35 × 17 mm, along with heterogeneous enhancing necrotic lesions posterior to the left parotid 3 × 3.5 cm, likely lymph node complex. The patient was diagnosed with recurrent spindle cell carcinoma of the left pinna and underwent wide local excision and modified radical neck dissection on 29.04.19. HPE s/o malignant adnexal tumor, differential diagnosis, 1 – trichilemmal carcinoma, 2 – hidradenocarcinoma [Size 1.2 x 0.6 × 0.5 cm] [Perineural invasion present, extranodal extension present, lymph nodes 5/48, medial margin free of tumour. Clearance for SM-0.7, DM-0.2 cm, LM-0.4.I M-0.2 cm]. Results The patient has been on follow-up for 5 months with no local recurrence with grade 1 skin reaction. Conclusions Hidradenocarcinoma is a very aggressive tumour characterised by high frequency of locoregional recurrence and notorious behaviour for distant metastases. The wide excision surgery along with adjuvant radiation therapy will be helpful in better local control. Patients should be closely kept on regular follow-up.

The incidence of endometrial cancer (EC) is on the rise in India. The median age at presentation is lesser than the Western population. Majority of the patients present in early stages with excellent overall survival rates after surgery. Adjuvant therapy is essential in high-risk stages I–III for improving outcomes. The quality and extent of surgery, and complete histopathological information are important factors for outcome and tailoring adjuvant therapy. Depending on patients and histopathological factors, various risk groups have been defined for prognostication and defining adjuvant therapy. Adjuvant therapy including external radiation, vaginal brachytherapy, chemotherapy and combined chemoradiotherapy has been tried depending on various risk groups. The purpose of this article is to review and interpret and update the results of existing literature on adjuvant therapy in EC with a special focus on Indian reports and standards.

Objectives To present a nomogram for prediction of overall survival (OS) in locally advanced cervical cancer patients (LACC) undergoing definitive radiochemotherapy including image guided adaptive brachytherapy (IGABT). Methods We retrospectively reviewed 720 patients with LACC acrrued onto the RetroEMBRACE database (12 international institutions). All patients were treated with External Beam Radiotherapy (EBRT) concurrent with Chemotherapy (CHT) and MRI/CT-guided brachytherapy. Missing data (7.2%) were imputed by multiple imputations and predictive mean matching. Stepwise selection of predictive factors with the Akaike information criterion (AIC) was used to obtain a predictive model and construct a nomogram for OS predictions 60 months from diagnosis. The model was internally validated by concordance probability as a measure of discrimination and a calibration plot (both corrected for optimism using bootstrap cross-validation). Results Through the predictive model (AIC), seven factors were selected to develop the nomogram: FIGO stage (2B vs.1A,1B,2A; 3A,3B,4A,4B vs.1A,1B,2A), age, corpus involvement, lymph node status, concurrent chemotherapy given, overall treatment time, volume of the high risk clinical target volume at the time of first brachytherapy (CTVHR). CTVHR is considered surrogate for response at concurrent EBRT+CHT. This OS nomogram had a satisfactory calibration and useful discrimination (concordance probability c=0.74). Conclusions Prognostic factors were used to develop the first nomogram for 5-year OS in patients with LACC in the setting of IGABT treatment. Response to concurrent EBRT and CHT (CTVHR) seems to be a new essential outcome predictor for OS. These nomograms can be used to better estimate individual and collective outcomes and may facilitate personalized patient counselling during the treatment.

