Platelet-to-albumin ratio and radiation-induced lymphopenia-prognostic biomarker for carcinoma esophagus.

BACKGROUND: Esophageal cancer has a poor survival outcome with 5-year OS at 16.7% despite treatment. Some inflammation-based prognostic indicators like the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been previously studied as potential biomarker for predicting outcome in esophageal cancer. Recently, platelet-to-albumin ratio (PAR) has been reported as a promising prognostic factor in gastrointestinal malignancies. METHODS: We performed a retrospective analysis of prospectively treated patients of carcinoma esophagus to evaluate the prognostic significance of inflammation-based prognostic indicators-neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and a composite inflammation-nutrition index: platelet-to-albumin ratio (PAR) in esophageal cancer. Based on previous studies, the optimal cut-off value of PAR was kept at 5.7 × 10^9, and 2.62 for NLR. RESULTS: A total of 71 patients of locally advanced esophageal cancer treated between 2019 and 2022, with either neoadjuvant or definitive chemoradiotherapy, were included. Median follow-up time was 19 months [range: 7-44 months]. Median OS and PFS in our study cohort were 11.3 months [range: 7-23 months] and 7.8 months [range: 3-17 months], respectively. In univariate analysis, lower PAR was found to be significantly correlated with shorter survival time (HR = 2.41; 1.3-4.76; p = 0.047). There was no association found between the OS and the NLR [HR = 1.09; 0.95-1.26; p = 0.222]. Univariate and multivariate linear and logistic regressions found no association between V15, V10, V5, or V2 of spleen and nadir lymphocyte count or between Dmax or Dmean and nadir lymphocyte counts. CONCLUSION: Present analysis found a trend toward an inverse association between PAR and OS. PAR, in the not-so-distant future, may evolve as a novel, convenient, and inexpensive prognostic indicator in esophageal cancer.

Hypo-fractionated accelerated radiotherapy with concurrent and maintenance temozolomide in newly diagnosed glioblastoma: updated results from phase II HART-GBM trial.

BACKGROUND: Glioblastoma (GBM) patients have poor survival outcomes despite treatment advances and most recurrences occur within the radiation field. Survival outcomes after dose escalation through hypofractionated accelerated RT(HART) were evaluated in this study. We previously reported the study's initial results showing similar survival outcomes with acceptable toxicities. Updated results after 5 years are being analysed to determine long-term survival trends. PATIENTS AND METHODS: 89 patients of newly diagnosed GBM after surgery were randomized to conventional radiotherapy (CRT) or HART. CRT arm received adjuvant RT 60 Gy in 30 fractions over 6 weeks and the HART arm received 60 Gy in 20 fractions over 4 weeks, both with concurrent and adjuvant temozolomide. RESULTS: 83 patients were eligible for analysis. After a median follow-up of 18.9 months, the median OS was 26.5 months and 22.4 months in the HART and CRT arms respectively. 5 year OS was 18.4% in the HART arm versus 3.8% in the CRT arm. This numerical difference in overall survival between the two arms was not statistically significant. The median PFS was not significantly different. CONCLUSION: The long-term results of the trial support HART as a promising treatment option with comparable survival outcomes to the current standard of care. Phase III trials are required for further validation of this regimen which has the potential to become the new standard of care in GBM.

Dose-dense neoadjuvant chemotherapy in triple-negative breast cancer: Real-world data from a developing country.

BACKGROUND: Dose-dense adjuvant chemotherapy has been shown to be associated with improved long-term survival outcomes in triple-negative breast cancer (TNBC). However, there is a lacuna of data on the benefits of dose-dense neoadjuvant chemotherapy (NACT) in TNBC. METHODS: This retrospective study included 217 newly diagnosed cases of TNBC treated with a sequential anthracycline and taxane-based NACT, followed by definitive surgery. Study groups consisted of 137 patients who received 3-weekly conventional chemotherapy (cNACT group) and 80 patients with 2-weekly dose-dense NACT (ddNACT group). Pathological complete response (pCR) rates, relapse-free survival (RFS), overall survival (OS), and grade-3/4 chemotoxicities were compared across the groups. RESULTS: No significant difference in the pCR rate (32.8% versus 31.3%; P = 0.808) was observed across the study groups. Relapse rate was lower in the ddNACT group compared to the cNACT group (odds ratio [OR]: 0.51, 95% confidence interval [CI]: 0.27-0.95). However, ddNACT had no RFS advantage over conventional chemotherapy (median RFS: not reached versus 56.1 months in cNACT; hazard ratio: 0.90, 95% CI: 0.52-1.53). OS was also comparable in both the groups with a 3-year survival rate of 78.8% (95% CI: 60.9-89.2) in the ddNACT group versus 84.3% (95% CI: 74.8-90.4) in the cNACT group. Younger age, menopause, the Eastern Cooperative Oncology Group ECOG status, and pCR were significantly associated with OS in our cohort. Grade-3 toxicities were comparable in both groups. CONCLUSIONS: This observational study focusing on ddNACT among TNBC patients demonstrated significant differences in the relapse rate with no survival benefits. Differential effects of ddNACT by tumor presentation (early vs. late), tumor size, tumor biology, and cost-benefits of granulocyte colony-stimulating factor support with such regimens need further exploration.

