WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update.

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.

Unique challenges and outcomes of young women with breast cancers from a tertiary care cancer centre in India.

BACKGROUND: Young (≤40 years) breast cancers (YBC) are uncommon, inadequately represented in trials and have unique concerns and merit studying. METHODS: The YBC treated with a curative intent between 2015 and 2016 at our institute were analysed. RESULTS: There were 1228 patients with a median age of 36 (12-40) years; 38 (3.1%) had Stage I, 455 (37.1%) - II, 692 (56.3%) -III, and remaining 43 (3.5%) Stage IV (oligo-metastatic) disease; 927 (75.5%) were node positive; 422 (34.4%) were Triple negatives (TNBC), 331 (27%) were HER-2 positive. There were 549 (48.2%) breast conservations and 591 (51.8%) mastectomies of which 62 (10.4%) underwent breast reconstruction. 1143 women received chemotherapy, 617 (53.9%) received as neoadjuvant and 142 (23.1%) had pathological complete response; 934 (81.9%) received adjuvant radiotherapy. At the median follow-up of 48 (0-131) months, 5-year overall and disease-free survival was 79.6% (76.8-82.5) and 59.1% (55.8-62.6). For stage I, II, III and IV, the 5-year overall-survival was 100%, 86.7% (82.8-90.6), 77.3% (73.4-81.2), 69.7% (52.5-86.9) and disease-free survival was 94% (85.9-100), 65.9% (60.3-71.5), 55% (50.5-59.5), and 29.6% (14-45.2) respectively. On multivariate analysis, TNBC and HER-2+ subgroups had poorer survival (p = 0.0035). 25 patients had BRCA mutations with a 5-year DFS of 65.1% (95% CI:43.6-86.6). Fertility preservation was administered in 104 (8.5%) patients; seven women conceived and 5 had live births. Significant postmenopausal symptoms were present in 153 (13%) patients. CONCLUSION: More than half of the YBC in India were diagnosed at an advanced stage with aggressive features leading to suboptimal outcomes. Awareness via national registry and early diagnosis is highly warranted. Menopausal symptoms and fertility issues are prevalent and demand special focus.

Nano-interface driven electrochemical sensor for pesticides detection based on the acetylcholinesterase enzyme inhibition.

Forensic Science Laboratories usually receive numerous cases of suicidal, accidental, and homicidal poisoning most often involving organophosphorus (OP) pesticides. The toxicity of the OP pesticides arises due to their ability to inhibit the activity of acetylcholinesterase (AChE), a cholinergic enzyme that is essential for the proper functioning of the central nervous system. Conventional techniques which are currently in use for pesticide detection are time-consuming, need upskilled technicians as well as suffer from low sensitivity. Therefore, the more rapid and sensitive electrochemical biosensors based on the principle of AChE enzyme inhibition have emerged out to be a simple and promising alternative to the conventional techniques. Since, most of the time, the poison isolated from biological material in poisoning cases is in nM quantities, an attempt has been made for the development of biosensor with enhanced sensitivity in the nM range using reduced graphene oxide (rGO) and zinc oxide nanoflowers (ZnONFs). The rGO and ZnONFs were synthesized chemically and deposited electrochemically on the Au electrode. AChE was immobilized onto this prepared nano-interface (ZnONFs/rGO/Au) through chitosan and glutaraldehyde cross-linking. The fabricated sensor was characterized step by step with cyclic voltammogram and electrochemical impedance spectroscopy. This advanced nanomaterials based techniques has been explored for detecting pesticides in visceral samples. The limit of detection (LOD) for the present sensor was 0.01 nM for OP pesticides.

Strengthened capacity of India´s bedaquiline Conditional Access Programme for introducing new drugs and regimens.

BACKGROUND: Addressing TB in India is critical to meeting global targets. With the scale-up of diagnostic networks and the availability of new TB drugs, India had the opportunity to improve the detection and treatment outcomes in drug-resistant TB (DR-TB).OBJECTIVE: To document how the introduction of new drugs and regimens is helping India improve the care of DR-TB patients.DESIGN: In 2016, India´s National TB Programme (NTP) introduced bedaquiline (BDQ) under a Conditional Access Programme (BDQ-CAP) at six sites after providing extensive training and strengthening laboratory testing, pre-treatment evaluation, active drug safety monitoring and management (aDSM) and follow-up systems.RESULTS: An interim analysis reflected earlier and better culture conversion rates: 83% of the 620 patients converted within a median time of 60 days. However, 248 serious adverse events were reported, including 73 deaths (12%) and 100 cardiotoxicity events (16.3%). Encouraged by the evidence of safety and efficacy of BDQ, the NTP took steps to systematically expand its access to cover the entire population by 2018.CONCLUSION: The cautious yet focused approach used to introduce BDQ under BDQ-CAP paved the way for the rapid introduction of delamanid, as well as the shorter treatment regimen and the all-oral regimen for DR-TB.

