Effect of contrast medium on treatment modalities planned with different photon beam energies: a planning study.

BACKGROUND: Routinely, patient's planning scans are acquired after administration of iodinized contrast media but they will be treated in the absence of that. Similarly, high energy photons have a better penetrating power, while low energy photons will result in tighter dose distribution and negligible neutron contamination. The aim of the study was to investigate a suitable photon beam energy in the presence of intravenous contrast medium. MATERIALS AND METHODS: An indigenously made original-contrast (OC) phantom was mentioned as virtual-contrast (VC) and virtual-without-contrast (VWC) phantom were generated by assigning the Hounsfield Units (HU) to different structures. Intensity-modulated (IMRT) and volumetric-modulated-arc (VMAT) plans were generated as per criteria of the TG-119 protocol. RESULTS: It was observed that the maximum dose to the spinal cord was better with 6 mega-voltage (MV) in IMRT. The coverage of Prostate PTV (PR PTV) was similar with all the photon energies and was comparable with TG-119, except for original-contrast (OC) phantom using the VMAT technique. Homogeneity-index (HI) was comparatively better for VMAT plans. CONCLUSION: The contrast CT images lower the dose to targets. IMRT or VMAT plans, generated on such CT images will be delivered with higher doses than evaluated. However, the overdose remains non-significant.

Impact of acuros XB algorithm in deep-inspiration breath-hold (DIBH) respiratory techniques used for the treatment of left breast cancer.

AIM: To investigate the impact of Acuros XB (AXB) algorithm in the deep-inspiration breath-hold (DIBH) technique used for treatment of left sided breast cancer. BACKGROUND: AXB may estimate better lung toxicities and treatment outcome in DIBH. MATERIALS AND METHODS: Treatment plans were computed using the field-in-field technique for a 6 MV beam in two respiratory phases - free breathing (FB) and DIBH. The AXB-calculations were performed under identical beam setup and the same numbers of monitor units as used for AAA-calculation. RESULTS: Mean Hounsfield units (HU), mass density (g/cc) and relative electron density were -782.1 ±â€¯24.8 and -883.5 ±â€¯24.9; 0.196 ±â€¯0.025 and 0.083 ±â€¯0.032; 0.218 ±â€¯0.025 and 0.117 ±â€¯0.025 for the lung in the FB and DIBH respiratory phase, respectively. For a similar target coverage (p > 0.05) in the DIBH respiratory phase between the AXB and AAA algorithm, there was a slight increase in organ at risk (OAR) dose for AXB in comparison to AAA, except for mean dose to the ipsilateral lung. AAA predicts higher mean dose to the ipsilateral lung and lesser V20Gy for the ipsilateral and common lung in comparison to AXB. The differences in mean dose to the ipsilateral lung were 0.87 ±â€¯2.66 % (p > 0.05) in FB, and 1.01 ± 1.07% (p < 0.05) in DIBH, in V20Gy the differences were 1.76 ±â€¯0.83% and 1.71 ±â€¯0.82% in FB (p < 0.05), 3.34 ± 1.15 % and 3.24 ± 1.17 % in DIBH (p < 0.05), for the ipsilateral and common lung, respectively. CONCLUSION: For a similar target volume coverage, there were important differences between the AXB and AAA algorithm for low-density inhomogeneity medium present in the DIBH respiratory phase for left sided breast cancer patients. DIBH treatment in conjunction with AXB may result in better estimation of lung toxicities and treatment outcome.

Early IUD insertion after medically induced abortion.

OBJECTIVE: There is insufficient evidence on the continuation, safety and acceptability of immediate insertion of the intrauterine device (IUD) after medical abortion. The objective of the present study was to evaluate clinical outcomes of early IUD insertion, compared with those of delayed IUD insertion, following medical abortion. METHODS: Women undergoing medical abortion with mifepristone and misoprostol up to 49 days' gestation and opting for Copper T 380A IUD contraception underwent early (5-14 days after mifepristone) or delayed insertion (3-4 weeks after mifepristone). The primary outcome measure was 6 month IUD continuation rate after medical abortion. Secondary outcome measures included user acceptability and safety. RESULTS: Between October 2015 and October 2016, post-medical abortion IUD insertion was performed in 120 eligible women fulfilling the inclusion and exclusion criteria. There was no statistically significant difference in the continuation rates of the early and delayed IUD insertion groups at 6 months (76.7 versus 83.3%, p = .75). The 6 month IUD expulsion rates were 6.7 and 3.3% in the early and delayed insertion groups, respectively (p = .56). There were 10 (16.7%) removals in the early and eight (13.3%) in the delayed insertion groups (p = .77). Level of satisfaction with postabortal IUD use was comparable in both groups. Adverse events were rare and did not differ significantly between the two groups. CONCLUSION: We demonstrated high continuation rates, safety and acceptability of early IUD insertion after medical abortion.