A systematic review exploring the role of modern radiation for the treatment of Hereditary or Familial Breast Cancer.

The diagnosis of hereditary or familial breast cancers influences the locoregional approach to breast cancer, with most patients undergoing mastectomy to avoid or minimize the use of adjuvant radiation therapy. We evaluated the current literature about known high- and moderate-penetrance genes and studied their impact on local control, toxicities, and contralateral breast cancers after adjuvant radiation therapy. The aim is to encourage the safe use of adjuvant radiation therapy when indicated in concordance with the updated guidelines.

Imaging in Carcinoma Cervix and Revised 2018 FIGO Staging System: Implications in Radiology Reporting.

The International Federation of Gynecology and Obstetrics (FIGO) staging system of carcinoma cervix saw a radical change in 2018 with the inclusion of cross-sectional imaging tools for the assessment of disease extent and staging. One of the major revisions is the inclusion of lymph node status, detected either on imaging or pathological evaluation, in the staging system. The changes were based on long-term patient follow-up and survival rates reported in literature. Thus, it becomes imperative for a radiologist to be well versed with the recent staging system, its limitations, and implications on the patient management.

Neoadjuvant pertuzumab plus trastuzumab in combination with anthracycline- free chemotherapy regimen in patients with HER2 positive breast cancer-Real-world data from a single center in India.

BACKGROUND: Dual targeted therapy with chemotherapy is one of the therapeutic approaches as neoadjuvant treatment in HER2/neu positive breast cancer (BC). However, the safety and efficacy data of dual-targeted, chemotherapy regimen (docetaxel, carboplatin, trastuzumab, & pertuzumab [TCH-P] is limited from the Indian subcontinent. METHODS: This retrospective study aims to evaluate the efficacy and toxicity of neoadjuvant TCH-P regimen in early, locally advanced, and oligometastatic (OM) HER2-positive BC, at All India Institute of Medical Sciences, New Delhi, India, in between the period 2015-2020. Total 6 cycles of 3-weekly neoadjuvant chemotherapy (NACT) protocol containing docetaxel (75 mg/m2), carboplatin (AUC = 6), trastuzumab (8 mg/kg loading followed by 6 mg/kg) and pertuzumab (840 mg loading followed by 420 mg) were planned. Subcutaneous peg-filgrastim was prophylactically administered on day 2 of each cycle. The primary outcome was the pathological complete response (pCR), and secondary outcomes were clinical overall response rate (ORR), rate of breast conservation surgery (BCS) for patients for whom modified radical mastectomy (MRM) was planned and toxicity. RESULTS: Forty-five patients with a median age of 48 years (31-65) were included in this study. The TNM (AJCC-7th edition) stage distribution was stage II, 14 (31.1%); stage III, 29 (64.5%); and stage IV (OM), 2 (4.4%). Clinical node positivity disease was found in 26 (57.8%) cases. Nineteen (42.2%) patients had hormone-positive and 26 (57.8%) cases were premenopausal. The clinical ORR and CR were seen in 100% and 60% respectively. Overall pCR rate was observed in 25 (55.6%) patients (70% in stage II). BCS was performed in 23 (51.1%) cases. In 12 (26.6%) cases, planned MRM was changed to BCS following NACT. Grade 3 and 4 toxicities were diarrhea 7 cases, thrombocytopenia in 6, neutropenia in 4, febrile neutropenia in 1, and anaemia in 2 cases. Ten patients required dose modification. No patient had congestive heart failure or induction death. CONCLUSIONS: This is the first study of the non-anthracycline-based neoadjuvant protocol in HER2 positive BC from India. The TCH-P is an effective, safe, and well tolerated protocol with a pCR rate of 55.6% and 26.6% BCS conversion rate from planned MRM.

