Papers by Pushpa Naga C.H
International Journal of Radiation Oncology Biology Physics, Jul 1, 2023
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Physics and Imaging in Radiation Oncology, 2022
Background and PurposeMagnetic Resonance Imaging (MRI) based target definition in cervix brachyth... more Background and PurposeMagnetic Resonance Imaging (MRI) based target definition in cervix brachytherapy is limited by its availability, logistics and financial implications, therefore, use of computed tomography (CT) and Trans Rectal UltraSonography (TRUS) has been explored. The current study evaluated the dosimetric impact of CT + TRUS based target volumes as compared to gold standard MRI.Methods and MaterialsImages of patients (n = 21) who underwent TRUS followed by MRI and CT, were delineated with High-Risk Clinical Target Volume in CT (CTVHR-CT) and in MRI (CTVHR-MR). CTVHR-CT was drawn on CT images with TRUS assistance. For each patient, two treatment plans were made, on MRI and CT, followed by fusion and transfer of CTVHR-MR to the CT images, referred as CTVHR-MRonCT. The agreement between CTVHR-MRonCT and CTVHR-CT was evaluated for dosimetric parameters (D90, D98 and D50; Dose received by 90%, 98% and 50% of the volumes) using Bland-Altman plots, linear regression, and Pearson correlation.ResultsNo statistically significant systematic difference was found between MRI and CT. Mean difference (±1.96 SD) of D90, D98 and D50 between CTVHR-MRonCT and CTVHR-CT was 2.0, 1.2 and 5.6 Gy respectively. The number of patients who have met the dose constraints of D90 > 85 Gy were 90% and 80% in MR and in CT respectively, others were in the borderline, with a minimum dose of 80 Gy. The mean ± SD dose-difference between MR and CT plans for bladder was significant (5 ± 13 Gy; p = 0.12) for D0.1cm3, while others were statistically insignificant.ConclusionCT + TRUS based delineation of CTVHR appear promising, provide useful information to optimally utilize for brachytherapy planning, however, MRI remains the gold standard.
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Clinical Oncology, Mar 1, 2022
AIMS Uterocervical motions and organ filling during cervical cancer conformal radiotherapy is com... more AIMS Uterocervical motions and organ filling during cervical cancer conformal radiotherapy is complex. This prospective, observational study investigated set-up margins (clinical target vo, ume [CTV] to planning target volume [PTV]) for pelvic nodal CTV and internal margin (CTV to internal target volume [ITV]) expansions for uterocervical movements during cervical cancer radiotherapy. MATERIALS AND METHODS During cervical cancer radiotherapy, a daily kilovoltage, cone-beam computed tomography (CBCT) scan was acquired. Bony anatomy-based rigid co-registration and matching to vessels/pelvic nodal region was carried out to document shifts, errors (systematic and random) and to calculate CTV to PTV margins. Subsequently, soft-tissue matching was carried out at the mid-cervical region and uterine fundus to record shifts, errors and to calculate CTV to ITV margins. RESULTS In 67 patients, 1380 CBCT scans were analysed. The mean (±standard deviation) couch shifts for CTV pelvic nodal region in all directions were within 4.5-5.3 mm, systematic and random errors 3.0-3.6 mm and set-up margins of within 10 mm (except anterior margin 10.3 mm). For the mid-cervical region, mean shifts were 4.5-5.5 mm, systematic and random errors 2-4 mm amounting to <10 mm internal margins (CTV-ITV for cervix) and for uterine fundus mean (±standard deviation) shifts were larger in the superior direction (12.1 mm) but 4.0-7.5 mm in other directions, systematic and random errors 2-7 mm amounting to anisotropic margins in various directions (10 mm in anterior-posterior and lateral directions, 12-20 mm in superior-inferior directions) (CTV-ITV for uterine fundus). CONCLUSION Our study suggests anisotropic CTV to ITV and CTV to PTV margins for cervical cancer radiotherapy.