Objective Extended-field radiotherapy (EFRT) with concurrent chemotherapy represents standard treatment in cervical cancer patients with para-aortic lymph nodal (PALN) metastasis. While EFRT with Intensity Modulated RT (IMRT) has been demonstrated to reduce toxicities, the dose thresholds for minimizing acute toxicity is not clear. The present study was undertaken to report the early toxicity with extended-field intensity-modulated radiotherapy (EF-IMRT) for carcinoma of the cervix in our cohort of patients and determine dose-volume parameters that predict ≥grade II haematological toxicity and diarrhoea. Methodology This was a retrospective study of consecutive cervical cancer patients with PALN metastasis treated with EF-IMRT. Patients received rotational IMRT +/- neoadjuvant chemotherapy (NACT) and/or concurrent chemotherapy (45-50 Gy/25#/5 weeks) followed by high-dose rate brachytherapy. Acute haematological and gastrointestinal toxicity (diarrhoea and vomiting) was correlated with doses received by bowel and marrow. Receiver operator characteristics curves were used for deriving thresholds that predict for increased toxicity and tested on univariate and multivariate analysis. Finally, disease free and overall survival (DFS and OS) was calculated. Results A total of 43 patients were included. One-fourth of the patients (11/43) received NACT and 88% received concurrent chemotherapy. Within the upfront EF-IMRT cohort, 22.6% and 9.7% patients developed grade ≥III haematological (HT) and gastrointestinal (GI) toxicity respectively, with an increase in HT (≥ grade III HT =67%) in patients receiving NACT (p = 0.007). In the entire cohort bone marrow Volume receiving 10 Gy (V10>) 90% correlated with an increase in ≥ grade III HT (p = 0.05). No dose volume thresholds could be validated for GI toxicity. The OS and DFS at 2 years was 56% and 54%, respectively. Conclusion EF-IMRT is a feasible option for cervical cancer patients with PALN involvement and is associated with acceptable grade III toxicity. Future studies need to focus on minimizing HT toxicity.

This paper reviews the conceptual, methodological, and technical innovations underpinning strategies for adaptive target volume selection and risk-adapted dose prescription in cervical cancer. An adaptive target volume concept has been developed which reflects tumor shrinkage at the end of initial chemo-radiation, which serves for an image-guided boost delivered through brachytherapy, with a risk-adapted dose prescription to different gross tumor- and clinical target volumes defined at diagnosis and after 40-50Gy external beam radiotherapy, and adaptation of the treatment technique according to the topography of the tumor after response and adjacent organs at risk. Clinical results of these innovations are presented based on prospective and retrospective multi-center trials (IntErnational study on MRI-based BRachytherapy in locally Advanced CErvical cancer [EMBRACE], retroEMBRACE) with large patient cohorts (n = 1416, n = 731). The potential benefit of applying these strategies and using a specific multi-parametric dose prescription protocol are explored (EMBRACE-II) and overall current and future research strategies are outlined. The challenges of dissemination and implementation of these complex new techniques into clinical practice are discussed.

Purpose This phase II study evaluated the utility of magnetic resonance imaging (MRI) and positron emission tomography for planning radiation and brachytherapy in patients with postsurgical recurrence of cervical cancer. Methods and Materials The study (NCT 01391065) recruited patients with residual or recurrent disease after hysterectomy. Patients underwent baseline T2 weighted (T2W) MRI, 18F-flouro-deoxyglucose (18F-FDG), 18F-flouro thymidine (18F-FLT) and 18F-flouromisonidazole (18F-F Miso) positron emission tomography (PET) and received external radiation (50 Gy/25 fractions for 5 weeks) and weekly cisplatin (40 mg/m2). MRI was performed at brachytherapy and used for delineation of clinical target volume (CTV). Patients with parametrial disease at baseline received interstitial brachytherapy (16-20 Gy/4-5 fractions) and those with vaginal disease received intracavitary brachytherapy (12-14 Gy/2-4 fractions). Kaplan-Meier analysis was performed to evaluate locoregional relapse, disease free survival, and overall survival. Common Toxicity Criteria for adverse event reporting (CTCAE) v4.1 was used for toxicity scoring and European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questtionaire Core 30 (QLQC-30) and Cx 24 for quality-of-life reporting. Results Between January 2011 and February 2016, 60 patients were included, of which 50 received study treatment. The mean gross tumor volume on T2 W MR was 20 (IQR 3.6-90) cc. The metabolic tumor volume was 15 (interquartile range [IQR] 2.1-56.1) cc. The median FLT volume was 10 (IQR 0-48) cc. A total of 8 patients had 18-F F Miso uptake. The median CTV at brachytherapy was 38 (12-85) cc. The median CTVD90 and D 98 was 71 (53-74) and 74 (53-74) Gy. At a median follow-up of 60 (5-93) months, the 5-year local control, disease free survival, and overall survival were 84%, 73%, and 74.5%, respectively. Grade III and IV proctitis and cystitis were observed in 4% and 2% of patients. On multivariate analysis baseline tumor volume, on T2 W MR impacted disease free (91% vs 65%, P = .03) and overall survival (96% vs 77%, P = .06). Conclusions Image-guided assisted radiation and brachytherapy are associated with good to excellent local control and survival in patients with vaginal recurrences of cervical cancer.

