Intracavitary Irradiation Research Articles

Intracavitary Irradiation as a Safe Alternative for Cystic Craniopharyngiomas: Case Report and Review of the Literature.

Craniopharyngioma treatment remains a challenge for clinicians and patients. There are many treatment alternatives; however one of them (intracavitary irradiation) seeks to control this type of benign brain tumor using minimally invasive techniques, with the specific aim of avoiding causing significant damage to important structures surrounding the sellar/suprasellar region. We present the case of a 3-year-old patient with a predominantly cystic craniopharyngioma who underwent intracavitary irradiation by stereotactic placement. Using this approach, the patient showed a successful response with remission of headaches and hydrocephalus. A reduction in the size of the cyst was achieved, without deterioration of visual fields, with no hormonal supplementation being needed, and with no evidence of focal neurological signs.

Window of lost opportunities: Time to consider a mandatory cervical cancer screening protocol??

We report 2 cases of carcinoma cervix treated at our institution where a window to detect malignancy at an early stage was available, yet missed. Case 1: A 38 year old nulligravida, post-renal transplant patient, reported with abnormal discharge per vaginum and inter-menstrual bleeding. She was found to have Squamous Cell Carcinoma of Cervix Stage Ib2 on evaluation. A decision to start IMRT was taken. The patient didn’t continue further treatment at our institute and was lost to follow up. Case 2: A 47 year old lady presented with 4 months postpartum bleeding. She had undergone caesarean delivery post-IVF 6 months ago. She was found to have Squamous cell carcinoma Stage IIa on evaluation, for which she underwent Radical Hysterectomy with bilateral pelvic lymph node dissection. She received Postoperative radiotherapy along with Intracavitary Radiotherapy.

Improved Survival of Cervical Cancer Patients in a Screened Population in Rural India

Objectives:To describe the survival experience of cervix cancer patients in a screened rural population in India.Methods:Included 558 cervical cancer patients diagnosed in 2000-2013 in a cohort of 100,258 women invited for screening during 2000-2003. The primary end point was death from cervical cancer. We used the Kaplan-Meier method to estimate cumulative observed survival and Cox proportional hazards regression to assess the effect of patient characteristics on survival after diagnosis.Results:Of the 558 cases included, 143 (26%) and 114 (20%) were diagnosed in stages IA and IB respectively; 252 (45.2%) were dead, and 306 (54.8%) were alive at the last follow-up. The overall 5-year observed survival was 60.5%. The 5-year survival of stage IA patients was 95.1% and 5.3% for stage IV patients. All surgically treated stage IA patients, 94.1% of stage IB patients receiving intracavitary radiotherapy, 62% of stage IIB, 49% of stage III and 25% of stage IV patients receiving radiotherapy survived for 5 years.Conclusion:Higher 5-year survival in our study than elsewhere in India is due to the high proportion of early stage cancers detected by screening combined with adequate treatment, resulting into a favourable prognosis.

Concurrent pelvic radiation with weekly low-dose cisplatin and gemcitabine as primary treatment of locally advanced cervical cancer: A phase II study

Purpose: This study was done to evaluate response, compliance and survival of weekly low dose cisplatin (20 mg/m 2 ) and gemcitabine (125 mg/m 2 ) concurrently with pelvic radiation as primary treatment of stage IIB-IIIB cervical cancer. Methods: External radiation consisted of 50 Gy/25 fractions using 6-10 MV photon followed by 600 cGy boost to parametrium if it was still felt thickened. Then, intracavitary radiotherapy to deliver 60 Gy at point A. Chemotherapy consisted of gemcitabine at a dose of 125 mg/ m 2 was given by i.v infusion over 30 minutes immediately after cisplatin 20 mg/ m 2 weekly for 5 weeks during EBRT. Forty–five eligible patients received the treatment protocol. Results: Toxicity was tolerable and manageable. No grade 4 toxicity while grade 3 was recorded in hematologic one only. In order of frequency; diarrhea, nausea and vomiting, and anemia (50%, 40%, 35.5%) were most common adverse events. Overall clinical response rate was 93.4% with pathological complete response of 62.2%. After median follow-up of 20 months, 2-year survival and progression-free survival rates were 90.5% and 81% respectively. Conclusion: Weekly combination of low- dose cisplatin and gemcitabine given concurrently with pelvic radiotherapy in primary treatment of locally advanced cervical cancer resulted in a high response rate with a good compliance. Further exploration is needed for the use of this approach prior to incorporating it into routine clinical care through phase III clinical trial.

