SEPT 2012 VOLUME 8 ISSUE 3

MD:ChairmanRoentgen-BLK Radiation Oncology Centre, BLK Hospital, New Delhi

A radiation therapy market survey in USA in 2006 predicted a 255% growth in Stereotactic Body Radiation Therapy (SBRT) in next 10 years. Actual data in 2009 confirmed the growth and predicted even bigger

growth. A survey of US radiation oncologists published in Cancer (2011) showed that 64% used SBRT and 76% users intend to increase the use in their patients.

The aim of SBRT is to deliver ablative doses of radiation and CyberKnife (CK) is one of the most potent means to achieve this goal in intracranial and extra cranial targets.

100% local control at 2 years for T1 tumors have been reported in medically inoperable lung cancer with CK by Van der Voort et al ( Radiother.Oncol: 2009:91,296-300). Other indications for the use of CK in lung tumors are patient refusal for surgery, failure of previous therapies, metastatic disease, and advanced primary lung cancer.

The indications for the use of CK in spine are spinal metastasis, benign tumors, primary malignant tumors, and spinal AVM's. A clinical study of 500 spinal metastasis in 393 patients showed CK treatment was effective and well tolerated with long term pain improvement in 86%, long term tumor control in 90%, and clinical improvement in 84% (Gerszten et al : Spine: 2007:32,193-199)

The indications in prostate cancer include monotherapy in low or intermediate risk and as boost after IMRT in high risk disease, and recurrent prostate cancer. Over 5000 patients of prostate cancer have been treated worldwide. Published results in low risk disease show a biochemical disease free control of 93% at a median follow up of 5 years (Freeman et al Radiat.Oncol: 2011: 6) with low toxicity rates (Katz et al: BMC Urol: 2010: 10:1) and 87% of men reported preservation of erectile function at 2 years (King et al: IJROBP:2009:73:1043).

Intracranial indications include brain metastasis, meningioma, pituitary adenoma, acoustic neuroma, schwannoma, gliomas, trigeminal neuralgia, AVM's and skull base tumors. Advantages over gamma Knife include sub millimeter accuracy, frameless treatment, and possibility of fractionated radiosurgery. CK tailors the dose to the target which is more homogeneous with lower peripheral dose representing advantages over Gamma Knife (Wowra et al: J Neurooncol.:2009: 94: 69-77.

In liver tumors the indications include liver metastasis, and

Dr S Hukku

Role of SBRT:

Lung Cancer:

Spine:

Prostate Cancer:

Intracranial Tumors:

Liver Tumors:

inoperable primary liver cancer. In liver metastasis a 100% local control is achieved for 24 months with a dose of 15 Gyx3 fractions (Dewas et al: IJROBP: Mar 2011). In inoperable HCC 59% 2 year OS has been reported ( Louis et al: Technol Cancer Res Treat: 2010:9: 479).

Inoperable and recurrent cancers of pancreas also benefit from CK treatments. Relief of pain for over 24 weeks post treatment, local tumor control of 91.7%, and increase in survival of margin positive resectable cases has been reported (Didolkar et al: Gastrointes Surg.: 2010: 14: 1547, Mahadevan et al: IJROBP:2010: 78: 735).

Two thirds of SBRT patients are treated on CK in USA although CK presented only 10% of total number of systems.

Pancreatic Cancer:

CYBERKNIFE SYSTEM LEADS THE TREND IN SBRT

PLACE OF CYBERKNIFE IN SRS/SBRT TREATMENT OF BENIGN AND MALIGNANT TUMORS

% of TotalSystems* 10% 35% 20% 13% 22%

radiosurgical precision -Other systems do not adapt to breathing

Courtesy: CyberKnife of San Diego

Other Facts about CK in USA1.18 of top 20 US SRS/SBRT sites are CK sites2.Leading sites in Europe have chosen CK3.On an average CK system treats 4 times as many SRS/SBRT patients as a gantry system.4.More than 1,00,000 patients treated worldwide5.More than 550 peer reviewed publications across key indications

CyberKnife® Gamma Knife® Other Linac Systems

Radiosurgery Dedicated Yes Yes NoAlso Does "Conventional" Radiotherapy No No YesAnatomic Area treatable with Radiosurgical Precision Brain, Spine, Brain Brain +/- other

Entire Body selected sites depending upon

Specific systemRigid Brain or Body Frame No Yes YesRequired for Radiosurgical Accuracy

Lesion Size Limitation No Yes No

Capable of divided treatments to Yes No Nobetter preserve adjacent tissues

Continuously adapts to lesion Yes N/A Nomotion caused by organ movement (real time lesion tracking)

