June 2010 News Letter - June 2010 final 1

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June 2010 News Letter - June 2010 final 1 Powered By Docstoc
					     JUNE 2010                                             VOLUME 6                                            ISSUE 2
           From the Desk of President..........                  thinking on similar lines and the suggestion will be
A meeting of AERB & AROI members were held on March              considered in due course.
3, 2010 regarding the problems faced by Radiation
                                                                 3. Calibration of Measuring and Monitoring Equipment:
Oncology departments across the country. AERB was
                                                                 Members of AROI expressed the problem faced by the
represented by Shri S.S.Bajaj, Chairman, AERB, Shri
                                                                 Radiotherapy Centres in getting their measuring and
S.K.Chande, Vice-Chairman, AERB, Shri S.A.Hussain,
                                                                 monitoring equipments calibrated, which is one of the
Head, RSD, AERB and Shri P.K.Dash Sharma, RSD,
                                                                 mandatory requirements. It was decided to discuss the issue
AERB while AROI was presented by Dr. Firoza Patel,
                                                                 with Head, Radiation Safety Systems Division, BARC.
President, AROI, Dr. S.K.Srivastava, Head, Dept. of
                                                                 Moreover, it was pointed out that AERB will be willing to
Radiation Oncology, TMH, Dr. R.Bilimagga, Medical
                                                                 consider its accreditation if AROI proposes any agency who
Director, Bangalore Inst. of Oncology, Bangalore
Various issues pertaining to Radiotherapy Practice were          would like to provide calibration services provided the
discussed during the above meeting and following decisions       agency meets all the technical requirements.
were taken during the meeting:                                   4) Resumption of patient treatment for Sri Durga Surgical
1. Number of Medical Physicists required in a Radiotherapy       Centre: Presently the telecobalt unit at Shri Durga Surgical
Centre: The members of AROI intimated that as per one of         Clinic is not in operation because the functionality of the
                                                                 unit is under review. A request has been received from Sri
the letters of AERB, one Medical Physicist is required per
                                                                 Durga Surgical Centre to allow the treatment of those
Radiotherapy Equipment, which leads to confusion about
                                                                 patients who were undergoing radiotherapy 5 months back
whether additional Medical Physicists are required for
                                                                 and treatment could not be completed because it was advised
Brachytherapy. It was clarified by AERB that the
                                                                 to stop the unit. The matter was discussed with the members
requirement of Medical Physicist is per Teletherapy
                                                                 of AROI. They opined that although there is only limited
Equipment unless the institution is dedicated for
                                                                 benefit of delivering Radiotherapy after such a long gap,
Brachytherapy facility only. Further, AROI members
                                                                 however it may be useful as palliative care. Dr. Bilimagga
suggested to allow sharing of Medical Physicists among the
                                                                 was requested to contact the institution to find out the status
nearby Radiotherapy centres during leave period of Medical
                                                                 of patients treated by the centre and provide names of those
Physicists. It was opined that at present such permission of
                                                                 who need palliative care. AERB will consider permission of
sharing of staff does not exist for any other practice and may
                                                                 treatment of those patients.
not be appropriate to allow such practice in Radiotherapy.
                                                                 5. Delay in Regulatory Clearances: Members of AROI
2. Agency for plan approval: It was suggested by AROI
                                                                 expressed that many a times the delay occurs when queries
members that to share the load of AERB and expedite the
                                                                 are sent by AERB for obtaining missing information in the
plan approval process, persons/agencies may be recognized
                                                                 application. To avoid the delay email / fax should be
who will evaluate the plan and recommend for approval to
