Oral glutamine: Is there a role in the amelioration of radiation-induced mucositis? A prospective case-control study at a tertiary care centre in North India.

BACKGROUND: The most frequently occurring painful and dose-limiting side effect of radiation therapy (RT) to the head and neck region is oral mucositis (OM). Several studies demonstrated that glutamine may reduce the severity and the duration of OM significantly during RT and chemo-radiotherapy in patients with head and neck cancer (HNC). MATERIALS AND METHODS: Between January 2021 and August 2022, a prospective single institutional case-control study compared the efficacy and safety of oral glutamine on radiation-induced mucositis in patients with HNC. Of 60 biopsy-proven patients with HNC, 30 patients in the study arm received oral glutamine suspension (10 g in 500 mL of water) orally once daily, 2 hours before RT, receiving definitive or adjuvant RT and chemo-radiotherapy, while as 30 patients in the control arm received placebo with the same dose and schedule (n = 30 in the study arm and n = 30 in the control arm). RESULTS AND ANALYSIS: A total of 27 (90%) in the glutamine arm and 28 (93.33%) patients in the control arm developed mucositis. Grade 3 mucositis (13.33%) and Grade 4 mucositis (6.66%), respectively, were significantly less (P = .040 and P = .004) in the glutamine arm. The mean duration of grade 3 and grade 4 mucositis was significantly less in the glutamine arm (8.94 days in the study arm vs. 14.54 in the control arm; P = .0001). The mean time of onset of OM was significantly delayed in the glutamine arm in comparison to the control arm with P < .001. CONCLUSION: Glutamine delays the onset of OM and decreases the severity of OM in patients of HNC receiving RT with or without chemotherapy.

Carcinoma cervix: A single institute experience from Kashmir, Northern India.

Background: Carcinoma cervix is the fourth most commonly diagnosed cancer worldwide, with an estimated 604,000 new cases and 342,000 deaths worldwide in 2020. Carcinoma cervix is an uncommon malignancy in Kashmir. In this retrospective study, we have tried to find clinicopathological characteristics of carcinoma cervix along with the survival rates at our tertiary care hospital. Materials and Methods: Case records of cervical cancer patients registered from January 1, 2015, to January 1, 2019, were retrieved. A total of 138 patients was registered. 22 had undergone surgery, and out of these 17 had received postoperative radiotherapy. 109 patients were treated with definitive chemoradiation and 13 with palliative radiotherapy. Descriptive statistics were used to summarize patient and treatment-related variables, and Kaplan-Meier analysis was performed for survival analysis. Results: A total of 138 cases that were registered from 2015 to 2019 were included in this study. The median age at the presentation was 56 years. Most of the patients had a performance status of 1 (98 patients (71.01)). Most of the patients 110 (79.71%) were married before 20 years of age, only 1 patient was unmarried, and 85 (61.59) patients were multiparous in our study group. Only 14 (10.14%) patients in our study group had a history of oral contraceptive use and most of them were non-smokers [124 (89.80%)]. Multiple marriages were present in 8 (5.79%) patients only. The most common presenting symptom was bleeding per vagina (78.26%), and the maximum number of patients fall in the post-menopausal group (67.39%). 116 patients had squamous cell carcinoma histology while 10 patients had adenocarcinoma histology. Most of the patients had stage II and stage III disease (85 patients). At last, follow up out of 138 patients 75 (54.35) were alive. 3 year disease-free survival was 54.34% and 3-year overall survival was 72.46%. Conclusion: Carcinoma cervix is an uncommon malignancy in Kashmir because of different socio-cultural and religious practices but the response to treatment, toxicity profile, and survival are similar to the rest of the world.

Bleeding Control in Advanced Gastric Cancer; Role of Radiotherapy.