Dosimetric influence of photon beam energy and number of arcs on volumetric modulated arc therapy in carcinoma cervix: A planning study.

AIM: Aim of the present study was to compare the dosimetric impact of different photon beam energies and number of arcs in the treatment of carcinoma cervix. BACKGROUND: Carcinoma cervix is a common cancer in women worldwide with a high morbidity rate. Radiotherapy is used to treat such tumours. Volumetric Modulated Arc Therapy (VMAT) is considered superior to other techniques with multiple arcs and energies. MATERIALS AND METHODS: Twenty patients with carcinoma cervix underwent radiotherapy in a prospective observation study conducted at our institute. Volumetric modulated arc plans with 6 MV, 10 MV and 15 MV photon energies using single arc (SA) and dual arc (DA) were generated. Several physical indices for planning target volume (PTV) like V95%, V100%, V110%, D98%, D50%, D2% and total number of MUs were compared. Normal Tissue Integral Dose (NTID) and dose to a shell structure PHY2.5 and PHY5.0 were analyzed. RESULTS: Comparable dose coverage to PTV was observed for all the energies and arcs. CI for DA6MV (1.095) was better than SA6MV (1.127), SA10MV (1.116) and SA15MV (1.116). Evaluated parameters showed significant reduction in OAR doses. Mean bladder dose for DA6MV (41.90 Gy) was better than SA6MV (42.48 Gy), SA10MV (42.08 Gy) and SA15MV (41.93 Gy). Similarly, p-value for the mean rectal dose calculated was 0.001 (SA6 vs 15), 0.013 (DA6 vs 10) and 0.003 (DA6 vs 15) and subsequently favoured DA6MV. Difference in NTID was very small. CONCLUSIONS: The study showed no greater advantage of higher energy, and DA VMAT plan with 6 MV photon energy was a good choice of treatment for carcinoma cervix as it delivered a highly homogeneous and conformal plan with superior target coverage and better OAR sparing.

Transoral robotic surgery in management of oropharyngeal cancers: a preliminary experience at a tertiary cancer centre in India.

BACKGROUND: The aim of this observational prospective study was to determine the technical feasibility, safety and adequacy of surgical margins for transoral robotic surgery (TORS) in oropharyngeal cancers. METHODS: From March 2013 to May 2014, 60 patients with oropharyngeal lesions underwent TORS with or without neck dissection using the 'DaVinci' robot. Patients were observed and data recorded on surgical time, blood loss, complications and functional outcome of patients. RESULTS: All 60 patients underwent TORS, with neck dissection performed in 45 of the patients. A positive margin was seen in two patients (3.3 %). Intent to treatment was radical in 42 patients and salvage in 18 patients. None of the patients required tracheostomy, and one patient (1.66 %) died postoperatively. Postoperative complications in the form of primary haemorrhage required active intervention in three patients. Average estimated blood loss was 26.5 ± 31.1 ml. Postoperatively, all patients had adequate swallowing and speech function with nasal twang reported in three patients on long-term follow up. Patients started tolerating oral feeds within a week of procedure (mean 3.96 days), with the nasogastric tube removed on the ninth postoperative day (mean 9.19 days). No long-term gastrostomy tube dependency was reported. CONCLUSION: TORS is a safe, feasible, minimally invasive procedure in patients with oropharyngeal cancers. It has the least morbidity and offers benefits in terms of avoidance of tracheostomy tube, prolonged Ryle's tube and gastrostomy dependency.

Squamous cell carcinoma of the superior gingivobuccal sulcus: an 11-year institutional experience of 203 cases.