Continuously adapts to lesion Yes N/A motion caused by breathing (real time respiratory tracking)

Varian Trilogy® uses respiratory gating but does

Throughout its history, the basic premise of radiation therapy has always been the same: delivering maximal dose to the tumor while saving the surrounding normal t i ssues . Most of the technological developments in the field of radiation delivery

have been towards this goal. Of late, radiation has been used as an ablative technique for a host of tumor types in extracranial locations. This is the technique popularly known as Stereotactic Body Radiotherapy or SBRT. Radiosurgery for cranial lesions however, has a longer history. Cranial Radiosurgery or Stereotactic Radiosurgery (SRS) is a technique developed using the basic concepts propounded by Horsley and Clarke1. Lars Leksell2 is credited for using this technique to treat cranial lesions with radiation employing stereotaxy. The gamma knife he invented remains a major tool for cranial radiosurgery worldwide. The logical next step was using a linear accelerator to deliver radiation to precisely localised cranial lesions. The Cyber knife Radiosurgery system3 took this one step forward by using a frameless system. It employs a linear accelerator mounted on a robotic arm using real time localisation & has been used to treat both intracranial & extracranial tumors.

With these systems in place, it was only natural that this form of ablative therapy would be used for extracranial lesions. The mid 1990s saw the use of this technique across Europe, Japan & North America4, 5, 6. Early experience with this technique was gained for medically inoperable lung cancer. With time, it was realised that local control rates for these patients were approaching those achieved with surgery. Acute toxicities were short lived.

SBRT is now being used for a variety of extracranial tumors namely, early stage lung cancer, liver metastasis, spine metastasis, localised early stage prostate cancer and inoperable localised pancreatic cancer to name a few. SBRT is being explored for other sites like hepatocellular carcinoma, melanoma & renal cell carcinoma.

The next issue at hand was understanding the radiobiology of SBRT. In vivo studies gave credible information. The study by Lotan7 of stereotactically irradiating prostate cancers in the flanks of nude mice gave us a dose-response relationship to work with. Another study by Walsh8 involved stereotactically irradiating renal cell cancers in the flanks of nude mice.

This study demonstrated the temporal relationship between dose & response. Eventually, the lesion driving tumor response was postulated to be endothelial cell apoptosis.

Dr. P.K.Julka HOD Radioncology AIMS New Delhi.

With greater understanding of the radiobiology behind SBRT, differential normal organ sensitivities were being increasingly recognised. The all too familiar differential sensitivity of the proximal airways in lung cancer SBRT is an important example.Thus, the gradual evolution of SBRT has traversed many areas starting with initial feasibility & extrapolation from established techniques to a greater understanding of the radiobiology, better tumor & normal organ definition & the differential organ sensitivities to fraction size.

That having being said, one must ask - what is the future of SBRT? The most exciting next step in the evolution of this technique is its applicability to tumors that are otherwise resectable. SBRT could very well become an important, non-invasive alternative to surgery for a host of tumor sites. As the radiation oncology community gains increasing experience with the techniques & thereby establishes long term results & toxicities of SBRT through well designed & successful randomised controlled trials, SBRT could replace surgery for certain tumor sites like lung & prostate cancer.

The key to doing this lies in gaining increased confidence with the technique based on prospective data & a thorough understanding of the radiobiology & dose-response relationships.

(1) Horsley V, Clarke RH. The structure and functions of the cerebellum examined by a new method. Brain 1908; 31:45-124(2) Leksell L. The stereotactic method and radiosurgery of the brain. Acta Chir Scand 1951;102:316-9.(3) Adler JR, Chang SD, Murphy MJ, et al. The Cyberknife: a frameless robotic system for radiosurgery. Stereotact Funct Neurosurg 1997;69:124-8(4) Blomgren H, Lax I, Naslund I, Svanstrom R. Stereotactic high dose fraction radiation therapy of extracranial tumors using an accelerator. Clinical experience of the ?rst thirty- one patients. Acta Oncol 1995;34:861- 870.(5) Uematsu M, Shioda A, Tahara K, et al. Focal, high dose and fractionated modi?ed stereotactic radiation therapy for lung carcinoma patients: a preliminary experience. Cancer 1998;82:1062-1070.(6) Timmerman R, Papiez L, McGarry R, et al. Extracranial stereotactic radioablation: results of a phase I study in medically inoperable stage I non-small cell lung cancer. Chest 2003; 124:1946 -1955.(7) Lotan et al. J Urol. 2006;175(5):1932-6.(8) Walsh et al. Eur Urol. 2006;50(4):795-800.