Multi-modality management of craniopharyngioma: a review of various treatments and their outcomes

Craniopharyngioma is a rare tumor that is expected to occur in ∼400 patients/year in the United States. While surgical resection is considered to be the primary treatment when a patient presents with a craniopharyngioma, only 30% of such tumors present in locations that permit complete resection. Radiotherapy has been used as both primary and adjuvant therapy in the treatment of craniopharyngiomas for over 50 years. Modern radiotherapeutic techniques, via the use of CT-based treatment planning and MRI fusion, have permitted tighter treatment volumes that allow for better tumor control while limiting complications. Modern radiotherapeutic series have shown high control rates with lower doses than traditionally used in the two-dimensional treatment era. Intracavitary radiotherapy with radio-isotopes and stereotactic radiosurgery may have a role in the treatment of recurrent cystic and solid recurrences, respectively. Recently, due to the exclusive expression of the Beta-catenin clonal mutations and the exclusive expression of BRAF V600E clonal mutations in the overwhelming majority of adamantinomatous and papillary tumors respectively, it is felt that inhibitors of each pathway may play a role in the future treatment of these rare tumors.

Abstract 1249: MLN4924, a protein neddylation inhibitor, induces apoptosis via endoplasmic reticulum (ER)-stress in human cervical cancer

Abstract Cervical cancer is the second most common cancer among the women worldwide. The treatment of the cervical cancer includes the surgery, chemotherapy, external and intracavitary radiotherapy adjusted to the different cancer stage. Despite these treatments, a certain proportion of women still die of the cancer due to recurrent or chemoresistent disease. The toxicity and side effect of these therapies are substantial. Therefore, it is important to develop new drugs or combination treatments to improve patient survival and minimize side effect of the therapy. MLN4924 is an inhibitor of NEDD8 activating enzyme (NAE), has been reported to elicit anti-tumor response in various malignancies. In this study, we aim to investigate the anti-tumor effect of MLN4924 on human cervical cancer and underlying mechanism in vitro and in vivo. We used two different grade human bladder cervical cell lines: ME-180 and HeLa. After exposing to MLN4924, the cell viability and apoptosis were measured by MTT and flow cytometry with annexin V-FITC labeling. The efficacy of cell proliferation was determined by BrdU incorporation assay. The cell cycle regulators, cell death-related molecules, and ER stress-related proteins were examined by Western blotting. We also use Nu/Nu xenograft mice model to clarify the effect of MLN4924 on tumor growth in vivo. We demonstrated that MLN4924 effectively induces dose-dependent cytotoxicity, apoptosis and anti-tumor phenomenon in cervical cancer cells. MLN4924 also activate cleaved-Bid, phospho-histone H2A.X, caspases and PARP, decresed phospho-Bcl2, and cause cell cycle arrest. Furthermore, MLN4924 possessed the ability to activate ER stress-related moleculors caspase-4, and CCAAT/enhancer binding protein homologous protein (CHOP), which were involved in UC cell apoptosis, and other stress responses (JNK and c-Jun activations). Moreover, we confirmed MLN4924 inhibited tumor growth and induced ER-stress in a cervical cancer xenograft mice model. Taken together, we demonstrated that MLN4924 induces cytotoxicity and cell cycle retardation, as well as activation of ER stress responses in human cervical cancer. The anti-tumor effect of MLN4924 provides a novel implication in clinical treatment of cervical cancer. Citation Format: Kuan-Lin Kuo, Yeong-Shiau Pu, I-LIN Ho, Chen-Hsun Hsu, Ju-Ton Hsieh, Wei-Chou Lin, Chien-Tso Chou, Kuo-How Huang. MLN4924, a protein neddylation inhibitor, induces apoptosis via endoplasmic reticulum (ER)-stress in human cervical cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1249. doi:10.1158/1538-7445.AM2015-1249