Summary Penile cancer is an aggressive neoplasm and nodal metastasis is a key factor in determining the outcome. While there is a paucity of tools predicting nodal metastasis, an elective groin node dissection (GND) may cause severe morbidity. We aimed to devise a histopathology-based risk stratification system to predict the risk of nodal metastasis in penile squamous cell carcinoma (SCC) patients. In this retrospective clinicopathological analysis, consecutive penile SCC patients who had undergone primary surgical treatment with GND from 2007 to 2012 were included. Histopathology slides were reviewed and a histopathological risk scoring system (ranging from 3 to 9) was devised by adding the values assigned to the following pathological variables: tumour grade (1–3); anatomical level of infiltration (1–3); and tumour infiltration pattern (1–3). Three risk groups were created based on histopathological risk scores. Final scores and risk groups were correlated with nodal metastasis, disease-free survival (DFS) and overall survival (OS). We also validated the earlier described prognostic index score (PIS) on our set of patients and compared it to our proposed scoring system. A total of 162 cases of primary penile resections with unilateral or bilateral groin node dissection were identified during the study period. Sixty-two of 68 patients (91.17%) and 58 of 94 patients (61.7%) had nodal metastasis on upfront and follow-up nodal basin surgeries, respectively. Chances of nodal metastasis for each risk group were as follows: low risk (score 3 and 4) 14.3%; intermediate risk (score 5) 52.6%; and high risk (scores 6–9) 83.7%. Follow-up was available in 145 patients (89.5%). Median follow-up was 21 months (1–96 months). The histopathological scoring system (p=0.04) and risk groups (p=0.005) had a statistically significant correlation with DFS but not with OS. Logistic regression model demonstrated that this stratification system was a good predictor of nodal metastasis. Further, this scoring system had better predictive sensitivity for detecting true node-negative cases and marginally better accuracy in detecting nodal metastasis as compared to the PIS. Our study demonstrates that the histopathological risk stratification can predict nodal metastasis and aid in planning management of penile cancer patients with judicious implementation of the morbid procedure of GND.

AIMS: The aim of this study is to compare the quality of life (QOL) between adjuvant three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) for cervical cancer. MATERIALS AND METHODS: QOL assessment was done at the baseline and then longitudinally after completing (chemo) radiation. All patients completed EORTC QLQ-C30 and EORTC QLQ Cx-24 modules. Independent-sample t-test was used to compare the mean scores between the two groups. Analysis of variance was used to compare differences in QOL measures over the six time points (baseline, post-RT, 3, 6, 9, and 12 months after treatment) and between treatment groups (3DCRT vs. IMRT). Linear mixed model was also performed to account for attrition. RESULTS: Overall, 64 patients (image-guided IMRT, n = 40 and 3DCRT, n = 24) completed QOL assessment. The median age and follow-up period were 48 years and 15.5 months, respectively. General QOL domains such as emotional (at 12 months, P = 0.04) and social (at 3 months, P = 0.02 and 12 months, P = 0.03) were better with IMRT. Pain (12 months, P = 0.03); fatigue (12 months, P = 0.05); nausea and vomiting (12 months, P = 0.03); insomnia (post-RT, P = 0.05 and 12 months, P = 0.03); appetite loss (post-RT and 12 months, P = 0.04); and diarrhea (6 months, P = 0.02 and 12 months, P = 0.003) scores were significantly better with IMRT. On linear mixed model analysis, there was a significant interaction between treatment cohort and assessment intervals for physical, emotional, and social functioning, appetite loss, diarrhea, lymphedema, and menopausal symptom scores were significantly better with IMRT. CONCLUSIONS: Treatment technique (IMRT vs. 3DCRT) impacts early QOL in undergoing adjuvant radiation for cervical cancer.