Seven-year DOTS-Plus pilot experience in India: results, constraints and issues.

BACKGROUND: India is initiating the DOTS-Plus strategy at the national level. OBJECTIVES: To highlight the results, constraints and issues of a pilot DOTS-Plus experience in an urban setting in India. METHODS: Records of 126 patients with multidrug-resistant tuberculosis (MDR-TB) enrolled from January 2002 to December 2006, who received a daily fully supervised standardised treatment regimen under a pilot DOTS-Plus study in India, were analysed retrospectively. RESULTS: Of the 126 patients enrolled, 61% were cured, 19% died, 18% defaulted and 3% failed treatment. There was an average delay of 5 months in the diagnosis of MDR-TB and a subsequent delay of approximately 3.3 months in initiating treatment. Of the 24 patients who died, 29% did so within a month of starting treatment. Migration was the most common reason for default. Cycloserine (CYC) had to be stopped in 15 patients and kanamycin (KM) in five due to major adverse effects. CONCLUSIONS: The DOTS-Plus programme in resource-poor settings may provide reasonable results; however, it may confront significant operational difficulties in the timely diagnosis and early initiation of treatment. Early diagnosis and start of treatment may prevent some deaths. Default is commonly due to migration. CYC proved to be the most toxic drug, followed by KM.

Planning and delivery of whole brain radiation therapy with simultaneous integrated boost to brain metastases and synchronous limited-field thoracic radiotherapy using helical tomotherapy: a preliminary experience.

Lung cancer is the commonest source of brain metastases, which has been traditionally treated with Whole Brain Radiation Therapy (WBRT) with or without focal boost. We herein report our preliminary experience of the planning and delivery of WBRT with Simultaneous Integrated Boost (SIB) to brain metastases along with synchronous limited-field thoracic radiotherapy using Helical TomoTherapy in four patients with lung cancer. All plans were iteratively optimized for maximal target volume coverage and organ-at-risk (OAR) sparing. Standardized dose metrics were used for plan evaluation. All treated regions were imaged with a megavoltage computed tomography (CT) prior to treatment and co-registered with planning CT for image-guidance. Helical TomoTherapy was able to achieve highly conformal and homogeneous dose distributions with excellent OAR sparing both in the brain and the chest. The mean (standard deviation) Dose Homogeneity Index (DHI) and Conformity Index (CI) was 0.06 (0.01) & 0.79 (0.07); 0.04 (0.02) & 0.57 (0.22); and 0.03 (0.02) & 0.77 (0.06) for whole brain, brain metastases, and chest, respectively. The mean monitor units (MU) per fraction and time taken for delivery were 8595 and 9898 MU and 9.8 and 11.3 minutes for the brain and chest plans, respectively. Although the dosimetric equivalence of SIB to a single fraction radiosurgery might still be questionable, our preliminary experience of WBRT with SIB to individual brain metastases using Helical TomoTherapy has been encouraging. In addition, it allows synchronous irradiation of other involved primary or metastatic sites for palliative effect.

Identification of source mobile hand sets using audio latency feature.

An experiment has been carried out for determination of source of digital audio recording using audio latency feature of mobile phones. The legal requirement of the source correspondence with the audio recordings in question has driven the necessity of such study. The evaluation is based on 300 audio recordings recorded with ten mobile handsets of MOTOROLA make but different model in three different format "3gp", "wav" and "m4a" format (ten audio recording in each format) recorded in stereo signal at 16 kHz and in different recording sessions using EASY VOICE RECORDER application. Adobe audition 3.0 software is used for analysis. The analysis of audio latency has been carried out in a set of ten mobile handsets having multimedia capability. The result of this study shows that the audio latency of mobile handsets of same make but different model carry the specific feature of latency and such audio latency is robust for establishing the source of audio recordings.

