Introduction: The risk of radiotherapy-associated cardiovascular disease has been a concern for decades in breast cancer survivors. The objective of our study is to evaluate the dosimetric benefit of Deep Inspiratory Breath-hold technique (DIBH) on organs-at-risk (OAR) sparing in left-sided breast cancer radiotherapy and to find out pre-treatment predictors of cardiac doses for guiding patient selection for DIBH. Material and methods: Pre-radiotherapy planning CT scans were done in Free Breathing (FB) and in DIBH [using Active Breathing Coordinator system (ABC TM)] in 31 left sided breast cancer patients. 3DCRT plans were generated for both scans. Comparison of anatomical and dosimetric variables were done using paired t test and correlation was evaluated using Pearson correlation. Linear regression was used to get independent predictors of cardiac sparing and Receiver Operating Characteristic (ROC) curve analysis was done to find out the specific threshold of the predictors. Results: There was a 39.15% reduction in mean heart dose in DIBH compared to FB (2.4 Gy vs 4.01 Gy) (p < 0.001), 19% reduction in maximum Left Anterior Descending (LAD) dose and a 9.9% reduction in ipsilateral lung mean dose (p = 0.036) with DIBH. A significant correlation was observed between reduction in Heart Volume in Field (HVIF) and Maximum Heart Depth (MHD) with reduction in mean heart dose. Reduction in HVIF (DHVIF) independently predicted cardiac sparing. Conclusion: DIBH leads to significant reduction in OAR doses and is suggested for all patients of left-sided breast cancer undergoing radiotherapy. However, HVIF and MHD predicted for cardiac sparing and threshold criteria of DHVIF and DMHD may be used by centres with high workload to select patients for DIBH.
Introduction:Fatigue is a major complain in breast cancer patients and survivors. Patterns and degree varies with schedule and type of the treatment. Different co-factors may aggravate fatigue. Multimodal approach is helpful in managing fatigue.Aim:To quantify prevalence, course and degree of fatigue in breast cancer patients on adjuvant treatment and effectiveness of different management approach.Materials and Methods:One Hundred and ten post-mastectomy breast cancer patients (Stage I to Stage III) were assessed. Patients on chemotherapy were assessed one week before, day after chemotherapy and two weeks later in every cycle. Patients on External Beam Radiation Therapy (EBRT) were assessed one week before and every week during radiation. Assessment was continued on second and fourth week of follow up. Functional Assessment of Chronic Illness Therapy - Fatigue subscale (FACIT-F) was used for assessment. Significant cofactors were also searched for.Results:Eighty four percent patients experienced fatigue. Fatigue was more prevalent during chemotherapy (91%) than EBRT (77%). Patients on Chemotherapy exhibit peak fatigue day after Chemotherapy and decreased level until the next cycle. Significant increase of fatigue was seen only in first cycle. Patient on EBRT had gradually increased fatigue during the course of treatment. Lower degree of fatigue was present in post treatment period. Anemia was a significant cofactor causing fatigue (P < 0.05). Blood Transfusion improved fatigue scores.Conclusion:Fatigue increases during chemotherapy and or EBRT. Different intervention strategies are needed to address the issue.
Objective:To enquire about the level of awareness regarding various important aspects of palliative medicine among doctors of various departments in four Medical Colleges in Kolkata through a questionnaire.Materials and Methods:A questionnaire was developed by few members of Indian Association of Palliative Care. It was distributed, to a convenience sample of doctors who worked at various departments in all four teaching hospitals in Kolkata. The distribution and collection of questionnaires was carried out within four months.Results:The results suggested that 85% of the doctors felt that cancer was the commonest reason for the palliative care teams to be involved. Seventy four percent of the doctors mentioned that pain control was their prime job; 53% said that they are enjoying their encounter with palliative care, so far; 77% of the doctors thought breaking bad news is necessary in further decision making process; only 22% of the doctors reported the WHO ladder of pain control sequentially, 35% of the doctors believed other forms of therapies are useful in relieving pain, 35% of the doctors thought that they gave enough importance and time for pain control; 77% said that they had heard about a hospice, among them still 61% of the doctors thought that the patients should spend last days of their life at home. Thinking of the future, 92% of the doctors think that more and more people will need palliative care in the coming days.Conclusion:Amongst the doctors of various departments, there is a lack of training and awareness in palliative care. Almost all the doctors are interested and they are willing to have more training in pain control, breaking bad news, communication skills and terminal care.