OBJECTIVE: The report presents an 11-year Institutional experience of 203 cases with superior gingivobuccal sulcus tumours receiving surgical intervention at a comprehensive tertiary cancer care centre. METHODS: A retrospective chart review of patients with a confirmed diagnosis of squamous cell carcinoma of superior gingivobuccal sulcus was done and data related to patient demographic profile; details of surgical procedure, follow-up and survival were collected. RESULTS: Infratemporal fossa clearance was performed in 56 patients. The 10-year overall survival and disease-free survival was observed to be 39 and 52%, respectively, with a median follow-up of 15 months. The overall survival was 40 and 36%, respectively, in cases with and without infratemporal fossa clearance. Similarly, the disease-free survival was found to be 58 and 49%, respectively, in cases with and without infratemporal fossa clearance. CONCLUSION: Patients with higher stage tumours who underwent infratemporal fossa clearance showed better overall and disease-free survival than those who did not undergo infratemporal fossa clearance.

Survival and Recurrence Patterns in Patients With Stomach Adenocarcinoma Receiving Chemotherapy or Chemoradiotherapy After D2 Gastrectomy in a Tertiary Care Cancer Institute: A Retrospective Real-World Evidence Cohort Study.

Purpose: Clinical trials comparing the efficacy of adjuvant chemotherapy (CT) and chemo radiation therapy (CTRT) for stomach adenocarcinoma have reported equivocal results. Hence, the current retrospective cohort study assessed the long-term survival and recurrence outcomes of these therapies, to generate evidence in a real-world scenario. Methods and Materials: Pathologically confirmed patients with stomach adenocarcinoma aged ≥18 years who underwent gastrectomy and D2 lymph nodal dissection at a tertiary cancer hospital from January 2010 to October 2017 were enrolled. Hospital-based follow-up was performed until December 2021. Data were gathered from electronic medical records, supplemented by telephonic interviews for patients who could not come for physical follow-up. CT-alone and CTRT cohorts were compared in terms of survival and recurrence outcomes. Results: The analysis included 158 patients (mean age, 56.42 years; 63.9% male; CT-alone cohort, 69; CTRT cohort, 89). Patients in the CTRT cohort had significantly worse tumor characteristics at baseline (29.2% had the diffuse type of tumor, 94.4% had stage II or III, 68.5% had lympho-vascular space invasion, and 85.4% had lymph node involvement). Recurrence was observed in 13 (19.7%) of the 76 followed-up patients. Although locoregional recurrence was higher in the CT-alone cohort (7 vs 2), distant metastasis was higher in the CTRT cohort (3 vs 1). The overall 5-year survival was 67.0% (SE, 5.0%) and 5-year recurrence-free survival (RFS) was 75.0% (SE, 5.0%). On multivariate Cox regression, no variable was significantly associated with the overall survival, whereas age, positive lymph nodes without extracapsular extension, and lymph node-negative were significantly associated with RFS. The CTRT cohort had significantly (84.0%) higher RFS (hazard ratio, 0.161; 95% CI, 0.056-0.464; P < .001). Conclusions: Patients who received adjuvant CTRT after D2 dissection showed similar overall survival but significantly higher RFS than the CT-alone cohort, despite having worse baseline tumor characteristics.

Management of cervical cancer during the corona virus disease-19 (COVID-19) era.

COVID-19 pandemic has had a catastrophic impact on the society, economy and heath-care system all over the globe with virus showing no signs of losing potency. As the situation appears to worsen, extra burden on other specialities like oncology seems to increase. Specific recommendations are necessary for management of cervical cancer in the current context. All concerned specialities must work together in the best interest of the patient. Attempts should be made at managing cervical cancer while limiting the viral spread among the patients and health-care workers without the loss of opportunity. Surgical intervention for early cervical cancer should be postponed or alternative modalities be considered. In a locally advanced disease, concurrent chemoradiation is the treatment of choice. In addition, the following under mentioned suggestions aim to discuss ways of minimizing infection spread, workload rationalization and providing guidance for management of cervical cancer in the presence of COVID-19 infection.

To study the role of pre-treatment microRNA (micro ribonucleic acid) expression as a predictor of response to chemoradiation in locally advanced carcinoma cervix.