References:

A BRIEF HISTORY OF STEREOTACTIC BODY RADIOTHERAPY (SBRT)

Following is the detail of applications received for different AROI Fellowships & Best Paper Categories. If name of anyapplicant is missing from the respective list, he /she may approach Secretary General with a proof that the application was submittedontime.

CIRCULAR

Application Received For Different AROI Fellowship 2012

Age Group More Than 50 years AROI KIRLOSKAR

Age Group More Than 40-50 years AROI-NOVARTIS, Dr. Reddy’s Merck

- IGMC SHIMLA- PATEL HOSPITAL JALANDHAR- PGIMER CHANDIGARH- MAMC NEW DELHI

1 DR MANOJ KUMAR GUPTA 2 DR HARPREET SINGH 3 DR SUSHMITA GHOSHAL4 DR MANOJ SHARMA

- RCC IGIMS PATNA- MAX HOSPITAL, SAKET- RCC RIMS IMPHAL, MANIPUR

1 DR RAJESH SINGH2 DR INDU BANSAL3 DR Y SOBITA DEVI

1 DR AMIT BEHL2 DR SHANKAR VANGIPURAPU3 DR BHAWANA RAI4 DR LEE HSUEH NI5 DR KANHU CHARAN

Age Group More Than 35-40 years AROI - NUCLETRON, Dr. Reddy’s , Fullford - PGI CHANDIGARH- MS PATEL CANCER HOSP, GUJRAT- PGI CHANDIGARH- DEHRADUN- MAHATMA GANDHI CANCER HOSP VISHAKHA PATNAM

Age Group More Than 30-35 years AROI, Dr. Reddy’s , AROI1 DR. DODUL MONDAL2 DR. MAITRICK MEHTA3 DR. VIKAS JAGTAP4 DR. JYOTIRUP GOSWAMI5 DR. ASIM RAI BHANAGAR6 DR. JAYANTHI CHAVVA7 DR. SUPRIYA MALLIK8 DR. SUNIL KUMAR9 DR. SANDEEP GOEL10 DR. MALIK TARIQ RASOOL11 DR. DIVYESH BEHL12 DR. GUNJAN BAIJAL13 DR. PARMOD KUMAR14 DR. DEEPAK GUPTA15 DR. GOVERDHAN HB

- AIIMS NEW DELHI- GCRI AHMEDBAD- BOROOAH CANCER INST. GUWAHATI, ASSAM- WESTBANK HOSP. HOWRA-

- AIIMS, NEW DELHI- SGPGI, LUCKNOW- ARTEMIS, GURGAON- GOVT, MED COLLEGE, SRINAGAR- SAFDURJUNG HOSPITAL,NEW DELHI - ROETGEN-RJSP CANCER HOSP,RANCHI- SGPGIMS LUCKNOW- - MEDANTA MEDICITY

1 DR SWETA KHANDUJA2 DR ROHAN KHARDE - PARVANA INST OF MED SCIENCE , LONI3 DR SONATH DEY - CMC VALLORE4 DR ABHIDA MALIK - CMC LUDHIANA5 DR SAURAV BANSAL 6 DR MOHIT KADIAN - SAFDURJUNG HOSPITAL, NEW DELHI7 DR SUNNY JAIN8 DR NIKESH H9 DR ANUPAM DUTTA - SSKM HOSP, KOLKATA10 DR ASIM RAI BHATNAGAR11 DR SAYAN KUNDU12 DR DEEPTI PHANOSKAR - CMC LUDHIANA

Neil Joseph Fellowship for PG Students

Fellowship for Medical Physicist1 DR N P PATEL - PGIMS, ROHTAK

1 DR SAIKAT DAS2 DR IRFAN BASIR3 DR LEE HSUEH NI4 DR MANJUNATH GN5 DR VIJAYA ADITYA Y6 DR MILIND SHETTI7 DR PUSHPA NAGA CH8 DR SANJEEV KUMAR GUPTA9 DR SAYAN KUNDU10 DR DIVYESH ANAND11 DR DIVYA KHOSA

- CMC, VELLORE- BATRA HOSP, NEW DELHI- DEHRADUN- RAMIAH MED COLLEGE BANGLORE- RAMIAH MED COLLEGE BANGLORE- RAMIAH MED COLLEGE BANGLORE- RAMIAH MED COLLEGE BANGLORE- TMC KOLKATA- Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute, Mumbai- Safdurjung hospital,New delhi- PGI CHANDIGARH- AIIMS, NEW DELHI- MEDANTA - MEDICITY- RGCI NEW DELHI- MS PATEL CANCER HOSP KARMSAR,ANAND, GUJRAT- TMC KOLKATA- GCRI AHMEDABAD- SGPGIMS LUCKNOW- TMC KOLKATA- RGCI NEW DELHI- TMH MUMBAI- MAX HOSP, SAKET- HINDUJA HOSP MUMBAI