Case-control study and meta-analysis of SULT1A1 Arg213His polymorphism for gene, ethnicity and environment interaction for cancer risk.

Cytosolic sulphotransferase SULT1A1 plays a dual role in the activation of some carcinogens and inactivation of others. A functional polymorphism leading to Arg(213)His substitution (SULT1A1*2) affects its catalytic activity and thermostability. To study the association of SULT1A1*2 polymorphism with tobacco-related cancers (TRCs), a case-control study comprising 132 patients with multiple primary neoplasm (MPN) involving TRC and 198 cancer-free controls was carried out. One hundred and thirteen MPN patients had at least one cancer in upper aerodigestive tract including lung (UADT-MPN). SULT1A1*2 showed significant risk association with UADT-MPN (odds ratio (OR)=5.50, 95% confidence interval (CI): 1.09, 27.7). Meta-analysis was conducted combining the data with 34 published studies that included 11 962 cancer cases and 14 673 controls in diverse cancers. The SULT1A1*2 revealed contrasting risk association for UADT cancers (OR=1.62, 95% CI: 1.12, 2.34) and genitourinary cancers (OR=0.73, 95% CI: 0.58, 0.92). Furthermore, although SULT1A1*2 conferred significant increased risk of breast cancer to Asian women (OR=1.91, 95% CI: 1.08, 3.40), it did not confer increased risk to Caucasian women (OR=0.92, 95% CI: 0.71, 1.18). Thus risk for different cancers in distinct ethnic groups could be modulated by interaction between genetic variants and different endogenous and exogenous carcinogens.

The DOTS strategy for treatment of paediatric pulmonary tuberculosis in South Delhi, India.

SETTING: Paediatric Pulmonology Department, TB Institute, New Delhi, India. OBJECTIVE: To evaluate the outcome of the DOTS strategy for paediatric pulmonary tuberculosis (TB). DESIGN: Retrospective analysis of 1098 children. RESULTS: The mean age of the children included in the study was 11.2 years, with more females (61.7%) than males (38.3%). In the 0-5, 6-10 and 11-14 year age groups, the percentage of patients was respectively 18.3%, 26.6% and 55.1%. Patients were registered as new cases (87.7%), relapses (1.9%), failures (1.0%), defaulters (5.0%), transferred in (0.9%) and others (3.5%). Of the total number of cases, 414 were smear-positive and 404 smear-negative, while sputum status was not known for 280 patients. Sputum positivity increased with age. Category I, II and III regimens were started by respectively 50.6%, 10.5% and 38.9% patients. The cure rate was 92.4% (302/327) for new and 92% (80/87) for retreatment cases (chi(2)(1) = 0.02, P = 0.901), but the treatment completion rate was significantly higher for new cases (97%, 636/656) than retreatment cases (53.6%, 15/28) (chi(2)(1) = 100.8, P < 0.001). The overall success rate was 95.4% and 82.6% for new and retreatment cases, respectively (chi(2)(1) = 30.35, P < 0.001). Overall, the rates for default, failure and death in the study were respectively 3%, 1.9% and 1%. CONCLUSION: DOTS appears to be a highly efficacious treatment strategy.

Zinc as a marker in viscera of suspected metal phosphide poisoning: a study by neutron activation analysis.

Zinc as a marker element in the viscera of suspected metal phosphide poisoning has been studied during the present work. Neutron activation analysis (NAA) has been employed to detect and quantify the concentration of zinc in the viscera/stomach portion. The methodology has been developed on simulated and real life viscera samples to quantify the amount of zinc using NAA. The results obtained by NAA for real-life samples have been validated using a complementary analytical technique (viz. differential pulse anodic stripping voltammetry), and the values obtained were in good agreement, within +/- 5-8%. This exercise could be useful in medico-legal field for framing a definitive opinion about zinc phosphide poisoning.

Practical consensus recommendations for tumor margins and breast conservative surgery.

My suggestion: There is no difference in survival of breast cancer patients treated with either mastectomy or with breast conservation therapy combined with external beam radiotherapy. A positive margin (s) is an important factor contributing to the increased risk of local recurrence. However, in published literature, there is a lack of consensus on the definition of acceptable margin (s). As a result decision process about need for re-excision after positive margins remains uncrear.