                                                                 considered as alternate means of communication. It was
AERB. It was informed by AERB that already AERB is
                                                                 clarified that communication by fax would be appropriate
                                                                 for submission of such information.
                                                                 6. Non-issuance of Regulatory Clearances due to availability
of Unused Sources: Members of AROI suggested that even             suggested by the members of AROI that permission may be
if unused sources are lying in the Radiotherapy Centres, the       granted by AERB to use HDR unit in teletherapy room with
clearances should not be stopped by AERB. It was clarified         necessary interlock so that only one unit can be used at a
that the practice of non-issuance of regulatory clearances is      time. It was clarified that although similar permission was
mainly to expedite the process of                                  being issued earlier, later it was felt that there is a possibility
decommissioning/disposal. Further, for HDR sources                 that HDR unit may be brought out of the teletherapy room
instead of issuance of authorisation for the sources required      (shielded enclosure) for maintenance and may lead to
for a year, authroisation is issued for one source each time       radiation emergency. The matter was discussed it was
subject to satisfactory progress in                                agreed that earlier practice of granting such permission will
decommissioning/disposal. For the hospitals using long             be followed.
lived sources and radiation generating equipments
regulatory clearances are denied pending                           10. Qualification of Dosimetrist: While discussing the new
decommissioning/disposal of the unused sources. Members            code on Radiotherapy, which is to be published, the
of AROI requested a copy of the list of centres having unused      requirement of Dosimetrist was intimated which is
sources, so that they can pursue the hospitals to dispose          recommendatory as per the code to be published. Members
unused sources. AERB agreed to provide the list.                   of AROI suggested that the qualification of a Dosimetrist
                                                                   should be such that senior technologist can also be inducted
7. Sharing of RFA: Members of AROI suggested that RFA
                                                                   as Dosimetrist in addition to the specified qualification of
may be allowed to be shared among the Radiotherapy
                                                                   B.Sc. (Physics) with relevant experience. It was felt that
Centres. It was clarified that since the RFA is not portable
                                                                   since the code is at its advanced stage of publication, it would
equipment and is required to perform with sub-millimeter
                                                                   be difficult to include this at this stage. However it was
accuracy, it is difficult to ensure the quality of its
                                                                   suggested that the feedback may be sent to AERB for
performance after its transportation. However, it was
decided that this being a technical issue it will be appropriate
                                                                   After the meeting we all felt that it was a very useful
to refer the matter to SARCAR.
                                                                   interaction between the AROI & the AERB & we were very
8)Using HDR as a mobile unit: Members of AROI suggested
                                                                   thankful that we had this opportunity to sit across the table &
that HDR unit may be allowed to be shared among various
                                                                   understand each others problems. I am personally aware that
centres. It was clarified that there are several problems such
                                                                   some of the points discussed during the meeting have already
as (i) assigning the responsibility for the safety and security
                                                                   been implemented & some have been taken to higher
of the sources, (ii) transporting the source in the unit, if the
                                                                   committees for their decisions
unit is not approved as a transport package
                                                                   I would personally like to take this opportunity to thank all
unit, if the unit is not approved as a transport package
                                                                   the members who helped in this meeting
 and (iii) ensuring the quality with respect to performance of
the equipment. It was decided, being a technical issue, the
                                                                   Dr Firuza Patel
matter may be referred to SARCAR for review.
                                                                   President, AROI
9. Using HDR unit in a teletherapy machine room: It was