Glioblastoma with Primitive Neuroectodermal Component Treated with Adjuvant Radiotherapy and Temozolomide: A Pooled Analysis of 23 Patients.

AIM: Glioblastoma (GBM) is one of the most aggressive neoplasms of the central nervous system with dismal survival. In recent years, different variants of GBM have been described in the literature. GBM with areas of neuroectodermal differentiation (GBM-PNET) is a relatively new entity in GBM. Presence of the neuroectodermal component increases the propensity of systemic dissemination as with other intracranial primitive neuroectodermal tumors (PNET). The optimal treatment for these patients remains a controversy, with authors reporting local radiotherapy to craniospinal irradiation and chemotherapy. We intend to analyze the pattern of care for GBM with neuroectodermal component. MATERIALS AND METHODS: We retrieved data of four patients with GBM-PNET treated in our institute; data were also retrieved from published series to derive treatment and outcome results. RESULTS: In this series, we report the outcome of a series of four patients of GBM-PNET treated with adjuvant radiotherapy and temozolomide. All but one patient underwent gross total resection of the tumor. Adjuvant hypofractionated radiation with concurrent and adjuvant temozolomide was used in all cases. The median follow-up was 12.9 months in the present series. One patient experienced local recurrence 18 months after the treatment. A review of published literature on GBM-PNET was done; studies with details of patient outcome were used for an independent analysis. Twenty-three patients were identified, and the pooled analysis revealed a median progression free and overall survival of 10 and 25, months respectively. Extent of surgery, local radiation vs. craniospinal irradiation, and age at presentation had no impact on the survival. CONCLUSION: GBM PNET is a new entity with only few cases reported so far. Clinical behavior and treatment outcome of these tumors are not different from conventional GBM. However, these patients are at higher risk of CSF dissemination. Hence, an individualized treatment approach is best suited.

Identifying Patterns of Failure and Risk Factors for Recurrence in Patients of Paratesticular Sarcomas: Protocol of a Systematic Review and Meta-Analysis.

INTRODUCTION: Para testicular sarcomas are rare mesenchymal tumors that affect patients of all ages. Unlike other sites of sarcoma, they tend to be of lower grade and have a higher propensity for lymphatic spread. Management is hampered by the small number of patients who differ in terms of tumor grade and histology. Current treatment approaches are based on case reports, small case series and literature reviews, resulting in a number of unresolved issues. The consensus on the type of surgery and adjuvant treatment is yet to be determined. The local relapse rates in the scrotum and groin after orchidectomy comes out to be 25%-37%, indicating the need for either aggressive surgery or adjuvant treatment. There is a paucity of data identifying the patterns of failure and risk factors for recurrence, which will help clinicians tailor appropriate treatment. METHODS: We aim to perform a systematic review and meta-analysis of the available data in the last 50 years in a methodologically rigorous and transparent manner to identify patterns of failure and high-risk factors for recurrence. The protocol is prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-P) 2015 guidelines. The protocol is registered in the International Prospective Register of Systematic Reviews (CRD42021237134). HIGHLIGHTS: Para testicular sarcomas are rare mesenchymal tumors that affects patients of all ages. Current treatment approaches are based on case reports, small case series and literature reviews, resulting in a number of unresolved issues. A systemic review was performed in 2013 based on survival rates, prognostic factors, and relapse sites on paratesticular sarcomas. However, it lacks a comprehensive review that can guide radiation oncologists to select in which patient's postoperative radiotherapy is warranted and define the target volume based on histopathological type, stage, and grade of the tumor. After 2013, new case series with improved methodology and sample size are published, which adds new information to the literature. In one case series, 22 patients with spermatic cord sarcoma were discussed, while in another study, long-term outcome analysis of 51 patients was discussed, and another study discussed eight patients.

Radiological evaluation of metastatic lymph nodes in carcinoma cervix with emphasis on their infiltrative pattern.