Practical consensus recommendaton for adjuvant bone-modifying agents in breast cancer.

Bone-modifying therapy is a primary research interest in breast cancer. Several features contribute to the importance of the bone environment in the management of breast cancer. Firstly, bone metastases represent the most common site of breast cancer metastases and secondly, the emergence of cancer treatment-induced bone loss (CTIBL) among breast cancer survivors and patients is of increasing concern. In the adjuvant setting, bisphosphonates can be given to prevent and treat tumor therapy-induced bone loss in premenopausal and postmenopausal women and, owing to their beneficial effect on bone turnover, have also been evaluated for prevention of bone metastases occurrence. Expert oncologists discusses on the update on the approaches of Bone-modifying Agents and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Cosmesis, late sequelae and local control after breast-conserving therapy: influence of type of tumour bed boost and adjuvant chemotherapy.

AIMS: To study the influence of various factors affecting cosmetic outcome and late sequelae in a large cohort of women treated with breast-conserving therapy. MATERIALS AND METHODS: Between 1980 and 2000, 1022 pathological stage I/II breast cancer patients underwent breast-conserving therapy. On the basis of the type of tumour bed boost they received after whole breast radiotherapy, these women were assigned to three groups: (A) low dose rate (LDR) brachytherapy of 15-20 Gy (n=383); (B) high dose rate (HDR) brachytherapy of 10 Gy (optimised) in a single fraction (n=153); (C) electron beam 15 Gy/six fractions (n=460). Systemic adjuvant therapy was given to 757 women, of whom 570 received adjuvant chemotherapy. RESULTS: Cosmesis at the last follow-up was good or excellent in 77% of women. Post-radiation worsening of cosmesis was observed in 11.5% of women and was similar in the three boost groups. Moderate to severe late breast sequelae were observed in 22% of women in group B, which was significantly higher than the 12% in group A (P=0.002) and 9% in group C (P=0.0001). The actuarial 5-year local control rate was 91% and was 90, 92 and 93% in groups A, B and C, respectively. Tumour size (P=0.049) and adjuvant chemotherapy (P=0.04) were the significant factors affecting cosmetic outcome on univariate analysis. On multivariate analysis, adjuvant chemotherapy was the only factor leading to worsening in the cosmetic outcome, with P=0.03 (hazard ratio 1.65 [95% confidence interval 1.05-2.59]). CONCLUSION: The type of tumour bed boost did not have a significant effect on the worsening of cosmetic outcome. However, there were significantly more late breast sequelae in women treated with single fraction HDR implants. Chemotherapy had an adverse effect on the cosmetic outcome, but the late breast sequelae and local control rates were comparable.

Black brown discoloration and hairy tongue - A rare linezolid side effect.

INTRODUCTION: Linezolid was approved for clinical use for methicillin resistant Staphylococcus aureus and vancomycin-resistant Enterococci. Additionally it is used in the management of drug resistant tuberculosis. It is well-tolerated however bone marrow suppression and neuropathies may occur in patients taking this antibiotic for more than 2 weeks. Black discoloration and black hairy tongue (BHT) due to linezolid is rarely reported. We report two cases of BHT. CASE REPORTS: Two patients of drug resistant pulmonary tuberculosis developed benign hairy tongue with linezolid 600mg per day. In both the cases black colored/hairy tongue was reported within 2-3 weeks of linezolid treatment. Both patients improved after withdrawal of linezolid. Subsequent reintroduction of linezolid with good oral hygiene was well tolerated and both patients completed the treatment of 2 years duration without any recurrence. CONCLUSION: Black discoloration and BHT is a rare but transient adverse reaction with linezolid. Reintroduction of linezolid with good oral hygiene is well tolerated.

Predicting loco-regional recurrence risk in T1, T2 breast cancer with 1-3 positive axillary nodes postmastectomy: Development of a predictive nomogram.