Purpose Ureteral stricture is a rare but severe side effect of radiation therapy for locally advanced cervical cancer. This report describes the incidence and risk factors for ureteral stricture in a large patient cohort treated with 3-dimensional image guided adaptive brachytherapy and radiochemotherapy within the EMBRACE studies. Methods and Materials A total of 1860 patients were included. Treatment consisted of external beam radiation therapy (45-50 Gy in 25-30 fractions), concomitant cisplatin, and image guided adaptive brachytherapy. Grade 3 to 4 ureteral strictures were assessed with Common Terminology Criteria for Adverse Events v. 3.0. Risk factors for grade 3 to 4 ureteral stricture were analyzed. These factors included age, hydronephrosis on imaging at time of diagnosis, TNM stage, high-risk clinical target volume, laparoscopic staging, chemotherapy, radiation therapy doses to targets and organs at risk, applicator type, intracavitary versus intracavitary/interstitial technique, and dose rate. Results At a median follow-up of 34 months (range, 2-163), 31 patients received diagnoses of grade 3 to 4 ureteral stricture. Actuarial 3- and 5-year risk for ureteral stricture grade 3 to 4 was 1.7% and 2.1%, respectively, for all patients. Advanced tumor stage T3-4 with hydronephrosis at diagnosis was the only independent risk factors for ureteral stricture (P = .01). Patients with TNM stage T1 (n = 359) had a low risk of 0.4% and 1.0% at 3 and 5 years, and those with T2 (n = 1085) had a low risk of 1.0% and 1.0% at 3 and 5 years, respectively. Patients (n = 274) with T3-T4 without hydronephrosis at diagnosis had a 3- and 5-year risk of 2.2% and 4.8%, respectively, compared with 11.5% and 11.5%, respectively, in those with baseline hydronephrosis (n = 142). Conclusions Severe to life-threatening ureteral stricture occurs rarely in patients with locally advanced cervical cancer with T1-2 tumors. The risk for ureteral stricture is significantly increased in patients with T3-T4 tumors with hydronephrosis at diagnosis.

Purpose Image guided adaptive brachytherapy (IGABT) for cervical cancer improves pelvic control and survival across all stages. Improvement in pelvic control is larger in advanced stages, but improvement in survival is similar across stages. This paper analyzes the patterns of failure in the RetroEMBRACE cohort to investigate this discrepancy. Methods and Materials 731 patients from 12 institutions treated with chemoradiation therapy and magnetic resonance imaging or computed tomography–based IGABT were evaluated. The pattern of failure at time of first relapse was analyzed. Results Three hundred twenty-five failures (single and synchronous) occurred in 222 of 731 patients (30%). Among the 325 failures, 9% were local and 6% regional. Pelvic (local or regional) failures made up 13%, paraaortic node (PAN) 9%, systemic 21%, and distant (systemic + PAN) 24%. Of the 222 patients with treatment failure, 21% had pelvic failure alone, 57% had distant failure alone, and 23% had both pelvic and distant failure. Of all failures that occurred, 40% to 50% occurred in the first year, with a further 20% to 30% occurring in the second year. Although local, regional, and PAN failure tended to plateau after year 3, systemic failure continued to occur up to year 10. Conclusions Implementation of IGABT has changed the patterns of relapse after chemoradiation therapy for cervical cancer. The predominant failure after IGABT is systemic, whereas the predominant failure with conventional brachytherapy is pelvic. Effective treatments to eradicate micrometastases in PAN and distant organs are needed in addition to IGABT and chemoradiation therapy to maximize local, regional, PAN, and systemic control and improve survival.