BACKGROUND: Concurrent chemoradiotherapy followed by brachytherapy is the standard of care in locally advanced carcinoma cervix. There is no prognostic factor at present to predict the outcome of disease in locally advanced carcinoma cervix. AIM: Differential expression of microRNAs can be used as biomarkers to predict clinical response in locally advanced carcinoma cervix patients. METHODS: Thirty-two patients of locally advanced carcinoma cervix with International Federation of Gynecology and Obstetrics Stage IB-IVA were enrolled from 2017 to 2018. Expression of microRNA-9 5p, -31 3p, -100 5p, -125a 5p, -125b-5p, and -200a 5p in formalin-fixed paraffin embedded (FFPE) biopsied tissue were analyzed by real time quantitative reverse transcriptase polymerase chain reaction (RT qPCR). Pretreatment evaluation was done with clinical examination and MRI pelvis. All patients received concurrent chemoradiotherapy followed by brachytherapy. Patients were evaluated for the clinical response after 3 months of treatment, with clinical examination and MRI pelvis scan using RECIST 1.1 criteria. Patients with no residual disease were classified as Complete responders (CR) and with residual or progressive disease were classified as Nonresponders (NR). Results were statistically analyzed using Mann Whiney U test to examine significant difference between the expression of microRNA between complete responders (CR) and nonresponders (NR). RESULTS: microRNA-100 5p was upregulated in complete responders (CR) which showed a trend towards statistical significance (p value = 0.05). CONCLUSION: microRNA-100 5p can serve as a potential molecular biomarker in predicting clinical response to chemoradiation in locally advanced Carcinoma cervix. Its role should be further investigated in a larger study population.

Effect of Hip Prosthesis on Photon Beam Characteristics in Radiological Physics.

INTRODUCTION: Aim of study is to investigate the effect of hip prosthesis on 6 and 15 MV photon beam energies. MATERIALS AND METHODS: Prosthesis was kept at the level of tray position. The measurements were done on Varian Clinac-iX linac. Customized prosthesis, termed as Prosthetic Metal Implant (PMI) was made up of wrought austenitic stainless steel rod and covered with paraffin-wax. 'Standard prosthesis' was made up of wrought titanium alloy. The dose profiles were measured for three field sizes i.e. 5, 10 and 20 cm at 100 cm SSD for 6 and 15 MV energies. The perturbation index (PI) was also calculated. RESULTS: Perturbation caused by standard prosthesis was approximately 50% higher than that of PMI. This result may be due to difference in dimension and not because of material composition. Variation of central axis dose might be due to the dimensions of PMI used for experiment which gave intermediate response (e.g. 102.1%, 141.0% and 117.7% for Open, Standard and PMI respectively for 10x10 cm2 field size, 10 cm depth and 15MV photon beam setup )as compared to the 'open' and 'standard' prosthesis. Percentage dose at 10 cm for 6MV photon increased rapidly with field-size for PMI. But, for 15MV photon, difference was not significant. Surface dose (Ds) for PMI remains significantly higher for smaller field. CONCLUSION: The perturbation index varied from 0.05 to 0.22 for the measured energies and gave an idea to the planner to assess the behavior of the prosthesis. This range is applicable for both type of implants and for all clinical field-sizes. The attenuation caused by the prosthesis was significant and this effect should be considered in the treatment planning calculations.

A case report evaluating combined effect of intensity-modulated radiotherapy and deep inspiratory breath-hold for mediastinal lymphoma: A dosimetric analysis.

Excellent survival has been reported after combined modality treatment in bulky mediastinal Hodgkin's lymphoma. Late effects such as cardiac morbidity and secondary cancers have been reported after radiotherapy (RT), especially in young adults. Advanced RT techniques such as deep inspiratory breath-hold (DIBH), intensity-modulated RT (IMRT), and volumetric arc therapy have been used recently to reduce these late effects with encouraging results. We hereby present a case report evaluating combined effect of DIBH and IMRT in a young adult with mediastinal lymphoma.

Dosimetric impact of variable bladder filling on IMRT planning for locally advanced carcinoma cervix.