BACKGROUND: Role of postmastectomy radiotherapy (PMRT) in early breast cancer with 1-3 positive axillary nodes is still controversial. Hence, there is a need to identify subgroup of patients who have sufficiently high risk of disease recurrence to benefit from PMRT. AIM: The aim is to evaluate clinical outcomes of patients postmastectomy having pathological T1-T2 tumors with 1-3 positive axillary lymph nodes (LNs) treated with adjuvant systemic therapy and develop a predictive nomogram. MATERIALS AND METHODS: Data collected retrospectively from eligible patients from 2005 to 2011. Kaplan-Meier survival analysis was used for all time-to-event analysis. Various known clinical and pathological risk factors were correlated with outcome using uni- and multi-variable analysis in SPSS version 21. All comparisons were two-tailed and P < 0.05 were considered statistically significant. The nomogram to predict the risk of loco-regional control (LRC) was developed using least absolute shrinkage and selection operator shrinkage model in hdnom.io software. RESULTS: 38/242 (15.7%) patients had recurrent disease at loco-regional (10 patients), distant sites (22 patients) and simultaneous loco-regional and distant sites (6 patients) at a median follow-up 59.5 (range 4-133) months. Five years estimate of LRC, distant disease-free survival (DFS), DFS, cause-specific survival and overall survival was 87.8%, 85.4%, 84.2%, 93.1%, and 91.5%, respectively. Pathological tumor size, margin status, LN ratio as continuous variables and grade and triple negative breast cancer status as categorical variables were the risk factors included in the model for building nomogram. CONCLUSION: The nomogram developed based on institutional data can be a valuable tool in guiding adjuvant PMRT depending on the risk of 5 years loco-regional recurrence.

Use of egg yolk antibody (IgY) as an immunoanalytical tool in the detection of Indian cobra (Naja naja naja) venom in biological samples of forensic origin.

An immunoglobulin Y (IgY) based indirect double antibody sandwich enzyme linked immunosorbent assay (ELISA) was developed for the detection of Indian cobra (Naja naja naja) venom in the biological samples of forensic origin. Polyclonal antibodies were raised and purified from chick egg yolk and rabbit serum. The cobra venom was sandwiched between immobilized affinity purified IgY and the rabbit IgG. The detection concentration of cobra venom was in the range of 0.1 to 300ng. The calibration plot was based on linear regression analysis (y=0.2581x+0.4375, r(2)=0.9886). The limit of detection of the assay was found to be 0.1ng. The coefficient of variation (CV) of different concentrations of working range in inter (n=6) and intra-assay (n=6) was observed to be less than 10%. The recovery of venom was found to be in the range of 80-99%, when different concentrations (0.002, 0.1, 0.2, 1, and 2microg) of cobra venom were spiked to pooled normal human serum (ml(-1)). No cross reactivity was observed with krait and viper venom in the immunoassay system in the concentration range of 0.1-1000ng. The method was initially, validated by analyzing specimens (autopsy) of experimental rats injected with cobra venom (1.2mgkg(-1) body mass). Further, human specimens (autopsy and biopsy) of snake bite victims of forensic origin were also analyzed. The methodology developed may find diagnostic application in forensic laboratories.

Epidemiological and survival analysis of triple-negative breast cancer cases in a retrospective multicenter study.

INTRODUCTION: This is a retrospective study with data collected from breast cancer cases from five major Apollo Hospitals across India, as part of a biobanking process. One aspect of our study focused specifically on data from triple-negative breast cancer (TNBC) cases. The aim of this study was to analyze epidemiology, treatment options, and survival of the patients with TNBC. Our goal was to draw conclusions on the preponderance of the disease and also to understand the outcomes using the existing therapy options. MATERIALS AND METHODS: Data were collected after due ethical clearances and were coded with regard to patient identifiers to protect patient privacy. Data were not only from the various departments of the respective hospitals and the treating physicians but also from the follow-up made by hospital staff and social workers. RESULTS: About 20% of all cases of breast cancer comprised TNBC. Although the disease is generally thought to be an early onset disease, there was no major difference in the median age of diagnosis of TNBC compared to other breast cancer cases. More than 85% of the TNBC cases were of early stage disease with <4% of the cases of metastatic cancer. Data on follow-up were somewhat sporadic as a good number of cases were lost to follow-up, but from the available data, recurrence rate was about 11%. Death, when it occurred, was mostly in the early periods of treatment with 35% of the events occurring before 3 years. The overall survival rates beyond 3 years were more than 86%. CONCLUSIONS: Data and sample collection are an ongoing process, so we expect this data set to be enriched with more cases and longer duration of follow-up in a year. Preliminary analysis sheds light on the potential of such a collection both for understanding the epidemiology of the disease and also for conducting future studies with an eye toward improving treatment outcomes.