12 DR NIKHIL JOSHI13 DR DEEPAK GUPTA14 DR UPASANA SAXENA15 DR SHANKAR VANGIPURAPU16 DR SOURAV GUHA17 DR MAITRIK J MEHTA18 DR PARMOD KUMAR GUPTA19 DR MOUJHURI NANDI20 DR SABEENA KATARIA21 DR CHANDANI HOTWANI22 DR RAJENDER KUMAR23 DR AJAY KOLSE

Application Received For Different Best-Paper

BEST PAPER G.C.PANT YOUNG DOCTOR AWARD

Mahavir Cancer Institute & Research Centre, Patna Under the dynamic guidance of Dr.J.K.Singh Director added facilities of Elekta Synergy Platform Linear Accelerator with 6, 10 and 15 MV Photon Energies & 4, 6, 8, 10, 12 and 15 MeV electron energies.In 2012 the machine was upgraded for taking portal images and KV volumetric images.: Oncentra BT 3D Planning System for Brachytherapy and CMS XIO, Monaco for Tele Therapy Planning.

Roentgen-RJSP Cancer Centre, promoted by Roentgen Oncologic Solutions PvtLtd, is functional at Ranchi. The centre offers state of the art treatment facilities in radiation, surgical, and medical oncology.DrGunjanBaijal has taken over as the consultant incharge of the centre. The facility will go a long way to provide modern cancer treatment to the people of Jharkhand.

Roentgen Oncologic Solutions in partnership with Interterra Medical Technologies and BLK SuperspecialityHospital hasestablished a new CyberKnifefacility at BLK Hospital in New Delhi. The VSI model provides facility for cranial and extracranial radiosurgery and is also capable of delivering robotic IMRT. Robotic IMRT provides an excellent dose distribution and organ sparing which is superior to the existing solutions in this class. The facility is managed by a team of radiation oncologists which has the largest experience in radio surgery in north India.

AROI- CME in Chennai on behalf of TN & PY chapter of AROI on 01/09/2012 on Non small lung cancer at Hotel Courtyard Marriot Mount Road Opposite DMS Chennai

The second teaching course on Basic Radiobiology for Radiation Oncologist was conducted successfully in the department of Radiotherapy, I.G. Medical College, Shimla on 8th September, 2012. Total 50 students from across the country participated. Students came from Karnataka, Gujarat, Bihar, Uttar Pradesh, Delhi, Haryana, Punjab, Chandigarh, Jammu & Kashmir, and Himachal. Course Director, Prof Manoj Gupta started the course with first modules and continued till evening with total five modules of 75 minutes duration each. At the end of the program, certificate of participation was distributed to all participants by Prof Rajeev K Seam, Chairman of the course followed by vote of thanks by Dr Madhup Rastogi, Coordinator of the course. The program was highly appreciated by the students.

Establishment of NEW Modern CANCER CENTRE

Latest computerized upgradation of Centres

Scientific Programs held during July-September'12

12 DR SAYAN DAS 13 DR RESHAM SRIVASTAVA14 DR KALLOL BHADRA15 DR ABDUL HAKIM16 DR PRAKASH KUMAR SWAIN17 DR ASHWATHY SUSAN MATHEW18 DR SANDIP SARKAR19 DR DEEPTI ARUN PHANSOKAR20 DR ABHIDHA MALIK21 DR KAZI SAZZAD22 DR ANIL KUMAR23 DR SANDIP BARIK

SGPGI, LUCKNOWMCH, KOLKATAPGIMER CHANDIGARHBHU VARANASITMH MUMBAITMC KOLKATACMC LUDHIANACMC LUDHIANAMED COLLEGE, KOLLKATAKIDWAI INST. BANGLORECSMMU , LUCKNOW

BEST PAPER PARVATI DEVI & J.M. PINTO GOLD MEDAL

1 DR AVINASH HU2 DR SOMNATH DEY3 DR DIPANJAN MAJUMDER4 DR SHRIDHAR MOIRT5 DR SUNNY JAIN6 DR POONAM GUPTA7 DR VANDANA KUMARI8 DR SHIRLEY LEWIS9 DR NIDHIN RAJ10 DR ARAMITA SAHA11 DR SOWMIYA PRITHVIRAJ