Background & objectives: Imaging has been added to the International Federation of Gynecology and Obstetrics (FIGO) 2018 staging system of cervical carcinoma. This study was performed to assess the impact of imaging in staging and to ascertain the prevalence and pattern of nodal metastasis on contrast-enhanced computed tomography (CECT) in patients with cervical carcinoma who were treated based on FIGO 2009 staging system. Methods: This retrospective study was conducted to evaluate all patients with biopsy-proven cervical carcinoma who underwent CECT of abdomen at a tertiary cancer centre in north India from April 2017 to April 2019 and for whom either baseline or follow up scans were available. In patients with enlarged or necrotic lymph nodes, the location, size and pattern of infiltration of adjacent organs were recorded. Results: A total of 602 patients of cervical carcinoma had undergone CT during the study period, of whom 138 (22.9%) underwent CT at baseline and 464 (77.1%) patients during follow up. The FIGO (2009) stage distribution at the time of presentation was stage IB: 109 (18.1%); stage IIA: 14 (2.3%), stage IIB: 118 (19.6%), stage IIIA: 12 (2%), stage IIIB: 277 (46%), stage IVA: 20 (3.3%) and stage IVB: 52 (8.6%). Ninety of the 138 (65.22%) patients underwent a stage shift according to the FIGO 2018 because of the presence of enlarged lymph nodes at baseline scan. Sixteen (2.7%) patients had infiltrative nodal masses most commonly involving the blood vessels (n=14) followed by ureter (n=8), bones (n=5), muscle and bowel (n=3, each). The majority (14/16) of these patients presented with vague abdominal pain, discomfort and vomiting, while two had bone pain. Interpretation & conclusions: CECT at baseline helps in accurately assessing the stage in cervical carcinoma. It helps in the identification of lymph node metastasis in cervical carcinoma, which is crucial for guiding accurate management.

Brachytherapy in head and neck malignancies: Indian Brachytherapy Society (IBS) recommendations and guidelines.

PURPOSE: Brachytherapy (BT) forms major treatment modality in squamous cell carcinoma of head and neck cancers (HNC). However, there is a dearth of literature and guidelines for the use in various indications. High-dose-rate brachytherapy (HDR-BT) in Indian scenario is an important treatment modality, and the recommendations in this guidelines aim to provide the necessary recommendations for the use of HDR-BT for uniform application across the country in patients with HNC. MATERIAL AND METHODS: A panel consisting of members of the Indian Brachytherapy Society (IBS), based on their clinical experience was invited. The process involved defining important steps, precautions, target volumes and indications, thorough literature review, and discussion with fellow members. The guidelines were established and formulated the recommendations for HDR-BT based on available evidences and individual experience for sites, relevant to Indian settings. RESULTS: The IBS recommends the use of HDR brachytherapy as a part of treatment of head and neck tumors. The scope of these guidelines and recommendations included practical suggestions, ensuring efficient use of brachytherapy treatment as radical with external beam radiotherapy (EBRT) boost, palliative and adjuvant as definitive, or re-radiation as salvage for HNC in India. The IBS has made specific site-wise recommendations for previously untreated and recurrent HNC patients on their selection criteria, implant techniques, target volume definition, and HDR treatment parameters, such as time, dose rate, total dose, and fractionation schedules. Limited experience exists with HDR-BT in patients with head and neck cancers in India and across the globe. CONCLUSIONS: IBS provided a consensus statement and guidelines for the head and neck brachytherapy and believed that these recommendations will overcome the fear of practicing radiation oncologists. This should generate interest amongst students and will help radiation oncologists all across the country to use the art of brachytherapy carefully in HNC patients, with better curative and salvage options.

Hypofractionated radiotherapy with temozolomide in diffuse intrinsic pontine gliomas: a randomized controlled trial.

INTRODUCTION: Diffuse intrinsic pontine glioma (DIPG) is the most common form of brainstem glioma. The present study was performed to assess if hypofractionated radiotherapy completed in < 3 weeks with temozolomide improves survival in DIPG. MATERIAL AND METHODS: The present study is a phase II open label randomized trial. The study included newly diagnosed patients with DIPG. Patients in arm A received conventional fractionated RT of 60 Gy in 30 fractions over 6 weeks while patients in arm B received hypo-fractionated radiotherapy of 39 Gy in 13 fractions over 2.6 weeks along with concurrent Temozolomide (TMZ) 75 mg/m2 from day 1 to day 17 followed by adjuvant TMZ for six cycles. The survival analysis was performed with modified intention to treat analysis. RESULTS: A total of 35 patients were randomized. 33 patients were evaluable. 93% (n = 14) of patients in the conventional arm completed treatment while only 17% (n = 3) of the children could complete planned course of treatment in the experimental arm. The median overall survival (OS) was 11 months (95% CI - 7.5 to 14.5 months) in the conventional arm and 12 months (95% CI - 10.5 to 13.5 months) in the experimental arm (p = 0.208). 28% (n = 5) patients in the experimental arm developed grade 3 or 4 hematological toxicity. CONCLUSION: The above study shows that hypofractionated radiotherapy with concurrent and adjuvant temozolomide does not improve OS and has higher hematological toxicity. Conventional radiotherapy remains the standard of care.

