Prospective evaluation of definitive chemoradiotherapy with volumetric modulated arc therapy in patients with muscle invasive carcinoma of urinary bladder.

INTRODUCTION: Concurrent chemoradiotherapy (CTRT) remains one of the treatment options in patients with muscle invasive bladder cancer (MIBC) unwilling/unsuitable for radical surgery. We evaluated the role of volumetric modulated arc therapy (VMAT) in MIBC patients treated with definitive CTRT. MATERIAL AND METHODS: 25 patients of histologically proven transitional cell MIBC (T2-T4a, N0, M0) unwilling/unsuitable for radical surgery (after maximal transurethral resection of bladder tumour) were recruited in this prospective study. Primary clinical target volume (CTV) consisted of the gross tumour and whole bladder. Primary planning target volume (PTV) and nodal PTV were prescribed 60 Gy and 54 Gy (both in 30 fractions). Concurrent chemotherapy was cisplatin (40 mg/m2) weekly. Acute toxicities were assessed as per Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Survival estimates were done from the date of registration using the Kaplan-Meier method. RESULTS: Median age was 70 years (37-80 years). Median overall treatment time was 45 days (44-51). Median number of chemotherapy cycles was 5 (range 3-6). 5 (20%) and 4 (16%) patients respectively suffered from acute grade ≥ 2 gastrointestinal and grade ≥ 2 genitourinary toxicities during treatment. One patient each had grade 3 anaemia and neutropenia. At a median follow-up of 34 months (10-45 months), 3-year progression-free survival and overall survival were 65.6% and 81.2% respectively. 3-year distant metastasis-free survival was 90.5%. Bladder preservation rate at 3 years was 68%. CONCLUSIONS: Definitive CTRT with VMAT is well tolerated in patients with MIBC unsuitable for surgery and yields decent survival and bladder preservation outcome.

Patterns of failure and clinical outcomes of post-operative buccal mucosa cancers treated with adjuvant ipsilateral radiotherapy.

PURPOSE: Adjuvant radiotherapy (RT) in buccal mucosa cancers is guided by histopathological factors. The decision to treat ipsilateral or bilateral draining lymph node is on physician discretion and guidelines do not have a defined indication regarding this. We aimed to analyze the failure patterns and survival in buccal mucosa cancers treated with adjuvant ipsilateral RT. MATERIALS AND METHODS: One hundred sixteen cases of post-operative buccal mucosa cancers-pT3 or more, node positive, close margins (1-5 mm), lymphovascular invasion positive, perineural invasion positive, depth of invasion >4 mm-treated with RT to primary and ipsilateral nodes from May 2013 to May 2019 were retrospectively analyzed. Patients were treated to a dose of 60-66 Gy (44 Gy in the first phase and a coned down boost of 16-22 Gy in the second phase) with three-dimensional conformal radiotherapy on a linear accelerator. Primary end point was to assess control rates and secondary end point was to evaluate the overall survival (OS) and disease-free survival (DFS) outcomes. RESULTS: Median age was 46 years with male; female ratio of 110:6. The edition of the American Joint Committee on Cancer stage distributions were I (3.4%), II (34.4%), III (24.1%), and IV (37.9%). At a median follow-up of 22 months, crude rates of local failure, regional failure, and contralateral neck failure were 9.4%, 10.3%, and 3.4%, respectively. The 2-year contralateral neck control rate was 94.9%. Pathological positive node portended poorer OS (86.6% vs. 68.6%; p = 0.015) and DFS (86.5% vs. 74.9%; p = 0.01). CONCLUSION: Incidence of contralateral recurrence with ipsilateral irradiation in buccal mucosa cancers is low with descent survival outcomes, particularly in node negative cases.

Evaluation of purely accelerated six fractions per week radiotherapy in postoperative oral cavity squamous cell carcinoma.