Objectives: The aim of our study is to see the efficacy of palliative radiotherapy (RT) for bleeding control in patients with advanced gastric cancer (AGC). Materials and Methods: It is a retrospective review based on observations of 74 AGC patients with a median age of 60 years (range 50-82 years) who had active tumour bleeding and were treated with palliative RT. Treatment response was assessed by both subjective symptom relief and objective change in parameters. Objective response to RT was defined by an increase in the median haemoglobin (Hb) level of patients and a decrease in number of packed red blood cell (RBC) units needed by patients after RT. Results: Response to haemostatic RT was observed in 52 patients out of 74 patients (70.27%). We observed a significant increase in mean Hb level after palliative RT. Pre-RT mean Hb was 6.14 ± 1.01 and post-RT mean Hb was 7.19 ± 1.75 (P < 0.05). Response to RT was also evident in a significant decrease in the number of packed RBC units post-haemostatic RT. The mean number of pre-RT transfused packed RBC units was 8.28 ± 3.76 and post-RT, it was 4.34 ± 2.91 (P < 0.05). The median overall survival was 90 days and the median transfusion-free survival was 40 days. Conclusion: RT may be an effective treatment option for bleeding control in AGC. In our study, we observed fair and reasonably durable haemostasis. A success rate of 70.24% was documented with clinical palliation, a higher Hb level and fewer transfusions after RT. This modality for bleeding control is more important and reliable in situations where alternative modalities are not feasible.

Clinical outcome of intensity-modulated radiotherapy versus two-dimensional conventional radiotherapy in locally advanced nasopharyngeal carcinoma: Comparative study at SKIMS Tertiary Care Institute.

Background: The management of nasopharyngeal cancer (NPC) at present is based primarily on radiotherapy, but the technique by which radiation therapy is delivered is different such as intensity-modulated radiotherapy (IMRT) and two-dimensional conventional radiotherapy (2D-CRT). Materials and Methods: In our study, IMRT and 2D-CRT were compared for their treatment outcome in locally advanced nasopharyngeal carcinoma (NPC) patients. Patients with Stage II to IVA nasopharyngeal cancer (NPC) as per the American Joint Committee on Cancer 7th and 8th edition 2017 treated with IMRT (n = 30) and 2D-CRT (n = 30) between October 2016 and October 2020 were retrospectively analyzed. We matched our patients by using the propensity-score matching method. OS was the primary endpoint of our study. The secondary endpoints were local relapse-free survival (LRFS), regional relapse-free survival (RRFS), disease-free survival (DFS), progression-free survival (PFS), and distant metastasis-free survival (DMFS). Acute and late radiation toxicities between IMRT and 2D-CRT were also compared. Results: In the propensity-matched cohort of 60 patients, 30 patients received 2D-CRT and 30 patients received IMRT. Compared with the treatment of 2D-CRT, the IMRT group is associated with a better 3-year OS (70% vs. 85% P = 0.045), LRFS (78% vs. 96% P = 0.047), RRFS (78% vs. 95% P = 0.015), DFS (80% vs. 95% P = 0.034), and PFS (84% vs. 90% P = 0.024), while as DMFS (85% vs. 85% P = 0.147) were comparable in both the groups. IMRT was also associated with a lower incidence of late toxicities such as xerostomia and trismus. Conclusion: Our study demonstrates that IMRT yields better long-term overall survival and local control including LRFS, RRFS, DFS, and PFS. In addition, late toxicities induced by irradiation in nasopharyngeal carcinoma (NPC) are lower with IMRT. IMRT may be an effective treatment in nasopharyngeal cancer (NPC) as compared to 2D-CRT, but further studies are needed to establish the association.

Modulated Radiotherapy with Concurrent and Adjuvant Temozolomide for Anaplastic Gliomas: Indian Single-center Data.