BACKGROUND: To evaluate the dosimetric impact of variable bladder filling on target and organ at risk (OARs) in cervical cancer patients undergoing chemoradiation. Forty consecutive patients with cervical cancer underwent radiotherapy planning as per the departmental protocol. All patients were asked to empty their bowel and bladder before simulation and catheterization was done. Normal saline was instilled into the bladder through Foleys till the patient had a maximal urge to urinate. Pelvic cast fabrication and CT simulation was done. Then, 30%, 50%, and 100% of the instilled saline was removed and rescans taken. Planning was done on full bladder (X) and the same plan applied to the contours with bladder volumes 0.7X (PLAN70), 0.5X (PLAN50), and empty (PLAN0). A dose of 50 Gy/25# was prescribed to the PTV and plans evaluated. Intensity-modulated radiotherapy plans with full bladder were implemented for each patient. Shifts in the center of mass (COM) of the cervix/uterus with variable bladder filling identified were noted. Statistical analysis was performed using SPSS software. A p value < 0.05 was considered significant. RESULTS: Bladder volume in 70%, 50%, and empty bladder planning was 78.34% (388.35 + 117.44 ml), 64.44% (320.60 + 106.20 ml), and 13.63% (62.60 + 23.12 ml), respectively. The mean dose received by 95% PTV was 49.76 Gy + 1.30 Gy. Though the difference in target coverage was significant between PLAN100 and other plans, the mean difference was minimal. A decrease in bladder filling resulted in an increase in OAR dose. Variation in the increase in dose to OARs was not significant if bladder filling was > 78.34% and > 64.44% of a full bladder with respect to the bowel and rectal/bladder doses, respectively. Inconsistent bladder filling led to a maximal shift in COM (uterus/cervix) in the Y- and Z-axis. CONCLUSION: Bladder filling variations have an impact on cervico-uterine motion/shape, thereby impacting the dose to the target and OARs. It is recommended to have a threshold bladder volume of at least 70-75% of optimally filled bladder during daily treatment. TRIAL REGISTRATION: Institutional review board (IRB) registered by Drug Controller General (India) with registration number ECR/10/Ins/DC/2013. Trial Registration number - RGCIRC/IRB/44/2016, registered and approved on the 14th of May 2016.

Diagnostic Performance of Serum Human Epididymis Protein 4 (HE4) for Prediction of Malignancy in Ovarian Masses

Background: Early diagnosis of ovarian cancer is essential for long term disease control and mortality reduction. This has been achieved using tumor markers like cancer antigen 125 (CA-125) which is elevated in malignant as well as non-malignant conditions. This dilemma led to efforts towards development of newer markers like serum human epididymis secretory protein E4 (HE4). Present study aimed to evaluate role of HE4 in diagnosing ovarian cancers and comparing it with CA-125. Methods: Serum samples from 67 patients with ovarian cancer, 42 with benign ovarian masses and 26 healthy controls were collected preoperatively and tested for serum HE4 levels and CA-125 levels. Diagnostic performance of both tumor markers (HE4/CA-125) to diagnose malignancy in ovarian masses was calculated and compared to each other. Results: Mean CA-125 and HE4 levels were significantly higher in patients with ovarian cancer than in those with benign disease (p<0.001) or healthy controls (p< 0.001). Serum HE4 levels significantly increased in epithelial ovarian cancers when compared to non-epithelial ovarian cancers (p<0.01). Using benign control as comparison, receiver operating characteristic curve (ROC) was generated to predict a cut-off value for diagnosing malignancy for serum HE4 and CA-125. Compared to CA-125, HE4 had a similar sensitivity (83.6% vs. 85.10%) and higher specificity (100% vs. 90.48%); combination of serum HE4 and CA-125 improved the sensitivity to detect ovarian cancer to 92.54%. Sensitivity of HE4 to detect early stage ovarian cancer was superior to CA-125 (92.61% vs. 63.41%). Conclusion: Serum HE4, a novel tumor marker, discriminated epithelial ovarian cancer from benign ovarian masses. HE4 levels were related to the stage and histological types with the lowest levels in mucinous epithelial ovarian cancer and non-epithelial malignancy. Measuring serum HE4 levels alongwith CA-125 may provide higher accuracy for detecting epithelial ovarian cancer particularly in the early stages.

Carcinosarcoma prostate with osteosarcomatous differentiation: a rare de novo presentation.

Carcinosarcoma is a rare histological event in the history of prostatic malignancies. Historically aggressive tumours with dismal outcomes reported in scarce literature available so far. Very few recent studies suggest good outcomes with modern era surgery and radiotherapy techniques in localised disease. The case presented here had no history of known risk factors like prior adenocarcinoma or prior radiation therapy. This case presented with obstructive urinary symptoms with no prostate-specific antigen elevation, diagnosed with imaging, managed aggressively with robotic surgery. Detailed immunohistochemistry and pathological review suggested diagnosis as carcinosarcoma with osteosarcomatous differentiation. Very rare such cases were reported in the past with complete clinical, radiological, pathological details and managed aggressively with good outcomes. The patient is disease free after 6 months of follow-up.