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Current Opinion in Oncology, Sep 1, 2018
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Radiotherapy and Oncology, 2019
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European Journal of Cancer, 2014
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International Journal of Radiation Oncology*Biology*Physics
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Radiotherapy and Oncology, 2021
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Radiotherapy and Oncology, 2019
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Physics and Imaging in Radiation Oncology, 2022
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Cancer Research Frontiers, 2017
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The British Journal of Radiology, 2018
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Radiotherapy and Oncology, 2019
PURPOSE Recent evidence from EMBRACE shows that around 16% patients with locally advanced cervica... more PURPOSE Recent evidence from EMBRACE shows that around 16% patients with locally advanced cervical cancer (LACC) have residual tumor in distal parametrium (DP) and pelvic wall disease (LPW) after concurrent radio-chemotherapy (CCRT). Adequate target coverage with standard brachytherapy approaches represents a challenge. Therefore, we modified the Vienna I applicator with an add-on cap allowing for additional oblique needles into the DP/LPW (Vienna II). We report here the feasibility and clinical outcomes using Vienna II applicator in LACC patients treated in 2 institutions. METHODS AND MATERIALS 69 patients with residual disease in DP/LPW after CCRT were accrued. FIGO (2009) stage was 26% IIB, 52% III, 15% IVA, 7% IVB (para-aortic nodes). At diagnosis 91% had disease involving DP/LPW. After CCRT, patients underwent image guided adaptive brachytherapy (IGABT) using Vienna II applicator. IGABT details, acute complications, dose volume parameters and clinical outcome variables were compiled and analyzed. RESULTS Residual DP/LPW disease at BT was found in 90% patients. Median total number of needles were 7 [3-15], oblique 4 [1-7]. Manageable intraoperative utero-vaginal complications occurred in 8 patients and manageable arterial bleeding in 6 patients during removal. Mean distance between tandem and outer contour of CTVHR was 38 mm and mean CTVHR (±SD) volume was 69 ± 32 cm3. The mean D90 CTVHR was 86 ± 7 Gy (EQD2) and mean (±SD) D2cm3 (Gy, EQD2) 86 ± 12, 68 ± 7, 68 ± 9 for bladder, rectum and sigmoid respectively. Actuarial LC, PFS, OS at 3/5 years was 76/72%, 56/50%, 62/54% and G3-4 late toxicities (n = 23) were observed in 14 patients (20%). CONCLUSIONS IGABT using Vienna II applicator allows for appropriate target coverage in tumors extending into DP/LPW at the time of BT. Clinical use is feasible and results in good local control, DFS and OS with moderate rate of acute and late ≥G3 toxicity.
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Gynecologic oncology, Feb 1, 2018
With an aim to investigate the impact of Human Papilloma Virus (HPV) 16/18 infection on clinical ... more With an aim to investigate the impact of Human Papilloma Virus (HPV) 16/18 infection on clinical outcomes in locally advanced cervical cancers treated with radical radio (chemo) therapy, we undertook this prospective study. Between May 2010 and April 2012, 150 histologically proven cervical cancer patients treated with radio (chemo) therapy were accrued. Cervical biopsies/brushings were collected at pre-treatment, end of treatment and at 3 monthly intervals up to 24months. Quantitative estimation of HPV 16/18 was done using real-time polymerase chain reaction (RT-PCR) and correlated with various clinical end-points. Out of 150 patients accrued, 135 patients were considered for final analysis. Pre-treatment HPV16/18 DNA was detected in 126 (93%) patients, with HPV-16 present in 91%. The mean log (±SD) HPV-16 and HPV-18 viral load at pre-treatment was 4.76 (±2.5) and 0.14 (±2.1) copies/10ng of DNA, respectively. Though significant decline in viral load was observed on follow-ups (p<...
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Brachytherapy, 2016
Purpose: To report results of squamous cell carcinoma (SCC) of vulva treated with High dose rate ... more Purpose: To report results of squamous cell carcinoma (SCC) of vulva treated with High dose rate (HDR) interstitial brachytherapy at tertiary oncological center in India. Materials and Methods: We performed a retrospective analysis of case records of Vulval cancer patients treated with HDR interstitial brachytherapy at Tata memorial Hospital, Mumbai from January 2001 to December 2015. Information regarding clinical details, treatment given including brachytherapy procedure details, follow up, complications and oncologic outcome data were retrieved.