PurposeImage guided brachytherapy (IGBT) for locally advanced cervical cancer allows dose escalation to the high-risk clinical target volume (HRCTV) while sparing organs at risk (OAR). This is the first comprehensive report on clinical outcome in a large multi-institutional cohort.Patients and methodsFrom twelve centres 731 patients, treated with definitive EBRT ± concurrent chemotherapy followed by IGBT, were analysed. Kaplan–Meier estimates at 3/5 years were calculated for local control (LC, primary endpoint), pelvic control (PC), overall survival (OS), cancer specific survival (CSS). In 610 patients, G3–4 late toxicity (CTCAEv3.0) was reported.ResultsMedian follow up was 43 months, percent of patients per FIGO stage IA/IB/IIA 22.8%, IIB 50.4%, IIIA–IVB 26.8%. 84.8% had squamous cell carcinomas; 40.5% lymph node involvement. Mean EBRT dose was 46 ± 2.5 Gy; 77.4% received concurrent chemotherapy. Mean D90 HRCTV was 87 ± 15 Gy (EQD210), mean D2cc was: bladder 81 ± 22 Gy, rectum 64 ± 9 Gy, sigmoid 66 ± 10 Gy and bowel 64 ± 9 Gy (all EQD23). The 3/5-year actuarial LC, PC, CSS, OS were 91%/89%, 87%/84%, 79%/73%, 74%/65%. Actuarial LC at 3/5 years for IB, IIB, IIIB was 98%/98%, 93%/91%, 79%/75%. Actuarial PC at 3/5 years for IB, IIB, IIIB was 96%/96%, 89%/87%, 73%/67%. Actuarial 5-year G3–G5 morbidity was 5%, 7%, 5% for bladder, gastrointestinal tract, vagina.ConclusionIGBT combined with radio-chemotherapy leads to excellent LC (91%), PC (87%), OS (74%), CSS (79%) with limited severe morbidity.

Gynecological cancers are among the most common cancers in women and hence an important public health issue. Due to the lack of cancer awareness, variable pathology, and dearth of proper screening facilities in developing countries such as India, most women report at advanced stages, adversely affecting the prognosis and clinical outcomes. Ovarian cancer has emerged as one of the most common malignancies affecting women in India and has shown an increase in the incidence rates over the years. Although cervical cancer is on a declining trend, it remains the second most common cancer in women after breast cancer. Many researchers in India have published important data in the field of gynecologic oncology, covering all domains such as basic sciences, preventive oncology, pathology, radiological imaging, and clinical outcomes. This work has given us an insight into the in-depth understanding of these cancers as well as the demographics and survival rates in the Indian population. This aim of this review is to discuss the important studies done in India for all gynecological cancers.

To evaluate the inter-assay variability of six commercially available prostate specific antigen (PSA) assays, its clinical impact in prostate cancer (PCa) and comparison of automated versus manual assays.Sera from 495 patients (425 with PCa and 70 men with Benign Prostatic Hyperplasia (BPH), were measured with six different assays [three automated assays (a-PSA) and three manual ELISA based assay (m-PSA)]. Variability, agreement and bias were measured and compared among assays using Bland Altman plots and Passing and Bablok regression analysis. The possible impact of inter-assay variability on important clinical scenarios was also studied.All the assays were well correlated (r: 0.88-0.98); however there was significant disagreement and bias between the systems, which were more pronounced among the a-PSA assays. The Bland Altman plot showed that the variability was high between the m-PSA assays and the standard Abbott system with mean difference of 3.8-5.8ng/ml. In contrast, the a-PSA had better agreement with mean difference of 0.8-2.3ng/ml. Beckman Coulter showed the best agreement to the institutional reference (slope-1.097; 95% CI: 1.06-1.14; p0.05, and intercept-0.20; 95% CI-0.38-0.58; p0.05, Passing Bablok). It led to significant variability in PCa risk stratification and failure to detect biochemical failure in more than 50% cases.The discrepancies between the assays lead to significant clinical misinterpretation with risk group migration and detection of biochemical failure post radiotherapy. There are significant discordances between automated and ELISA based assays.