      A Report on the 8 postgraduate teaching program of Indian College of Radiation Oncology (ICRO)

The 8th postgraduate teaching program of Indian College of Rath, Prof. K Julka, Prof. Subhashini John, Dr S N Senapati,
Radiation Oncology (ICRO) and Association of Radiation Dr Rakesh Jalali, Dr Siddhartha Laskar, Dr Vijay Anand P
Oncologists of India (AROI) was held in Christian Medical Reddy, Dr J P Muliyil, Dr Prathap Tharyan, Dr Geeta Chacko,
College Vellore on 8th and 9th May 2010. Organized by the Dr Sridhar Gibikote, Dr Ganapathi Ramanan, Dr Biju George,
Department of Radiation Oncology, Dr Subhashini John was Dr Rajesh I, Dr Rajesh B, Dr Aby Abraham, Dr Girish
the chairperson of the organizing committee and Dr Saikat Das Chinnaswamy participated as faculty members and addressed
was the organizing secretary. The aim of this teaching program various issues related to Pediatric Oncology, Hemato-oncology
was to enhance the academic and research activities in Radiation and Medical Statistics. A visit to the different facilities of
Oncology with its related disciplines, to improve the overall Radiation Oncology department was also organized. At the end
standards of post-graduate teaching, clinical practice and of the teaching session an assessment test was conducted by Dr
adequate growth of this discipline as per the needs of our S.N.Senapati,Secretary ICRO and Dr Saikat Das,Organising
country. Around 46 second year or final year MD / DNB Secretary.The winners of this CME were Dr Shilpi Roy) of
students from different parts of the country attended the K.M.C,Manipal stood 1 and Dr Nandita Shashi Kiran,from
meeting. The topic of the program was Pediatric Oncology and NIIMS Hyderabad stood 2
Hematological Malignancies. Dr Suranjan Bhattacharji, .At the Validectory function The Secretary ICRO,formally
Director, CMC Vellore was the chief guest. In his inaugural announced the names of both the winners.He requested all the
address, Director Dr Suranjan Bhattacharji emphasized on the participants to present the same teaching programme in their
interdisciplinary nature of knowledge and need to disseminate respective departments to disseminate the knowledge.
knowledge through collaboration of different institutes. Senior The meeting was successful in sensitizing students to current
faculty members from All India Institute of Medical Sciences, evidence based practice in clinical oncology and importance to
Tata Memorial Hospital, Mumbai, AHRegional Cancer Centre evidence-informed health care
Cuttack, Christian Medical College Vellore, Apollo Cancer
Hospital Hyderabad, Apollo Hospital, Chennai, delivered
lectures on current state of art in management of childhood and            Dr P.K.Julka                           Dr S.N.Senapati
hematological malignancies and medical statistics. Prof. G K               Chairman ICRO                             Secy.ICRO

                                                    Upcoming Conferences
National Conferences
                                                                       International Conferences
1.        NZ-AROI to be held in 23-24 Oct 2010 being organisedby
                                                                       1        1.        23-27 Sept 2010, Stockholm. ESTRO Joint
Govt. Medical College Jummu.NZ members (PG student Sr.
                                                                       ECCO 16 & 36th ESMO Multidisciplinary congress
Residents) are requested to send this papers for best papers session
any suggestions are also welcome. Contact: Dr.Ashutosh Gupta
                                                                       2        12-16 September 2010 / Barcelona, Spain. ESTRO's
Phone: +91 9419190696.
                                                                       major scientific congress will offer cutting edge science and
2.       31st Conference Association of Medical Physicists of
                                                                       education in radiation oncology, radiation biology, radiation
India, being held at SGPGI, Lucknow from November 18-21 2010.
                                                                       physics and technology.
Contact Persons: Dr. KJ Maria Das, Organizing Secretary,
                                                                       3        13th Biennial Meeting of the International
AMPICON 2010, Dept. pf Radiotherapy, SGPGI, Lucknow.
                                                                       Gynecologic Cancer Society (IGCS), Prague, Czech Republic,
Phone: 91-522-2668644, 2494461. Email:
                                                                       October 23-26, 2010
3.   8th Tata Memorial HospitalWomen's Cancer Initiative (TMH-
WCI) on Updating the guidelines inPrimary Breast Cancer and
Cervical Cancer on 22nd 24th October 2010
                        Stereotactic Body Radiotherapy ( SBRT) An Emerging Concept