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Journal of Medical Imaging and Radiation Sciences, 2017
PURPOSE The purpose of the study was to evaluate the feasibility and efficacy of an accelerated r... more PURPOSE The purpose of the study was to evaluate the feasibility and efficacy of an accelerated radiotherapy schedule using weekend boost in terms of tumor response, compliance, and acute toxicities for head and neck squamous cell carcinoma, and to report long-term clinical outcomes. MATERIALS AND METHODS Twenty-six patients with stages III-IV head and neck squamous cell carcinoma receiving radical chemoradiotherapy were accrued prospectively into the study. External beam radiation therapy to a total dose of 66-70 Gy in 33-35 fractions, 1.8-2.0 Gy per fraction along with concurrent weekly cisplatin was planned. Radiation regimen included delivery of six fractions per week, with boost field delivered as the sixth fraction on the weekend. The compliance, tumor response, and toxicities were recorded. Survival curves were estimated using the Kaplan-Meier method. RESULTS Twenty-one of 26 patients (81%) completed treatment as planned and five patients died during the course of treatment. Sixteen patients (62%) completed treatment in less than 44 days and, at the end of 3 months' follow-up, 18 patients (69%) showed complete response and two patients (8%) showed partial response. The 2- and 5-year actuarial disease-free survival were 90% and 65%, respectively, and 2- and 5-year actuarial overall survival were 60% and 38%, respectively. CONCLUSION Accelerated fractionation using weekend boost, along with concurrent weekly concurrent cisplatin, is an effective and promising approach with favorable impact on initial tumor response, comparable results, and acceptable toxicities.
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International Journal of Radiation Oncology*Biology*Physics, 2017
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International Journal of Radiation Oncology*Biology*Physics, 2017
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Radiation oncology journal, 2014
To evaluate the clinical outcome of high-dose-rate (HDR) interstitial brachytherapy (IBT) in pati... more To evaluate the clinical outcome of high-dose-rate (HDR) interstitial brachytherapy (IBT) in patients with oral cavity cancer. Sixteen patients with oral cavity cancer treated with HDR remote-control afterloading brachytherapy using (192)Ir between 2001 and 2013 were analyzed retrospectively. Brachytherapy was administered in 11 patients as the primary treatment and in five patients as salvage treatment for recurrence after the initial surgery. In 12 patients, external beam radiotherapy (50-55 Gy/25 fractions) was combined with IBT of 21 Gy/7 fractions. In addition, IBT was administered as the sole treatment in three patients with a total dose of 50 Gy/10 fractions and as postoperative adjuvant treatment in one patient with a total of 35 Gy/7 fractions. The 5-year overall survival of the entire group was 70%. The actuarial local control rate after 3 years was 84%. All five recurrent cases after initial surgery were successfully salvaged using IBT ± external beam radiotherapy. Two pa...
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Current Opinion in Oncology, 2005
Cervical cancer is a significant global public health problem. In underdeveloped countries where ... more Cervical cancer is a significant global public health problem. In underdeveloped countries where screening programs are not widely available and in underserved populations in developed countries, women commonly present with locally advanced disease that is not curable by any extent of radical hysterectomy. This review will critically evaluate the evidence supporting the available treatment modalities for locally advanced cancer of the uterine cervix. Concurrent cisplatin-based chemotherapy and radiation have demonstrated significant survival improvement for patients with locally advanced cervical cancer. Advances in imaging and radiotherapy technologies, the inclusion of newer agents to the chemoradiation regimens, the use of new hypoxic cell radiosensitizers and monoclonal antibodies that inhibit cell growth, with consequent increase in malignant cell kill fractions, are some of the new therapeutic options that may be used to improve the survival of these patients. Continued improvement in understanding the natural history of cervical cancer, the limitations of the current staging system, and these newer therapeutic options will increase the efficacy of chemoradiation and improved the survival of these patients.