Source identification of Indian opium based on chromatographic fingerprinting of amino acids.

Total and free pool of amino acids was determined in Indian opium samples using liquid chromatography (LC) with post-column opthalaldehyde derivatization followed by its fluorimetric detection. The limit of detection (LOD) was found to be in the range of 2-10 pmol with a signal to noise ratio of 3:1 and limit of quantitation (LOQ) was found to be in the range of 7-31 pmol with a signal to noise ratio of 10:1. The recovery of amino acids was found to be in the range of 86-103%. A total of 124 Indian opium samples were collected from the states of Madhya Pradesh (MP), Uttar Pradesh (UP) and Rajasthan (Raj), covering 14 licit opium growing divisions of India were chromatographically fingerprinted for the presence of various amino acids. The amino acids identified in sample hydrosylate included D, T, S, S, G, A, V, I, L, Y, F, H, K and R, while the analysis of free pool of amino acids (80% aqueous ethanol extract) indicated the presence of D, T, S, E, A, V, I, L, Y, H, K respectively. Multiple discriminant analysis was applied to the quantitative total amino acid data to determine an optimal classifier in order to evaluate the source of Indian opium. The foremost amino acid variables that accounted for the true discrimination were identified as D, E, G, A, F and K in evaluating the geographical origin of Indian opium and the predictive value based on the discriminant analysis was found to be 90% in relation to the source of opium samples. Chemometrics performed with amino acid analytical data was used successfully in discriminating the licit opium growing divisions of India into three major groups, viz. groups I, II and III. The methodology developed may find wide application in forensic analysis.

Simple liquid chromatographic method for the rapid and simultaneous determination of propoxur and its major metabolite isopropoxy phenol in rat blood and urine using solid-phase extraction.

This research paper describes the development and validation of an analytical method for the simultaneous determination of propoxur and isopropoxy phenol (IPP, a major metabolite) in both blood and urine of rat using reversed-phase high-performance liquid chromatography (HPLC) employing solid-phase extraction (SPE). Sample purification was performed using a weak cation-exchange cartridge (Isolute CBA). Separation was achieved by HPLC with UV detection at 270 nm. Recoveries of propoxur and IPP from blood and urine by SPE exceeded 85%. The validated calibration range for propoxur is from 0.5 to 100 microg/L and 2 to 100 microg/L for IPP in both rat blood and urine. The limit of quantitation for propoxur in blood and urine is 0.5 and 0.8 pg/L, respectively, and 2.0 and 4.2 microg/L, respectively, for IPP. Validation results on specificity, sensitivity, linearity, precision, accuracy, and stability are shown. The applicability of the method was demonstrated by the analysis of urine and blood from rats that were orally fed propoxur at minimum dose.

Use of tomotherapy in treatment of synchronous bilateral breast cancer: dosimetric comparison study.

OBJECTIVE: Synchronous malignancy in both breasts is a rare incidence. The present study aims at dosimetric comparison of conventional bitangential radiotherapy (RT) technique with conventional [field-in-field (FIF)] and rotational [Helical TomoTherapy(®) and TomoDirect™ (TD); Accuray Inc., Sunnyvale, CA] intensity-modulated RT for patients with synchronous bilateral breast cancer (SBBC). METHODS: CT data sets of 10 patients with SBBC were selected for the present study. RT was planned for all patients on both sides to whole breast and/or chest wall using the above-mentioned techniques. Six females with breast conservation on at least one side also had a composite plan along with tumour bed (TB) boost using sequential electrons for bitangential and FIF techniques or sequential helical tomotherapy (HT) boost (for TD) or simultaneous integrated boost (SIB) for HT. RESULTS: All techniques produced acceptable target coverage. The hotspot was significantly lower with FIF technique and HT but higher with TD. For the organs at risk doses, HT resulted in significant reduction of the higher dose volumes. Similarly, TD resulted in significant reduction of the mean dose to the heart and total lung by reducing the lower dose volumes. All techniques of delivering boost to the TB were comparable in terms of target coverage. HT-SIB markedly reduced mean doses to the total lung and heart by specifically lowering the higher dose volumes. CONCLUSION: This study demonstrates the cardiac and pulmonary sparing ability of tomotherapy in the setting of SBBC. ADVANCES IN KNOWLEDGE: This is the first study demonstrating feasibility of treatment of SBBC using tomotherapy.