PURPOSE Penile cancer, although rare, is one of the common genitourinary cancers in India affecting mostly aged uncircumcised males. For patients presenting with small superficial lesions < 3 cm restricted to glans, surgery, radical external radiation or brachytherapy may be offered, the latter being preferred as it allows organ and function preservation. In patients receiving brachytherapy, testicular morbidity is not commonly addressed. With an aim to minimize and document the doses to testis after adequate shielding during radical interstitial brachytherapy for penile cancers, we undertook this study in 2 patients undergoing brachytherapy and forms the basis of this report. MATERIAL AND METHODS Two patients with early stage penile cancer limited to the glans were treated with radical high-dose-rate (HDR) brachytherapy using interstitial implant. A total of 7-8 tubes were implanted in two planes, parallel to the penile shaft. A total dose of 44-48 Gy (55-60 Gy EQD2 doses with α/β = 10) was delivered in 11-12 fractions of 4 Gy each delivered twice daily. Lead sheets adding to 11 mm (4-5 half value layer) were interposed between the penile shaft and scrotum. The testicular dose was measured using thermoluminescent dosimeters. For each patient, dosimetry was done for 3 fractions and mean calculated. RESULTS The cumulative testicular dose to left and right testis was 31.68 cGy and 42.79 cGy for patient A, and 21.96 cGy and 23.28 cGy for patient B. For the same patients, the mean cumulative dose measured at the posterior aspect of penile shaft was 722.15 cGy and 807.72 cGy, amounting to 16.4% and 16.8% of the prescribed dose. Hence, the application of lead shield 11 mm thick reduced testicular dose from 722-808 cGy to 21.96-42.57 cGy, an "absolute reduction" of 95.99 ± 1.5%. CONCLUSIONS With the use of a simple lead shield as described, we were able to effectively reduce testicular dose from "spermicidal" range to "oligospermic" range with possible reversibility.

e18102 Background: To evaluate the clinicopathological factors, outcome and prognostics factors of uterine carcinosarcoma. Methods: All patients of uterine carcinosarcoma treated between January 2013 and December 2018 were identified and their clinical, laboratory and imaging details were retrieved from electronic medical record. Details of the treatment received, toxicity profile and outcome were recorded and analyzed. Patients (including stage I) were considered for four cycles of chemotherapy (Paclitaxel +Carboplatin) followed by radiation (EBRT to pelvis with vaginal brachytherapy). Survival analysis was done using the Kaplan–Meier method and compared between treatment groups using the Log-rank test. Results: Of 81 cases, 48 % presented with early stage disease (FIGOI-II) and 52 % with late stage (FIGO III-IV) disease. Median age was 58 years (30-80 years). Most women (83%) were postmenopausal and 80% of them presented with postmenopausal bleeding. Six patients developed carcinosarcoma on adjuvant tamoxifen (given for breast cancer) after a median drug intake of 8 years. In early stage, 10% patients received only surgical treatment; 46% received both chemotherapy (CT) and radiation therapy (RT) while 33 % received RT alone. In advanced stage, 31% received only CT, 14 % received only RT and 33% received both CT and RT after surgery. About 8% of patients had myelosuppression(grade I/II), 10 % had peripheral neuropathy (grade I/II) and 11% had electrolyte imbalance. At a median follow up of 2 years (1- 80 months), median DFS and OS in early stage group was 28.5 months and 31.0 months while in advanced stage group it was 13.0 months and 15.0 months respectively. Distant metastasis (omentum, peritoneum and lung being the common site) were seen in 30% of patients while local relapse was seen in 5 % cases. On univariate analysis stage of disease and receipt of adjuvant therapy were the factors found to be significantly associated with improved OS (p < 0.001) and adjuvant RT alone was associated with improved DFS (p < 0.023). Conclusions: Adjuvant treatment (chemotherapy and or radiation therapy) is associated with improved overall survival in uterine carcinosarcoma, irrespective of stage at presentation.