Can Chemotherapy be Integrated with Brachytherapy in Locally Advanced Carcinoma Cervix- A Proof of Principle Study.

Introduction: Cancer of the cervix is the second most common cancer in women in India. Chemoradiotherapy is the standard treatment for locally advanced carcinoma cervix. Chemotherapy is not given on days of brachytherapy due to the fear of increased toxicity though studies supporting or refuting it are limited. We intended to study feasibility of adding chemotherapy to brachytherapy with assessment of acute toxicity and response rates. Methods: 29 patients of locally advanced carcinoma cervix (FIGO IIB to IIIB) were assigned to receive either three sessions of high dose rate (HDR) brachytherapy alone or HDR brachytherapy with concurrent chemotherapy of Paclitaxel and Carboplatin after completion of external beam radiation with concurrent Cisplatin. Patients were assessed for compliance of treatment, toxicity and response rates at three and six months. The p-value less than 0.05 was considered statistically significant. Fischer's exact test was used for statistical analysis. Results: 15 patients were assigned to the standard of care arm and 14 patients to the experimental chemo-brachytherapy arm. The median number of cycles of chemotherapy possible with brachytherapy was two (Range: 1 -3). At three months after treatment all patients except one patient in each arm had a complete response. There was two acute grade 3 hematological toxicity and two acute grade 3 or higher gastrointestinal toxicity in the experimental arm but none in the standard arm. The experimental arm had a statistically higher incidence of acute grade 3 and 4 toxicity than the standard arm (p=0.042). Conclusions: Chemo-brachytherapy is associated with higher acute toxicity with comparable response rates. Small patient numbers and short follow up impedes us from providing conclusive evidence.

Indian Brachytherapy Society Guidelines for radiotherapeutic management of cervical cancer with special emphasis on high-dose-rate brachytherapy.

Brachytherapy (BT) for locally advanced cervical cancer is vital for optimal outcomes. There is heterogeneity in brachytherapy treatment practice for cervical cancer across India. In an attempt to standardize various processes involved in cervical cancer brachytherapy, the expert members of the Indian Brachytherapy Society (IBS) developed a document related to radiation therapy treatment of cervical cancer with special emphasis on brachytherapy. The guidelines are based on high quality clinical evidence, expert opinion and consensus wherever evidence was lacking. The document provides a guide for external beam radiation and details of all the processes involved in high-dose-rate (HDR) brachytherapy including patient selection, preparation, principles and technique of BT applications, target and normal tissue definition, dose prescriptions, BT planning, reporting parameters, common complications of BT and their management, scope for research, etc. In summary, we present here practical tips and tricks, recording and reporting of cervical cancer brachytherapy, which can be implemented in various clinical environments and forms the basis of this report.

Discordance in Biomarker Expression in Breast Cancer After Metastasis: Single Center Experience in India.

PURPOSE: Biomarker-estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2/ neu) -discordance plays an essential role in the management and prognosis of patients with metastatic breast cancer. Rates of discordance have been previously reported around 12% to 35%, 30% to 50%, and 5% to 15%, respectively, in Western literature. Data are sparse regarding the same from developing countries, such as India. METHODS: We performed an ambispective review of paired biomarker status in patients with breast cancer-stage I, II, and III as per American Joint Committee on Cancer, 7th edition-who developed metastasis at recurrence (N = 103 patients). Biomarker status and clinical and radiologic parameters were documented at baseline and subsequent follow-up. RESULTS: Discordance was present in 21.3% for ER, 29.1% for PR, and 15.5% for HER2/ neu receptor. In our cohort, 7.8% had positive to negative ER and 13.6% negative to positive. Whereas 21.4% had positive to negative PR, 7.8% had negative to positive PR. Approximately 6.8% had positive to negative HER2/ neu receptor and 8.7% negative to positive. In our cohort, 41 patients (40%) had single-site metastasis-bone, 15.5%; lung, 11.7%; nonregional lymph node, 7.8%; liver, 3.9%; and brain, 0.97%. More than one site of metastasis was present in 62 patients (60%). The most common sites of metastasis were visceral-lung and liver-followed by bone, nonregional lymph node, skin, and brain. CONCLUSION: The current study demonstrated that metastatic disease evolution in breast cancer is characterized by change in the tumor biology, which leads to discordance in receptor status. Repeat biomarker studies at metastatic recurrence is warranted, especially if treatment plans include hormone and targeted therapy.