Dosimetric Analysis of Unflattened (FFFB) and Flattened (FB) Photon Beam Energy for Gastric Cancers Using IMRT and VMAT-a Comparative Study.

PURPOSE: To evaluate the feasibility of flattening filter free beam (FFFB) for the treatment of gastric tumors and to review their benefits over 6MV flatten beam (6MV_FFB). METHODS: Fifteen patients with histologically proven gastric carcinoma were selected. CT scans with slice thickness of 0.3 cm were acquired and planning target volume (PTV) and organ at risk (OAR) were delineated. Plans were made retrospectively for each patient for the prescription dose of 45 Gy/25 fractions to the PTV. Four isocentric plans were compared in the present study on Varian TrueBeam linear accelerator (Varian Medical Systems, Palo Alto, CA, USA). RESULTS: PTV D98% was 44.41 ± 0.12, 44.38 ± 0.13, 44.59 ± 0.14, and 44.49 ± 0.19 Gy for IMRT 6MV_FFB, IMRT 6MV_FFFB, VMAT 6MV_FFB, and VMAT 6MV_FFFB respectively. 6MV_FFFB beam minimizes the mean heart dose Dmean (P = 0.001). VMAT dominates over IMRT when it came to kidney doses V12Gy (P = 0.02), V23Gy (P = 0.015), V28Gy (P = 0.011), and Dmax (P < 0.01). VMAT has significantly reduced the doses to kidneys. It was analyzed that 6MV_FFFB significantly reduces the dose to normal tissues (P = 0.006 and P = 0.018). VMAT significantly reduces the TMU, which is required to deliver the similar dose by IMRT (P < 0.01). CONCLUSIONS: Unflattened beam spares the organs at risk significantly to avoid the chances of secondary malignancies and reduces the intra-fraction motion during treatment due to provision of higher dose rate. Hence, we conclude that 6MV unflattened beam can be used to treat gastric carcinoma.

Comparative Evaluation of a 6MV Flattened Beam and a Flattening Filter Free Beam for Carcinoma of Cervix ­ IMRT Planning Study

Purpose: Intensity modulated radiotherapy (IMRT) plan quality, beam on time and integral dose were compared using 6MV FB (Flattened Beam) and FFFB (Flattening filter free beam) for carcinoma of cervix. Materials and Methods: Ten patients with stage II­IIIB cervix cancer (Ca.Cx) were retrospectively identified from the department database. Target volume (TV) and organ at risk (OAR) were delineated as per Radiation Therapy Oncology Group (RTOG) cancer guidelines. Dose prescribed to planning target volume (PTV) was 50.4Gy in 28 fractions. Two plans (6MV FB IMRT and 6MV FFFB IMRT) were generated to achieve 95% of prescription dose to PTV and sparing OAR as per normal tissue guidelines. Numbers of beams and their orientations were the same for all plans. The homogeneity index (HI), conformity index (CI), treatment monitor unit (MU), beam on time (BOT) and non-tumor integral dose (NTID) were chosen for comparison. Results: FFFB generated plans were clinically acceptable. There was a statistically significant difference among the FB IMRT and FFFB IMRT plans with respect to CI, HI, D50%, D2% in PTV coverage, bladder V50Gy, MU, mean NTID and non-tumor low dose volume. Conclusions: 6MV flattened and flattening filter free photon beams produce comparable plans by IMRT . FFF beams allow time efficient treatment delivery and may help reduce the risk of secondary malignances in carcinoma cervix cases.

Adjuvant Radiation Therapy and Temozolomide in Gliosarcoma: Is It Enough? Case Series of Seven Patients.