PurposeDistension and shape of urinary bladder may vary during intracavitary brachytherapy (ICBT) for cervical cancer, significantly affecting doses to bladder, rectum, sigmoid colon and small intestine and consequently late radiation toxicities. This study is to evaluate the effects of different fixed volume bladder distention on dosimetry, assessed by three dimensional image based planning, in different organs at risk during the treatment of cervical cancer with ICBT.Material and methodsForty seven cervical cancer patients (stage IB to IVA) were qualified for ICBT following external beam radiotherapy. Urinary bladder was distended with different volumes of normal saline instilled by a Foley's catheter. Planning CT scans were performed after insertion of applicators and three dimensional treatment planning was done on Brachyvision® treatment planning system (Varian Medical Systems, Palo Alto, CA). Dose volume histograms were analyzed. Bladder, rectum, sigmoid colon and small intestine doses were collected for individual plans and compared, based on the amount of bladder filling.ResultsMean dose to the bladder significantly decreased with increased bladder filling. However, doses to the small volumes (0.1 cc, 1 cc, 2 cc) which are relevant for brachytherapy, did not change significantly with bladder filling for bladder, rectum or sigmoid colon. Nevertheless, all dose values of small intestine are decreased significantly with bladder filling.ConclusionsBladder distension has no significant effect on doses received during brachytherapy by relevant volumes of bladder, rectum and sigmoid colon except intestine where values are decreased with bladder distension. A larger study with clinical correlation of late toxicities is essential for proper evaluation of this strategy.
PurposeThis study was initiated to prove feasibility of hydrogel application in recto-vaginal space in intracavitary brachytherapy (ICBT) of cervical cancer in order to reduce rectal toxicity.Material and methodsIn a case of stage IIB cervical cancer, after external beam radiotherapy (EBRT), we planned ICBT 7 Gy × 3 fractions. In 1st fraction (Plan 1), due to narrow separation between rectum and cervix (0.18 cm), only 5 Gy was delivered at point A (with high-risk clinical target volume [HR-CTV] D90 5.94 Gy, intermediate risk clinical target volume [IR-CTV] D90 4.54 Gy, rectum D2cc 5.72 Gy, bladder D2cc 5.52 Gy, and sigmoid colon 5.82 Gy). In 2nd fraction (Plan 2), interstitial brachytherapy (ISBT) was attempted. For the prescription of 5 Gy, we get dose levels almost similar to the 1st insertion: HR-CTV D90 (6.7 Gy), IR-CTV D90 (3.06 Gy), bladder D2cc (5.7 Gy), rectum D2cc (4.8 Gy), sigmoid colon D2cc (1.3 Gy) (separation = 0.23 cm). During 3rd fraction (Plan 3), prior doing interstitial insertion, we instilled 50 cc of hydroxypropyl methylcellulose (Viscomet®) up to the tip of recto-vaginal septum. A repeat computed tomography (CT) scan was done 4 hours after Plan 3 treatment and it was re-planned (Plan 4) to find out migration of hydrogel if any and its dosimetric impact.Results9 Gy was delivered to point A with a separation of 1.1 cm in Plan 3 (with HR-CTV D90 16.4 Gy, IR-CTV D90 11.3 Gy, rectum D2cc 3.6 Gy, bladder D2cc 6.9 Gy, and sigmoid colon 2.2 Gy). We achieved an optimum cumulative EQD2 dose (HR-CTV D90 98.4 Gy, IR-CTV D90 76.1 Gy, rectum D2cc 67.7 Gy, bladder D2cc 73.2 Gy, and sigmoid colon 59.3 Gy). Hydrogel volume was decreased in Plan 4 without a major dosimetric changes.ConclusionsHydrogel instillation is a useful tool for recto-vaginal separation during cervical cancer brachytherapy. It increases therapeutic ratio without any adverse event.
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