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Papers by Pushpa Naga C.H
Materials and Methods: Retrospective analysis of nutritional status of 20 head and neck cancer patients during radical radiation therapy with and without Prophylactic PEG tube insertion. Results: Mean weight loss during radiation treatment with PEG is 7.4 Kg while in the control group it is 9.7 Kg (p = 0.03). While the mean percentage weight loss of 14.07 % and 17.6 % in patients with PEG and without any feeding procedure respectively is also found to be significant (P = 0.01). The mean albumin reduction during RT is 0.11 gm/dl and 0.37 gm/dl in the group with PEG tube and the control group respectively which is statistically significant (p = 0.04). Six out of ten patients in PEG group had no treatment related interruptions while seven patients had treatment related interruptions in the control group.
Conclusion: Prophylactic Percutaneous Endoscopic Gastrostomy placement is a safe and convenient procedure. It has shown to reduce the weight loss and unplanned treatment interruptions to a significant extent and should be used in all patients receiving concurrent chemoradiation to head and neck.
Materials/Methods: Clinical database of a Phase III trial that randomizes patients to adjuvant IG-IMRT or 3DCRT was searched to identify patients that received concurrent chemoradiation (CRT) (50 Gy/25#/5 wks) and cisplatin (40 mg/m 2) followed by vaginal brachytherapy from January 2011 to December 2016. The IG-IMRT planning aimed at restricting V15 and V40 Gy Small Bowel to 200 and 100 cc. No prospective bone marrow (BM) constraints were applied. The 3DCRT cohort received treatment with four-field conformal box technique. All treatment-planning scans were dearchived to evaluate BM doses. BM was retrospectively delineated in 2 sets; whole bone (WB), and freehand (FH) inner cavity of bone. Various BM sub-volumes namely whole pelvis + lumbar (WPL), lumbar vertebra, sacrum, ilium, ischium, femoral head and neck, whole pelvis (WP), lower pelvis (LP) were contoured and dose volume histo-grams (DVH) parameters were obtained. The worst grade of overall HT and anemia, leucopenia, neutropenia, thrombocytopenia was recorded using CTCAE v 4.0. The incidence of HT was compared between 3DCRT and IMRT arm. Univariate and multivariate analysis was performed to identify factors predictive for grade II HT. Results: Overall, 141 patients received CRT with either IG-IMRT (n Z 73) or 3DCRT (n Z 68). Of these, 94% patients received >4 cycles of chemotherapy with no difference in chemotherapy compliance in IG-IMRT/3DCRT cohort. The mean V10 and V40 of whole pelvic lumbar BM with IGIMRT and 3DCRT was 90% vs. 83% (P < 0.0001), and 33% and 40% (P < 0.0001) respectively suggesting unintentional but desirable bone marrow sparing in both cohorts. Grade 0, I, II, III, and IV HT was observed in 5.5%, 54.8%, 34.2%, 5.5%, 0% in IGIMRT cohort and in 11.9%, 64.2%, 20.9%, 3%, 0% in 3DCRT cohort. No patient had treatment break secondary to HT. On univariate analysis, only use of IG-IMRT (39.7% vs. 26.9%; P Z 0.10) and delivery of >4 cycles of concurrent chemotherapy (35.3% vs 0%, P Z 0.05) was associated with increased incidence in Grade II HT. On linear by linear association for grade of HT, 3DCRT was deemed superior especially for grade II HT (34.2% vs. 20.9%, P Z 0.03). No difference was observed in incidence of Grade II neutropenia with 3DCRT/IG-IMRT. On multivariate analysis use of IG-IMRT and delivery of > 4 cycles independently predicted for increased HT (P Z 0.05 and 0.02). Conclusion: During adjuvant CRT, use of IG-IMRT and > 4 cycles of concurrent chemotherapy independently predicted for increased Grade II HT. The 3DCRT was associated with reduced incidence of HT. Further prospective investigation of BM sparing IMRT is recommended before adapting in clinical practice.