OBJECTIVE: To report acute hematological toxicity (HT) in patients receiving post-operative bowel sparing intensity-modulated radiotherapy (IMRT) and cisplatin and its dosimetric predictors. METHODS: Clinical database of Phase III trial (NCT01279135), that randomized patients to post-operative conformal or intensity modulated radiation therapy, was searched to select patient strata that received bowel sparing IMRT (50 Gy/25#/5 wks) and concurrent cisplatin (40 mg m(–)(2)). Pelvic bone marrow (BM) was retrospectively delineated in two sets: whole bone (WB), and freehand (FH) inner cavity of bone. Dose volume histograms (DVH) of BM were obtained. Receiver operating characteristic (ROC) curve identified DVH thresholds that predicted for Grade≥ II HT with highest specificity. Univariate and multivariate analysis was performed. RESULTS: Overall 75 patients received concurrent cisplatin. Grades I–V HT was observed in 38.7%, 42.7%, 14.7%, 0%, and 0% patients, respectively. Grade ≥ II leukopenia, neutropenia, anemia, and thrombocytopenia were observed in 26%, 40%, 26.5%, and 1.4% respectively. None of the HT resulted in treatment break. On univariate analysis, whole pelvis+ lumbar FH V30 >55% & V40>35%, whole pelvis WB and FH V40 > 35%, and lower pelvis WB and FH V40 >20% correlated for Grade ≥ II leucopenia and neutropenia. None of the BM dose volume constraints predicted for overall HT or neutropenia on multivariate analysis. CONCLUSION: The IMRT arm of NCT01279135 (PARCER study) that employed strict bowel constraints had unintentional but desirable BM sparing. None of the BM subvolume DVH parameters could be validated on multivariate analysis. ADVANCES IN KNOWLEDGE: The prospective study reports feasibility of bone marrow sparing with bowel sparing post-operative pelvic IMRT and concurrent chemotherapy for cervical cancer. The present study reports low incidence of hematological and gastrointestinal toxicity during post-operative chemoradiation with IMRT. As both whole bone and freehand pelvis BM contours predicted for HT, hence an easier method of whole bone contouring should continue to be used till further validation of more specific BM subvolumes becomes available. The study results highlight the need for further research into dose volume constraints during post-operative IMRT.

Purpose Chartrounds ( www.chartrounds.com ) was established in the United States in 2010 as a web-based platform for radiation oncologists to review cases with leading disease-site experts. However, the need for access to experts for peer review and education is not unique to the United States, and the Chartrounds platform was therefore adapted for improved global reach. Chartrounds was first expanded to India, and herein we report our initial experience with this initiative. Methods and Materials The US Chartrounds platform was adapted to create Chartrounds India ( ind.chartrounds.com ). Through collaboration with the Association of Radiation Oncologists of India, India-based specialists were recruited, and the association's membership list was used to announce sessions to potential participants. Results Between June 2017 and January 2018, 27 Chartrounds India sessions were completed, led by 21 different specialists (representing 10 centers in India) and covering 11 different disease sites/topics. A total of 240 members from 126 centers (private: 56%; teaching: 36%; public: 8%) across 24 states/territories participated in ≥1 session. Of the 240 members who participated in ≥1 session, 159 (66%) participated in ≥2 sessions and 60 (25%) participated in ≥5 sessions. The average number of participants per session was 34 (range, 13-72). On average, 80% of respondents rated the sessions as high or very high quality; 87% and 95% agreed or strongly agreed that the time was used effectively and that the sessions were relevant to daily practice, respectively. Seventy-six percent agreed or strongly agreed that the sessions will result in a change in their practice. The average feedback survey response rate was 32% (range, 17%-49%). Conclusions Chartrounds has proven to be an effective resource for US-based radiation oncologists, and our initial experience with Chartrounds India suggests that an online platform for radiation oncology case review and education can be successfully implemented globally with use of local disease site experts.

Two corrections were made to the above publication following its original online publication on 4th May 2018.

BackgroundDespite significant advances in the screening, detection, and treatment of preinvasive cervical lesions, invasive cervical cancer is the fifth most common cancer in European women. There are large disparities in Europe and worldwide in the incidence, management, and mortality of cervical cancer.ObjectiveThe European Society of Gynaecological Oncology (ESGO), the European Society for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) jointly develop clinically relevant and evidence-based guidelines in order to improve the quality of care for women with cervical cancer across Europe and worldwide.MethodsThe ESGO/ESTRO/ESP nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of cervical cancer (23 experts across Europe). To ensure that the guidelines are evidence based, the current literature identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 159 international reviewers, selected through ESGO/ESTRO/ESP and including patient representatives.ResultsThe guidelines cover comprehensively staging, management, and follow-up for patients with cervical cancer. Management includes fertility sparing treatment; stage T1a, T1b1/T2a1, clinically occult cervical cancer diagnosed after simple hysterectomy; early and locally advanced cervical cancer; primary distant metastatic disease; cervical cancer in pregnancy; and recurrent disease. Principles of radiotherapy and pathological evaluation are defined.