   Dr. A K Anand, Chief of Radiation Oncology, Max                         guidance such as Cone beam CT, the tumor itself can serve
Cancer Centre, Max Hospital, New Delhi                               as the fiducial obviating the need for external markers. 4D-CT
President North Zone, AROI                                           planning is employed to take care of organ motion while
     Intracranial Stereotactic Radiosurgery (SRS) has become a       delivering SBRT.
routine treatment option for patients with varies benign and              Thus SBRT involves a different concept of dose
malignant tumors of the Brain including metastases. SBRT is a        fractionation, highly accurate tumor delineation, motion control
technique of Radiation Therapy to deliver high radiation dose to     in four- dimensions, image guidance, conformal and compact
limited cancer metastases (oligometastasis) located in various       dose distributions and high levels of quality assurance during
organ / sites such as spine, lung, liver etc. Oligo-metastasis has   treatment delivery.
been hypothesized to represent a state of distant metastasis in           PATIENT SELECTION:- SBRT is typically utilized for
which local therapy, such as resection or radiation, may offer a     patients with Oligo-metastasis i.e. Four or fewer tumors less
cure in some patients [2, 3]. Local control of Oligo-metastatic      than 5cm ideally from colon, breast, sarcoma or renal cell
lesion may slow or prevent further metastatic progression.           primary tumor [1]. Patients should be capable of self care with
     SBRT is an alternative approach for unresectable lesions,       controlled primary and minimum expected life span of 6
medically unfit patients or patients who do not desire surgery. It   months.
is often given in conjuction with chemotherapy to augment its             RESULTS:          Impressive local control rates have been
effects on focal areas of gross disease.                             reported with SBRT. It is in the range of 80 90% with a median
     DOSE AND VOLUME CONCEPT: - Very potent dose                     follow up of 8-18 months for lesions in the lung and liver [1,3].
hypofractionation schedules have been used with SBRT such            Milano from University of Rochester have reported 4 year
that the treatment is generally both ablative and convenient.        local control rate of 60% in patients with five or fewer metastasis
Since the treatment is damaging to tissue within and about the       [4].
target, the volume of adjacent normal tissue must be strictly             SBRT is very well tolerated treatment with no severe
minimized to avoid toxic late effects.                               (Grade > 4) toxicity observed in most of the series [4].
     Since treatments are highly focused, one needs to be highly          MAX CANCER CENTRE EXPERIENCE: We have
accurate in defining the target volume. CT-MR fusion and CT-         started SRS and SBRT with Novalis Tx- Brainlab platform for
PET fusion should be typically employed to improve the               cranial and extracranial sites. 2 patients with Oligo-metastasis in
accuracy of defining tumor extent. PTV is usually generated          lung, 2 patients with liver metastasis, 1 patient with isolated
with a GTV expansion of 10mm in the craniocardial direction          Para-aortic lymphnode failure ( Fig-1) and 1 patient with local
and 5-7 mm in all other directions.                                  failure from carcinoma pancreas (Fig-2) have been treated with
     Typically doses of the order of 50Gy are delivered in 10Gy      SBRT. All patients were planned and treated either with Gating
fractions (5Gy per fraction) over 2 weeks. In some sites like        or 4D-CT. Cone Beam CT scan was done in each fraction for
vertebra single fraction of 20-24Gy can also be delivered in         setup verification. Few patients had additional mid treatment
selected cases. Other acceptable dose fractionations are 40-         CBCT as well.
48Gy in 8Gy fractions and 42-48Gy in 6Gy fractions.                       Tolerance to the treatment has been good with no patient
     ORGAN MOTION: Tumors in the body are subject to                 reporting more than grade 2 toxicity. Results of local control
motion like breathing and digestion. To deliver potent               would be available in next 2-3 months.
hypofractionation schedules, the planning target must be mostly
pure tumor. Adding large safety margins for motion constitute
additional damage to normal tissue and subsequent toxicity
     Currently available methods for motion management
include Gating and tracking. Gating involves tracking the
respiratory cycle throughout inspiration and expiration during
free breathing. The beam is activated only when the patient is in
specific phase of the respiratory cycle.
     SBRT WORKFLOW: The whole workflow relates to the
correlation of tumor target position to reliable fiducials with
known positions. Fiducials are used to define a coordinate               Figure 1 Isolated Para-aortic lymph node recurrence in a patient with
system that can be used to target the tumor, orient the treatment    Non-Seminomatous testicular tumor following chemotherapy and twice
planning process and ultimately guide the therapy towards            RPLND,treated withRAPID ARC - SBRT
    Figure 2 - Ca. Pancreas- local recurrence following surgery and radiation therapy, treated with SBRT. Target area delineated with
CT-PET fusion. DVH on the right shows high dose deposited in the target area with sharp fall-off the dose in the surrounding critical
organs like liver, kidney, spinal cord and small bowel.
    1)         Kavanagh Semin Radiat Oncol 16:77-84, 2006               3)Milano Cancer 2008; 112: 650-658
    2)         Hellman Nat. Clin. Pract. Oncol. 2005;2:60-61            4)Milano IJROBP 2008; 72(5): 1516-1522