Cobalt-60 is a logical, economical and comparable alternative to Ir-192: analysis and institutional experience from western India

AbstractObjectives: The objective of the study was to examine the dosimetry of intracavitary radiotherapy (ICRT) in carcinoma of the cervix using cobalt-60 (Co-60) as source of ICRT, and as an alternative to iridium-192 (Ir-192).Design: This was a retrospective study.Subjects and setting: The study was on 80 ICRT patients attending the radiotherapy department at Maharana Bhupal Government Hospital, Udaipur, India.Outcome measures: The dosimetry of ICRT was studied retrospectively in 80 related applications. The dose to point A, 60 Gy isodose reference volume, and bladder and rectum maximum and mean doses were defined.Results: It was found that dosimetry with Co-60 as a brachytherapy source was consistent with the International Commission on Radiation Units (ICRU 38) recommendations.Conclusion: Co-60 is a logical alternative to Ir-192 in low socio-economic settings when repeated changing of the source is not an option.

New approach to relieving pain and distress during high-dose-rate intracavitary irradiation for cervical cancer.

To relieve the pain and distress experienced by women who undergo high-dose-rate intracavitary radiotherapy (HDR-ICRT) for cervical cancer and to improve the current status of gynecologic brachytherapy in Japan, a new intravenous anesthetic protocol involving the administration of a combination of propofol and ketamine was developed. The primary aim of this study is to investigate the efficacy and safety of this new anesthetic protocol during HDR-ICRT for cervical cancer. All the patients who were diagnosed with cervical cancer between December 2008 and February 2011, treated with three-channel brachytherapy and subjected to the new sedation protocol, were evaluated. A visual analog scale (VAS) was used to assess the pain during brachytherapy, and we collected VAS score at the next HDR-ICRT. Toxicities were graded using the Common Toxicity Criteria, version3. A total of 178 sessions of HDR-ICRT were delivered to 57 patients. The patients' median VAS pain score was 0 (range, 0-10). The most frequent side effect was Grade 1-2 nausea, which occurred in 33 sessions (34%). However, 13 of 14 patients received concurrent cisplatin chemotherapy. None of the patients experienced Grade 3 or 4 adverse events. We have demonstrated that our new intravenous anesthetic protocol produces appropriate effects and can be performed by radiation oncologists who were required to finish training in basic life support and the cooperative system of emergency according to in-house guideline.

ADJUVANT RADIOTHERAPY FOR LOW AND MODERATE RISK ENDOMETRIAL CANCER: PRO AND CONTRA

Most patients with endometrial cancer (EC) have stage I disease, the treatment of choice is a total hysterectomy with bilateral salpingo-oophorectomy with or without pelvic lymphadenectomy. Concerning adjuvant radiotherapy for early endometrial cancer is unclear and determined by the risk of recurrence. In accordance with the depth of invasion of the myometrium, histological type and degree of differentiation stage I endometrial cancer is classified into low, intermediate and high risk of lymph node and distant metastasizing. Randomized studies have shown significant improvement in local control after radiation of pelvis and/or intracavitary radiation of the vagina without improving overall survival among patients of high and intermediate risk. At the same time the most controversy associated with the using of adjuvant radiation therapy in intermediate risk EC due to the heterogeneity of the group, which required selection of a subgroup of high intermediate risk, taking into account additional factors: lymphovascular invasion and age. In a subgroup of high-intermediate risk loco-regional effect of adjuvant radiotherapy was more significant. Taking into account the heterogeneity of patients with early EC, the complexity of the assessment of prognosis in case of not provided regional lymphadenectomy and the risk of late radiation complications attempts to optimize the indications, the volume and method of adjuvant radiation therapy in accordance with the risk factors.