BANGLORE MEDICAL COLLEGE MADRAS MED COLLEGE, CHENNAIMED COLLEGE, KOLLKATAPGIMER CHANDIGARHTMH MUMBAI

CMC VELLOREMED COLLEGE, KOLLKATASAFDARJUNG HOSP NEW DELHICSM MEDICAL UNIVERSITY, LUCKNOWCSMMU , LUCKNOW

MS RAMIAH MED COLLEGE BANGLORE

UPGRADATION OF THE RADIOTHERAPY FACILITY

Second Teaching Course on "Basic Radiobiology for Radiation Oncologists" held at Indira Gandhi Medical Colleg Shimla on 8th September, 2012

BEST PAPER FOR MEDICAL PHYSICIST:

1. Dr. S. Senthil Kumar2. Dr. N.P. Patel

3. Dr. Kartik Paha2. Dr. Rajesh A Kinhikar

NZAROICON12 was held on 29-30th Sept. 2012 at Bathinda which was attended by around170 participants and had over 70 senior faculty members. There were 25 invited talks and 34 oral presentations by PG and Post PG members. 'Life Time Achievement Awards' were also presented to stalwart as gratitude. Everyone appreciated the scientific contents, deliberations and above all the Punjabi hospitality.With RegardsDr. Rajesh Vashistha,Chairman, Organizing Committee, NZAROICON12

NZAROICON 2012

On 1st Dec'12 at Conference centre Kolkata at 5.30 P.M. or after completion of Scientific agenda Confirmation of previous GBM minutes Enrollment of new members To give fellowship to post PG students 30-35 years for training in advanced centres for deserving Radiation oncologist which could carry a grant of Rs. 45000/- or 50000/- two in numberLetter from Dr.K.L.Gupta for Lecture/Best paper /Fellowship/ by the name of Dr.M.S.Gujral On 1st Dec'12 after completion with a gap of 15 minutes of 1st GBM at Conference centre Kolkata

1st GBM

2nd GBM

NOTICE

Dr. Shelly Hukku President AROI

Dr. Rajesh VashisthaSecretary General, AROI

Innoguuration of NZAROICON'2012 by vice chancellor Baba Farid University

Dr.S.S.Gill and Vice Chancellor Central University Punjab Dr .Jairup Singh

Dr. Monica Malik RECEIVED IDEA PC AWARDS

TO BY A.S.C.O

Dr. Divya Khosla Received YOUNG “Radiation Oncologist Fellowship Award”

In Advanced Radiation Techniques

Dr. M. BABAIAH

Chief Minister Mr. N. Kiran Kumar Reddy Received UGADI PURASKARAM AWARD 2012

From

'The Best Doctor Award' by the Dr MGR Medical University Dr. S. ALEX A. PRASAD

International

National

8. AROI -ESTRO Teaching Course in Head & Neck 14-15-16-17 Oct 2012,

1.4th International Conference On Innovative Approaches in Head & Neck Oncology, ICHNO-2013, 7th to 9th Feb 2013, Barcelona, Spain, www.estro.org2.ASTRO's 54th annual meeting, 28th to 31st October 2012, Boston, www.astro.org3.ESMO, 28th September to 02nd October 2012, Vienna, Austria, www.esmo.org

1.34th AROICON 2012, Annual National Conference of Radiation Oncologists of India, November 29-December 2,2012, KolkataVenue: ITC The Sonar, Kolkata1, J.B.S. Haldane Avenue,Kolkata Secretariat: Dr. Santanu Pal, Organising Secretary, Department of Radiotherapy, Medical College Kolkata, 88, College street, Pin-700073 Email: aroicon2012@gmail.com, info@aroicon2012kolkata.org2.8th Annual Conference of North East Chapter of AROI, 5th-6th October 2012, Shillong, Meghalaya, Organising Secretery: Dr. DK Parida, dkparida@hotmail.com3.10th Annual Conference of Association of Nuclear Medicine Physicians of India hosted by Fortis Memorial Research Institute, Gurgaon, 29th September to 1st October 2012, Indian Habitat Center, New Delhi, www.anmpi2012.com4.18th North Zone AROICON-2012, 29th to 30th September 2012, Organised by Max Superspeciality Hospital, Bathinda, Punjab, nzaroi12@gmail.com, nzaroi12@hotmail.com 5.International Cancer Conference, Pune, November 2012, Contact: Dr. Arvind Kulkarni, kulkarni_arvind@hotmail.com6.33rd Annual Conference of Medical Physicists of India, AMPICON-2012, 1st-3rd November 2012, Manglore, India, www.ampicon2012.org.in

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A Salute To Our Awards

The Executive Committee of AROI & ICRO

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