Clinicopathologic Characteristics and Treatment Outcomes of Patients With Up-Front Metastatic Breast Cancer: Single-Center Experience in India.

PURPOSE: Approximately 5% to 10% of patients with breast cancer present with up-front metastasis and carry a poor prognosis (5-year survival rates of approximately 20%). To date, little is known about the long-term outcome of patients with metastatic breast cancer from developing nations. MATERIALS AND METHODS: We performed an ambispective review of approximately 1,800 patients who were registered in breast cancer clinics between January 2012 and August 2018. Approximately 410 (22.8%) patients presented with up-front metastasis. Out of 410, 375 were considered for additional analysis. Clinical, pathologic, and radiologic details were obtained from the medical records. RESULTS: Median age of presentation was 49 years (range, 22 to 80 years), and median duration of symptoms was 6 months (interquartile range, 3-12 months). Baseline receptor status suggested that 234 patients (62.4%) were hormone receptor (HR) positive, 145 (38.6%) were human epidermal growth factor receptor positive, and 69 (18.6%) had triple-negative breast cancer. Various sites of metastasis were: visceral 219 (58.4%), bone only 100 (26.7%), nonregional lymph node metastasis 21 (5.6%), brain 10 (2.7%), and others 25 (5.8%). Approximately 309 patients (82.4%) received up-front chemotherapy, 192 HR-positive patients (82.1%) received endocrine therapy, and 78 human epidermal growth factor receptor-positive patients (53.8%) received targeted agents. Median progression-free survival was 14.2 months (95% CI, 12.7 to 16.8 months), and median overall survival (OS) was 31.7 months (95% CI, 25.8 to 38.2 months) for the cohort. Median time of follow-up was 22.2 months. On multivariable Cox regression analysis, HR-positive disease, good performance status (0 or 1), and oligometastasis were associated with better OS, whereas triple-negative breast cancer and liver and brain metastasis were associated with inferior OS. CONCLUSION: This is the first comprehensive study, to our knowledge, of metastatic breast cancer from India. HR-positive status, oligometastasis, and good performance status were associated with better outcomes.

Peritoneal metastasis in Stage IB1 adenocarcinoma cervix: A rare entity.

The presence of ovarian or peritoneal metastasis in early-stage cervical malignancy is a rare entity. It often poses a diagnostic challenge whether it is a synchronous primary tumor or a metastatic lesion. A 63-year-old postmenopausal woman presented with Stage 1B1 carcinoma cervix with ascites, and a 5.8 cm × 4.2 cm × 3.5 cm left solid adnexal mass. She underwent Type III radical hysterectomy, excision of peritoneal mass, with bilateral pelvic and paraaortic lymphadenectomy and infracolic omentectomy. On histopathology, cervix showed features of adenocarcinoma, and the peritoneal mass revealed similar histomorphology as cervical growth with metastatic tumor deposits in omentum. Immunohistochemistry (IHC) was utilized to determine the origin of mass. The early stage disease and histology may not always predict the distant metastasis. Therefore, a thorough pretreatment evaluation, meticulous intraoperative assessment, and IHC are mandatory for optimum management and prognostication.

National Cancer Grid of India Consensus Guidelines on the Management of Cervical Cancer.

Standard guidelines for the management of early and locally advanced cervical cancer are available from various academic consortiums nationally and internationally. However, implementing standard-of-care treatment poses unique challenges within low- and middle-income countries, such as India, where diverse clinical care practices may exist. The National Cancer Grid, a consortium of 108 institutions in India, aims to homogenize care for patients with cervical cancer by achieving consensus on not only imaging and management, but also in addressing potential solutions to prevalent challenges that affect the homogenous implementation of standard-of-care treatment. These guidelines therefore represent a consensus statement of the National Cancer Grid gynecologic cancer expert group and will assist in homogenization of the therapeutic management of patients with cervical cancer in India.