Unusual Metastasis from Carcinoma Cervix

Although the incidence of cancer cervix has reduced in India during the last two decades, still most of the patients presenting in tertiary care centers are in advanced stages. At this center, we see 6% of cancer cervix cases every year, and most of these cases are in stage III and IVa. All these patients have squamous cell carcinoma and were treated with a combination of external and intracavitary radiotherapy along with concurrent cisplatin given once weekly. Eighty-nine point nine % patients had achieved a complete response. Local recurrence was seen in 17.9% at a median duration of 10.5 months, and 8.17% developed distant metastasis involving lung, liver, bone, and supraclavicular lymph nodes. Three patients developed metastasis at unusual sites involving breast, paraspinal muscles, and duodenum which are very rarely involved. These patients were treated with chemotherapy using carboplatin and Paclitaxel combination but succumbed within 8-10 months of development of metastasis. The cause of involvement of these unusual sites is not clear, but it may be hematological spread, and we want to share these reports such that these sites are seen during follow-up of patients of cancer cervix.

Tailored radiotherapeutic strategies for disseminated uterine cervical cancer patients.

BackgroundTo investigate the role of radiotherapy (RT) in and to suggest radiotherapeutic strategies for patients presenting with disseminated cervical cancer.MethodsWe retrospectively analyzed 50 patients diagnosed as the disseminated cervical cancer with distant lymph nodal or visceral organ metastasis between September 1980 and August 2012. Patients were divided into two subgroups according to visceral organ metastasis: 35 patients diagnosed with distant lymph node metastasis only (group A) and 15 patients with visceral organ metastasis (group B). All patients received external beam RT to the pelvis (median dose 45 Gy) and high-dose rate intracavitary RT (median dose 30 Gy). Thirty-nine patients (78%) received chemotherapy.ResultsMedian follow-up time was 74 months. The 5-year pelvic control rate (PCR) was 85.8%, and the progression-free survival (PFS), and overall survival (OS) rates were 28.7%, and 36.2%, respectively. The major treatment failure was systemic progression (32 patients, 64%). The 5-year PCRs in groups A and B were 87.4% and 74.7%, respectively (p > 0.05). Meanwhile, PFS and OS rates for group A were significantly better than those for group B (35.3% vs. 13.3%, p = 0.010; and 46.3% vs. 13.3%, p = 0.009, respectively).ConclusionOur data revealed considerable prognostic heterogeneity in disseminated cervical cancer. Even though a high PCR was achieved in patients treated with definitive RT, survival outcomes were dependent on progression of visceral organ metastasis. Therefore, personalized RT and chemotherapy treatment strategies according to the presence of visceral organ metastasis in disseminated cervical cancer patients may help improve clinical outcomes.

Symptom relief effect of palliative high dose rate intracavitary radiotherapy for advanced esophageal cancer with dysphagia.

Intracavitary radiotherapy (ICRT) for the palliative treatment of advanced esophageal cancer with dysphagia is currently performed at the University of Tokyo Hospital (Tokyo, Japan). In the present study, 24 patients exhibiting advanced esophageal cancer with dysphagia received palliative ICRT. ICRT, which was delivered 5 mm below the esophageal mucous membrane, with the exception of one case, was administered at a dose of 6 Gy/fraction. Specific patients additionally underwent definitive or palliative external beam radiation therapy for esophageal cancer a minimum of three months prior to ICRT. The effect of treatment on symptom alleviation was examined by comparing the dysphagia score prior to and following ICRT, with the patients’ medical records and a questionnaire used to calculate a dysphagia score ranging from zero (no dysphagia) to four (total dysphagia). In consideration of the individual efficacy of the treatment, the maximum number of repeated ICRT fractions was four (median, 1.7 times). A trend in the improvement of the symptom of dysphagia was observed in response to esophageal ICRT, with the average dysphagia score markedly decreasing from 2.54 to 1.65, however, the difference was not significant (P=0.083). Furthermore, pain was the most frequent side-effect of the esophageal ICRT and no patients exhibited severe complications. Thus, esophageal ICRT at a dose of 6 Gy/fraction may present an effective strategy for relieving the symptom of dysphagia in cases of advanced esophageal cancer.