OBJECTIVE: We present our experience of gliosarcoma (GSM) in oncology tertiary care center over the last 5 years. MATERIALS AND METHODS: We carried out a retrospective analysis of seven patients with GSM diagnosed between April 2008 and December 2012. Demographic data, clinicopathological data, treatment strategies employed, details of recurrence, and survival patterns were reviewed. RESULTS: The median age at diagnosis was 54 years, ranging between 34 and 63 years with a female predominance (57.1% females). Headache and neurological deficit were the most common symptoms with parietal region being the most common site of lesion. Subtotal resection followed by concurrent chemoradiation therapy was delivered to six patients. The results following completion of planned schedule of concurrent chemoradiotherapy were quite disappointing with two patients having no evidence of disease, one patient was lost to follow-up, and other three had progressive disease. One patient with progressive disease subsequently received eight cycles of bevacizumab on a clinical trial protocol. Fifteen-month posttreatment, she had stable disease on follow-up. CONCLUSIONS: Our experience suggests that despite treatment, the diagnosis of GSM portends a poor prognosis and the use of bevacizumab could represent a treatment approach to improve outcome in these patients. Although the role of targeted therapy in GSM remains unclear because of paucity of experience, the treatment decision should be according to patient's performance status, ability, and willingness to receive additional treatment.

Simultaneous integrated boost by Intensity Modulated Radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery - A clinical and dosimetric perspective.

AIM: To study feasibility of simultaneous integrated boost by intensity modulated radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery and its impact on cosmesis and dosimetry. PATIENTS AND METHODS: Between January 2014 and June 2017, all breast cancer patients fulfilling inclusion and exclusion criteria were enrolled in a prospective study conducted at a tertiary cancer centre in North India. All patients received adjuvant radiotherapy by simultaneous integrated boost technique following breast conserving surgery. Clinical information including patient and pathological characteristics, observed acute and chronic toxicities along with cosmesis using Harvard score were recorded and analysed. Univariate analysis and multivariate logistic regression analysis were performed for those variables which were found to be significant (p < 0.050) to study the influence of clinicopathological and dosimetric factors on toxicity and cosmetic outcome. RESULTS: Maximum acute skin toxicity during treatment was Grade 0-1 in 68.2% and Grade 2-3 in 31.8% of cases, respectively. Fibrosis was the commonest late toxicity with ≥Grade II fibrosis being noted in 16.3% of cases. Assessment of global cosmesis at 12 months follow-up showed good/excellent cosmesis in 88.4% of cases. Mean age, tumor size and homogeneity index (HI) were the significant factors associated with fair or poor cosmetic outcome and ≥Grade 2 fibrosis on multivariate analysis. Telengectasia and breast edema were more frequent in patients with larger tumor size/GTV volume. There were 5 recurrences including 1 ipsilateral local breast tumor recurrence. CONCLUSION: SIB-IMRT is a dosimetrically feasible option in patients undergoing breast conserving surgery and provides good/excellent cosmetic outcome.

Primary Cutaneous Amyloidosis: A Clinical, Histopathological and Immunofluorescence Study.

INTRODUCTION: Primary Localized Cutaneous Amyloidosis (PLCA) is a relatively rare chronic condition characterized by amyloid deposition in dermis without associated deposits in internal organs. Histopathology of cutaneous amyloidosis using Haematoxylin and Eosin (H&E) stain shows eosinophilic hyaline material in papillary dermis, which can be further confirmed by Congo Red (CR) staining or Direct Immunofluorescence (DIF) Test or immunohistochemistry. AIM: To assess the concordance between the clinical, histo pathological and DIF findings in various subtypes of (PLCA). MATERIALS AND METHODS: Data was collected from patients attending the Outpatient Department (OPD) at a tertiary care centre in Karnataka, India, over a period of one and half years. A total of 50 patients with clinical features suggestive of cutaneous amyloidosis were subjected to histopathological examination with H&E, CR stain and immunofluorescence. RESULTS: Among 50 clinically suspected patients, the most common subtype was macular amyloidosis (70%) and lichen amyloidosis seen only in 16%. A biphasic pattern comprising of both macular and lichen amyloidosis was seen in 14% cases. Extensor aspect of the arm was the most frequently (76%) involved area. All the cases had multiple site involvement. Immunofluorescence positivity was 88% as compared to 86% on histopathology using CR stain. Amyloid deposits were detected in 80% of clinically diagnosed macular amyloidosis cases by histopathology using CR stain and in 85.7% by DIF, whereas in 5.7% cases, it was not detectable by both CR stain and DIF. Both immunofluorescence and CR staining were able to detect amyloid in all the cases of lichen amyloidosis. In biphasic amyloidosis, amyloid was detected in 100% cases on histopathology versus 85.7% cases on immunofluorescence. CONCLUSION: CR stain and DIF are complimentary to each other for detection of macular amyloidosis. In case of lichen and biphasic amyloidosis, both CR and DIF are comparable modalities.