FH, p< 0.04,0.02) and V40 FH>35% (p<0.02), Whole pelvic V10 WB>90% (p<0.03), Whole Pelvic FH V20>75% (p<0.03) and lower pelvis FH >55% (p<0.04) and femoral head and neck FH V10> 80% and V20>35% (p< 0.03 and 0.02 respectively). On multivariate analysis, whole pelvic lumbar FH V40 >35%, whole pelvic WB V10>90%, femoral head and neck V 20 >35% predicted for Grade II neutropenia. Of the identified DVCs, V40 and V20 are better spared with IMRT (p<0.0001) whereas V10 is better spared by 3DCRT (p<0.0001).
Conclusion: BM sub-volume doses predict for Grade II neutropenia in patients receiving CRT. As both high dose and low dose regions are important, the planning aim for BM sparing IMRT should be defined accordingly in prospective studies.
To report acute hematological toxicity (HT) and dose
volume correlates in patients receiving postoperative
bowel sparing intensity-modulated radiotherapy (IMRT)
and cisplatin within a Phase III trial for late bowel toxicity
reduction in patients with cervical cancer.
Material and Methods
Clinical database of Phase III trial (NCT01279135) that
randomizes patients to IMRT (Tomotherapy) and 3DCRT
was searched to select patient strata that received IMRT
(50 Gy/25#/5 wks) and concurrent cisplatin (40 mg/m2)
from Jan, 2011 to Jun, 2016. The IMRT planning aimed at
restricting V15 and V40 Small Bowel to ≤ 200 and 100 cc
respectively. No prospective bone marrow (BM)
constraints were applied. The data base was reviewed to
determine worst grade of HT toxicity. IMRT planning scans
were dearchived and pelvic BM was delineated in 2 sets;
whole bone (WB), and freehand (FH) inner cavity of bone
from top of L3 vertebra to ischial tuberosity. Various BM
sub-volumes namely whole pelvis + lumbar (WPL), lumbar vertebra, sacrum, ilium, ischium, femoral head and neck, whole pelvis (WP), lower pelvis(LP) were contoured and dose volume histograms (DVH) parameters (V5, V10, V20, V30, and V40) were obtained. Receiver operating characteristic (ROC) curve identified DVH thresholds that predicted for grade≥ II HT toxicity with highest specificity.
All data was dichotomized across these cut-offs.
Univariate and multivariate analysis was performed with
SPSS, version 20.
Results
Of the 94 patients randomized to IMRT arm, 74 received
concurrent cisplatin (median cycles=4). Grades I-V HT was seen in 55.5%, 32.5%, 5%, 0% and 0% patients, respectively demonstrating low incidence of HT during bowel sparing IMRT. Leukopenia, neutropenia, anemia, and thrombocytopenia ≥ grade II was observed in 24.3%, 5.3%, 17.6%, and 0%, respectively. None of the HT resulted in treatment break. On comparing BM delineation techniques the FH sub volumes were 25%-47% of WB sub-volumes. The mean V5, V10, V20, V30, and V40 for WP FH and WB were 99%, 93%, 77%, 60%, and 36%; and 99%, 94%, 80%, 60%, and 36%, respectively suggesting unintended desirable BM
sparing. On univariate analysis WPL FH V30 > 55% (p=0.04)
predicted for overall grade ≥ II HT, WP V10 >95% (p= 0.04) for grade ≥ II leucopenia and ilium V20 > 90% (p=0.04) for hemoglobin toxicity. On multivariate analysis, only WP FH V10 >95% (p value 0.04, OR 3.3 (1-11.5) was statistically significant for grade ≥ II leucopenia.
Conclusion
The IMRT arm of NCT01279135 (PARCER study) that
employed strict bowel constraints also had unintentional
dosimetrically desirable BM sparing. This was associated with low absolute rates of HT. Within the setting of bowel sparing IMRT WP FH V10 should be restricted to ≤95% for simultaneous bowel and BM sparing. However as none of the other dosimetric variables predicted for HT, WB marrow contours could serve as a resource sparing strategy while planning pelvic IMRT.