Dosimetric Comparison of Fixed and Flexible Geometry ICRT Applicators in Patients Treated for Carcinoma Cervix

In intracavitary radiotherapy (ICRT) for cancer cervix, applicator geometry has the potential to impact the doses to organs at risk (OARs) and the coverage of the target volume. At our centre two Varian made Fletcher-style applicator sets, namely defined (fixed) geometry and flexible geometry, are used for ICRT. In the present work, the two types of applicators were compared dosimetrically as per the recommendations of the International Commission on Radiation Units and Measurements (ICRU-38) while delivering high dose rate brachytherapy. Twenty four patients who underwent ICRT were considered for this study. Radiographic method was used for treatment planning on Abacus planning system. ICRU-38 recommended parameters were estimated and compared. Flexible geometry applicator showed 8.8% and 16% higher bladder and rectum point doses as compared to the fixed geometry one but the difference was statistically not significant. The thickness of the pear-shaped isodose volume was larger for the flexible geometry implant also indicating towards higher doses to OARs. The higher bladder and rectum point doses in the case of flexible applicator will need to be validated by a larger data set.

Expedience of conventional radiotherapy in locally advanced cervix cancer: A retrospective analysis

Objective: Analysis was done to assess the implications of total radiation treatment duration towards locally advanced cervical cancer. Methods: A comparative study was conducted in CNCI, Kolkata. A total of 38 patients were studied with interdigited brachyttherapy during the course of conventional teleradiotherapy and they were compared to a total of 39 patients with conventional sequential teletherapy and brachytherapy. Results: In the experimental arm all the patients had complete response to treatment whereas, 24 patients (85.7%) in the conventional arm had complete response [ P = 0.08]. At the last follow up 28 patients (73.68%) in the study arm and 17 patients (43.58%) in the control arm were free of disease. The failure rate in the conventional control arm was significantly higher [ P = 0.035]. Test of proportion derived from data also showed that the proportion of patients with no evidence of disease at the time of last follow-up was significantly higher in the study arm compared to the control arm [ P P P = 0.2463]. Conclusion: we should hence minimize treatment time and avoid any planned or unplanned interruptions or delays by timely integration of external beam and intra-cavitary irradiation that may yield a better local control in locally advanced cervical cancer.

A new template for MRI-based intracavitary/interstitial gynecologic brachytherapy: design and clinical implementation.

PurposeTo describe the potential clinical use of a new brachytherapy applicator for gynecological tumors, with special attention to locally advanced cervical carcinoma. This device allows the combination of intracavitary radiotherapy and MRI-compatible transperineal interstitial needles. The design of this template addresses the disadvantages of currently commercially available templates: the inability of the intracavitary component to reach deep into the cervix (MUPIT), and the MRI-incompatibility of these templates (MUPIT and Syed), which necessitates use of CT imaging for the dosimetry.Material and methodsThe newly developed Benidorm Template applicator allows titanium needles in a template with straight and angled holes to provide different angles of divergence to be used with currently existing MRI-compatible intrauterine tubes. It can provide total coverage of the craniocaudal and lateral extension of the tumor (intrautherus, parametrial, and paravaginal). This method is mainly indicated in advanced cervical carcinoma with bulky parametrial invasion (medial or distal), with bulky primary disease that responds poorly to external beam radiotherapy extensive paravaginal involvement (tumor thickness greater than 0.5 cm) extending to the middle or lower third of the vagina, or for disease that has invaded the bladder or rectum (stage IVA).ResultsBetween April 2013 until December 2014, we treated 15 patients with locally advanced cervical carcinoma employing the Benidorm Template. The median dose at D90 for the CTV was 79.8 Gy (71.5-89.9 Gy), at D2cc for the bladder it was 77.6 Gy (69.8-90.8 Gy), and at D2cc for the rectum it was 71.9 Gy (58.3-83.7 Gy). Values expressed in EQD2, assuming α/β of 10 for CTV and 3 for OAR.ConclusionsThis new applicator allows the use of MRI-based dosimetry, thus providing the advantages of MRI volume definition. As such, it facilitates determination of complete intracavitary and interstitial CTV coverage and the sparing of normal tissues.