Hypofractionated accelerated radiotherapy (HART) with concurrent and adjuvant temozolomide in newly diagnosed glioblastoma: a phase II randomized trial (HART-GBM trial).

INTRODUCTION: Maximal safe surgical resection followed by adjuvant chemoradiation has been standard for newly diagnosed glioblastoma multiforme (GBM). Hypofractionated accelerated radiotherapy (HART) has the potential to improve outcome as it reduces the overall treatment time and increases the biological effective dose. METHODS: Between October 2011 and July 2017, a total of 89 newly diagnosed GBM patients were randomized to conventional fractionated radiotherapy (CRT) or HART. Radiotherapy was delivered in all patients with a three-dimensional conformal radiotherapy technique in CRT arm (60 Gy in 30 fractions over 6 weeks @ 2 Gy/per fraction) or simultaneous integrated boost intensity modulated radiotherapy in HART arm (60 Gy in 20 fractions over 4 weeks @ 3 Gy/per fraction to high-risk planning target volume (PTV) and 50 Gy in 20 fractions over 4 weeks @ 2.5 Gy/per fraction to low-risk PTV). The primary endpoint of the trial was overall survival (OS). RESULTS: After a median follow-up of 11.4 months (Range: 2.9-42.5 months), 26 patients died and 39 patients had progression of the disease. Median OS for the entire cohort was 23.4 months. Median OS in the CRT and HART arms were 18.07 months (95% CI 14.52-NR) and 25.18 months (95% CI 12.89-NR) respectively, p = 0.3. Median progression free survival (PFS) for the entire cohort was 13.5 months (Range: 11.7-15.7 months). In multivariate analysis patients younger than 40 years of age, patients with a gross total resection of tumor and a mutated IDH-1 had significantly better OS. PFS was significantly better for patients with a gross total resection of tumor and a mutated IDH-1. All patients included in the trial completed the planned course of radiation. Only two patients required hospital admission for features of raised intracranial tension. One patient in the HART arm required treatment interruption. CONCLUSION: HART is comparable to CRT in terms of survival outcome. HART arm had no excess treatment interruption and minimal toxicity. Dose escalation, reduction in overall treatment time, is the advantages with use of HART.

Recurrent Vaginal Cuff Dehiscence in a Treated Case of Carcinoma Cervix.

Vaginal Cuff Dehiscence (VCD) is partial or total separation of anterior and posterior vaginal cuff layers. We report a case of recurrent vault cuff dehiscence in a patient of cervical carcinoma. A 60-year-old treated case of carcinoma cervix post surgery and radiotherapy was found to have vault dehiscence and intestinal prolapse second time during a routine speculum examination. She underwent an emergency laparotomy and closure of vault. Vaginal Cuff Dehiscence with Evisceration (VCDE) is a rare but potentially fatal complication following hysterectomy. Postoperative infection, poor technique, hematoma, coitus before healing, radiotherapy, corticosteroid therapy are the risk factors. Radiotherapy leads to progressive obliterative endarteritis and resultant tissue hypoxia. There is paucity of literature regarding the best management of VCD, but early corrective intervention is necessary. Patients and the treating physicians should be made aware of this possibility especially those receiving adjuvant radiation or cases of robotic or laparoscopic hysterectomies.

Primary pediatric mid-brain lymphoma: Report of a rare pediatric tumor in a rare location.

Primary central nervous system lymphoma (PCNSL) is a rare disease in pediatric age group. A thirteen-year-old male child presented with complaints of headache for six months, vomiting and diplopia for three days. Magnetic resonance imaging of the brain showed a single lesion of 1.7 cm × 1.6 cm × 1.6 cm in the mid brain and tectum. He underwent a gross total resection of the tumor. The histopathological evaluation revealed B cell high grade non Hodgkin lymphoma. The patient was treated with High dose methotrexate and cranio spinal radiation. The patient was alive without disease 12 mo after completion of treatment. This case highlights importance of keeping PCNSL as differential in brain stem lesions of pediatric patients also. Radiation and chemotherapy remains the most important treatment for such patients.