                                                PAIN MANAGEMENT IN CANCER PATIENT

    Pain should be considered fifth vital sign especially in                       VAS 0 - means no pain
    patient of cancer. It has been estimated that worldwide 43%                     VAS 5 - means moderate pain and
    of all cancer patients experience pain at some point of their                   VAS 10 - means worst possible pain.
    disease period; 20 -50% experience it at diagnosis while 75                     Localization is done by mapping pain on a diagram of
    – 90% experience it at advanced and terminal stages of                         human body.
                                                                                   AA drowsiness, vomiting, constipation, d) Patient
    disease. Pain management sometimes become really
    frustrating in terminally ill, when even the strongest of                      Ques5: What is the place of Fentanyl (Durogesic) patch in
    opiods are not able to achieve adequate control and side-                      pain management scenario?
    effects become debilitating. There is therefore lot to learn                   Ans5 : Studies have shown that fentanyl is nearly
    regarding optimal pain management and the commonest                            equipotent to morphine in management of severe pain.
    questions that come in the minds of cancer specialists are as                  Constipation, drowsiness, nausea and vomiting is much
    follows:                                                                       less as compared to morphine. It's availability in the form
    Ques1: How to measure pain?                                                    of patch is of great help as far as patient compliance and
    Ans1: Complete assessment of pain is done by four                              maintainence of uniform blood levels of the drug is
    parameters i.e. Intensity, Localization, Type and Cause of                     concerned.
    pain. Intensity is measured by Visual Analog Scale(VAS)                        Dr. Jatin Sarin MD. (Radio therapy)DM(Med.ONC)
    or Numeric Pain Intensity scale (0 – 10).                                      IVY Hospitals, Mohalli

                   The field of radiation Oncology is progressing at a very brisk pace. So our members may be changing their work places. In their busy
 schedules, sometimes they forgot to update their location with us. We at AROI are taking care to update AROI database, so that all the information regarding
 AROI should reach them. This being election year, we would like to bring to the kind attention all our colleagues to spare some time to check their status on
 AROI website. and also update with Dr. Subhir Gangoly Election commissioner for Election. The procedure to view and update Bio-data on website is:
     1. Go to
    2. Go to member login area on left area.
    3. Enter used ID as LM-XXXX (For LM-4 it is LM-0004, For LM-13 it is LM=0013
    4. Enter password (same as user ID that is LM-XXXX).
    5. If you want to update the date, please update it on the website & also send a mail to
 Members can change their password once he / she has logged on at the website.
AROICON 2010 is being organized under the banner of Bihar Chapter of AROI Under the chairmanship of
Dr. J.K.Singh(
You are requested to participate & make it a success for details you can visit the conference website (
Suggestions to improve the Association working are welcome
Dr. Firuza Patel                                                                                                               Dr.Rajesh Vashistha
President, AROI                                                                                                                Secretary General, AROI

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