Biliary stent versus combined biliary stent with intracavitary irradiation using 125I seed implantation in the treatment of malignant obstructive jaundice

Objective To compare biliary stent versus combined biliary stent with intracavitary irradiation using 125I seed implantation to treat patients with malignant obstructive jaundice.Methods 62 patients with malignant obstructive jaundice after drainage with PTCD were randomized into two groups:Group A:biliary stent combined with 125I seed implantation (the treatment group),Group B:biliary stent alone (the control group).Postoperative change in jaundice,tumor recurrence,T lymphocyte subsets and survival time were compared between these two groups.Results The change in total serum bilirubin in the two groups of patients showed no significant difference at postoperative 1 month (P ＞ 0.05).However,Group A was better than Group B (P ＜ 0.05) at postoperative I month and 3 months.On follow-up,one patient developed recurrent biliary obstruction in Group A and 12 patients in Group B (P ＜ 0.05).When compared with the preoperative values,CD4 and the ratio of CD4/CD8 increased significantly in Group A at 1 to 2weeks postoperative (P ＜ 0.05),and there was no difference in CD3 (P ＞ 0.05).For patients in Group B,there were no significant difference in CD3,CD4 and CD4/CD8 ratio at 1 ～ 2 weeks postoperative when compared with the preoperative values (P ＞ 0.05).The median survival time for Group A was 10.9 months and for Group B 7.1 months (P ＜ 0.05).Conclusions Intracavitary irradiation using 125I seed implantation combined with biliary stent was better than stenting alone in the treatment of malignant obstructive jaundice.The combined treatment better relieved jaundice,improved immune function and prolonged survival time. Key words: 125 I ; Biliary stent ; Malignant obstructive jaundice ; Intracavitary irradiation ; Immunity

Values of stereotactic guidance of intraoperative high-field magnetic resonance imaging for multiple intracranial lesions

To explore the diagnostic and therapeutic values of stereotactic guidance of intraoperative high-field magnetic resonance imaging (iMRI) for multiple intracranial lesions. We retrospectively assessed 18 patients with multiple intracranial lesions undergoing stereotactic guidance of high-field iMRI between June 2011 and May 2013. The procedures included biopsy of stereotactic guidance (n = 6), stereotactic aspiration and drainage for brain abscess (n = 4), stereotactic aspiration and intracavitary irradiation with (32)P for mixed solid and cystic craniopharyngiomas (n = 3) and stereotactic hematoma evacuation (n = 5). For 6 cases with high-field iMRI stereotactic guidance, the target lesions were precisely predetermined and pathological specimens confirmed by clinical follow-up results. For 12 cases with multiple cystic lesions and multiple intracranial hematoma, aspiration of hematoma and liquids was satisfactory. And the course of clinical treatment was significantly shortened. And there was a lower incidence of postoperative complications. iMRI may guide precisely stereotactic surgery. And it has important clinical significance for confirming the diagnosis of multiple intracranial lesions and shortening their treatment courses.

Combined external and intracavitary irradiation in treatment of advanced cervical carcinomas: predictive factors for treatment outcome and early and late radiation reactions.