OBJECTIVE: To evaluate early clinical outcome for anaplastic gliomas (AG) treated in the era of modulated radiotherapy (RT) and concurrent plus adjuvant temozolomide (TMZ) in an Indian setting. MATERIALS AND METHODS: Fifty-three patients with AGs treated with modulated RT and concurrent (95%) and adjuvant TMZ (90%) were analyzed. About 80% of patients had Karnofsky performance status (KPS) at least 90 with 30% seizure at presentation. Postoperative magnetic resonance imaging was available in 65% cases and RT dose was 60 Gy in 30 fractions. First posttreatment imaging was performed at 1 month and then at 3 and 6 months post-RT and then every 3 months. Kaplan-Meier analysis was used to estimate disease-free survival (DFS) and overall survival (OS), and analysis was done using SPSS version 18.0. RESULTS: With median follow-up of 25 months, 2-year DFS and OS were 75% and 88%. There were only 5% symptomatic central nerves system and 8% symptomatic hematological toxicities. At the 1st evaluation, 30.4% had complete response (CR), at 3 months 40%, and at 6 months 43%. At 6 months, only 4% had progressive disease. Forty-six patients were evaluable till the last follow-up with and 55% had stable to CR. On univariate analysis for DFS, KPS at presentation >90 (P = 0.001) and response at 6 months (P = 0.02) were significant and for OS KPS at presentation (P = 0.004) alone. CONCLUSION: Modulated RT with TMZ among Grade III glioma patients resulted in minimum treatment-related toxicities and encouraging survival. Molecular prognostic markers will determine most favorable groups in future.

Clinical outcomes of adaptive radiotherapy in head and neck cancers.

OBJECTIVE: The present study evaluated the efficacy and toxicity of adaptive radiotherapy (RT) among patients with head and neck cancer. METHODS: 36 patients eligible for radical RT underwent RT planning scans and were planned for 54-Gy dose to both high-risk and low-risk target volumes in Phase I. All patients underwent a second (adaptive) scan during the fifth week of RT. Phase II plans for 16 Gy to high-risk planning target volume were developed on these mid-treatment scans. The primary end point was local response. Disease-free survival (DFS), overall survival (OS) and treatment-related morbidity were secondary end points. RESULTS: Median reductions in gross primary and nodal disease volumes on mid-treatment scans were 34% and 43.2%, respectively. 16 patients experienced grade 3 acute mucositis. No patient had grade 3 or above haematologic toxicity. Four patients developed local recurrences, all within the RT field. Median DFS and OS were 17.5 and 23.5 months, respectively. CONCLUSION: Adaptation to changes in the anatomic and tumour volume or shape may help tilt the balance towards more efficient dose delivery as well as better normal tissue sparing. ADVANCES IN KNOWLEDGE: This study supports the need for adaptive replanning for minimizing normal tissue toxicity without compromising local control and adds to the existing body of literature.

Quantification of trends in radiation oncology infrastructure in Pakistan, 2004-2009.

AIM: To provide objective estimates of radiation oncology infrastructure in Pakistan for the years 2004 and 2009 in order to quantify trends in radiotherapy facilities, patient load and to identify the future needs. METHODS: Nationwide surveys using structured questionnaires were conducted in 2005 and 2010 by the Institute of Radiotherapy and Nuclear Medicine, Peshawar, to assess the status of radiation oncology infrastructure in 2004 and 2009. The data were analyzed to observe the trends. RESULTS: Megavoltage teletherapy machines increased from 37 in 2004 to 41 in 2009. New patients registered in all radiotherapy centers were 33 369 in 2004 and 46 114 in 2009. Conventional simulators used for tumour localization increased from 15 to 21 and computerized tomography simulators from 0 to 07. Radiation treatment planning systems for dose calculations of tumors and vital organs increased from 15 to 26 and brachytherapy units from 12 to 13. There were 725 patients per medical physicist in 2004 versus 632 in 2009. Patients per radiation oncologist were 439 in 2004 versus 549 in 2009. Number of radiotherapy technologists/shift/machine was 1.69 in 2004 versus 1.90 in 2009. Repair maintenance personnel improved from 2.11/2 megavoltage units in 2004 to 2.49 in 2009. CONCLUSION: While there was an increase in number of radiotherapy centers, equipment and human resources available, this was insufficient to comply with international guidelines. An adequate enhancement in radiation oncology infrastructure is needed to cope with the predicted rise in cancer incidence.