The objective of this study was to find out predictive factors of tumor control as well as acute and late radiation reactions in treatment of advanced cervical carcinomas. In a series of 134 primary cervical carcinomas in International Federation of Gynecology and Obstetrics stages I to IV treated with combined external pelvic and intraluminal cervical-vaginal brachytherapy, predictive and prognostic factors were analyzed with regard to tumor control, recurrences, survival data, and adverse effects. Concomitant chemotherapy was given to 48 patients (35.8%). The external beam therapy was given with a 4-field technique (50-60 Gy) and brachytherapy was given with a high-dose rate (iridium-192) afterloading technique using a ring applicator set. A computed tomographically based 3-dimensional dose-planning system was used for the external beam therapy and for the brachytherapy planning. The mean age of the patients was 65 years. A total of 110 tumors were squamous cell carcinomas and 24 were adenocarcinomas or adenosquamous carcinomas. A total of 111 tumors were in International Federation of Gynecology and Obstetrics stages I to II; 23 tumors, in stages III to IV. The primary control rate of the complete series was 92.5%. Tumor size, the brachytherapy dose, the combined external and brachytherapy dose, as well as the number of days of interruption (delay) of irradiation were all significant predictive factors for local tumor control. Forty recurrences (30%) were recorded. Early radiation reactions were recorded in 67% (mostly grade 1) and were associated with the widths of the anterior-posterior and lateral pelvic fields. Serious late radiations reactions (grade 3-4) were noted in 11%. The width of the lateral pelvic fields, left point A and B doses, dose to the rectal reference point, as well as asymmetry of the dose distribution were associated with late severe reactions. Prior abdominal and pelvic surgery was also a high-risk factor for late tissue reactions. Concomitant chemotherapy did not increase the risk for acute or late toxicity.

Total Rectal Dose Estimated From Radical External Beam and Intracavitary Radiation Therapy for Uterine Cervical Cancer Using Deformable Image Registration Method

Patients with uterine cervical cancer are generally treated with both intracavitary brachytherapy (ICBT) and external beam radiotherapy (EBRT) using a midline block in Japan. However the actual total dose delivered to the rectum is hard to calculate, because the location of the high dose region may not be identical for each fraction. To calculate the cumulative dose more accurately, we have adapted the deformable image registration (DIR) method and analyzed the difference between the cumulative rectal dose by adding rectal D2cc (simple rectal D2cc) and the cumulative rectal D2cc estimated on the basis of DIR (DIR-based rectal D2cc).

PT181 Treatment delays in Primary Angioplasty. The influence of the Diabetic Trend on Long Term Mortality

To evaluate the prognostic significance of response to external beam radiation (EBRT) in predicting the clinical outcomes in stage IIIB cancer cervix and to find out factors affecting response to EBRT.This retrospective study included 556 patients of cancer cervix stage IIIB treated between 1996 and 2001 with EBRT (46 Gy/23fx/4.5 weeks) followed by intracavitary radiotherapy (ICRT). At the end of EBRT, response to EBRT was grouped as ‘no gross residual tumor’(NRT) or ‘gross residual tumor’(GRT).Follow up ranged from 2 to 93 months with a median of 36 months. Median dose to point A was 81 Gy. At the end of EBRT, 393 patients (70.7%) attained NRT response. NRT responders had significantly better 5 year pelvic control, disease free survival (DFS) and overall survival (OS) than those who had a GRT response (75.6 vs. 54.6%; 60.6 vs. 31.9% and 62.6 vs. 33.7%, respectively; all P values <0.0001). Apart from response to EBRT, overall treatment time also has emerged as an independent factor to affect all clinical outcomes in multivariate analysis but age had significant impact on pelvic control only. Age was the only factor, which significantly influenced the response to EBRT in univariate as well as multivariate analysis (P=<0.001, OR=1.973, 95% C.I. 1.357–2.868). Patients with age more than 50 years had more NRT response (77%) than patients with age less than 50 years (63.8%).Patients who attain NRT response to EBRT will have an impressive long term pelvic control, DFS and OS in stage IIIB cancer cervix. Older patients (≥50 years) attain significantly higher NRT rates than younger patients.