OBJECTIVES: Randomized controlled trials have shown improved loco-regional control (LRC) and disease-free survival (DFS) by modest acceleration using six fractions per-week radiotherapy (RT) as compared to conventional fractionation in patients of head and neck squamous cell carcinoma. We aimed to evaluate the role of pure modestly accelerated fractionated radiotherapy (PM-ART) using six fractions per-week in patients of postoperative oral cavity squamous cell carcinoma (OCSCC). MATERIALS AND METHODS: Between May 2015 and July 2016, 40 OCSCC patients with ≥ 1 indication of RT were treated with adjuvant PM-ART, 60 Gray in 30 fractions over 5 weeks by three-dimensional conformal technique on a linear accelerator with a sixth 2 Gray fraction on Saturday using same fields. Primary endpoint was to assess acute toxicity, which was reviewed weekly during RT using Radiation Therapy Oncology Group criteria. RESULTS: Maximal grade 3 oral mucositis, pharynx/esophageal toxicity, and skin toxicity were seen in 77.5%, 25%, and 17.5%, respectively. Two patients had grade 4 mucositis. 47.5% were on tube feeding during RT. All the patients were taken off Ryle's tube within 4 weeks of RT completion. The median RT completion duration was 36 days. Three patients had treatment interruptions. With a median follow-up of 21.2 months, the 2-year LRC, DFS, and overall survival rates were 87.5%, 83.5%, and 85%, respectively. There were two distant failures. CONCLUSION: PM-ART is feasible and tolerable. The high acute mucositis rates did not result in increased consequential late toxicity.

Postoperative radiotherapy dose requirement in standard combined-modality practice for head and neck squamous cell carcinoma: Analysis of salient surgical and radiotherapy parameters in 2 cohorts.

BACKGROUND: This study compared 2 sequential cohorts to identify the postoperative radiotherapy (PORT) dose requirement for head and neck squamous cell carcinoma (HNSCC). METHODS: Two distinct PORT dose regimens were prescribed over 11 years; group 1 received 56 Gy or less, and group 2 received 60 Gy or more. The 2D and 3D techniques were used. RESULTS: Two sequential cohorts consisted of 478 patients, with mean and median follow-up for group 1 and 2 as: 37.0 versus 28.5 months and 13.8 versus 13.1 months, respectively. Grades 3-4 mucosal toxicities (11.4% vs 28.3%), hospitalization (3.2% vs 17.4%), and nasogastric feeding (11.9% vs 29.7%) were higher in group 2. The 2-year disease-free survival (DFS) was higher with PORT >60 Gy for the following factors: age ≤ 50 years (P = .041); ≥ 4 positive nodes (P = .029); and overall treatment time (OTT) ≥ 100 days (P = .042). CONCLUSION: Except for the benefit of doses >60 Gy for limited parameters, a lower PORT dose did not compromise the results and can potentially reduce the morbidities and healthcare costs.

Outcomes of thymoma treated with multimodality approach: a tertiary cancer center experience of 71 patients.

AIMS: To explore the demographics and clinical outcome of patients with thymoma treated with a multimodality approach at our institute. METHODS: A total of 71 patients with thymoma (Masaoka stage II-IV and WHO subtype AB-B3) treated from 1999-2013 were included in this retrospective analysis. Age, stage, WHO subtypes, details of surgery, radiotherapy, and chemotherapy were noted. Progression-free survival (PFS) was estimated using Kaplan-Meier method and SPSS (version 21.0) was used for statistical analysis. RESULTS: Male:female ratio was 56:15 with median age at presentation of 41 years. Stage-wise distribution was 6:46:19 for stage II, stage III, and stage IV, respectively. A total of 31 patients (44%) had associated myasthenia gravis and 3 had pure red cell aplasia. A total of 57 patients (80%) underwent radical thymectomy and all of these patients received adjuvant radiotherapy. A total of 15 patients and 7 patients received adjuvant chemotherapy and neoadjuvant chemotherapy, respectively. At median follow-up of 19.3 months (range 7.9-72.3 months), 2-year and 3-year PFS rate for the entire cohort was 78.3% and 57.1%, respectively. On univariate analysis, surgery (hazard ratio [HR] 3.881; 95% confidence interval [CI] 1.784-19.220; p = 0.006) and stage (HR 5.457; 95% CI 1.567-18.996; p = 0.0001) were significant prognostic factors and association with myasthenia gravis (HR 0.404; 95% CI 0.151-1.078; p = 0.078) trended towards better PFS. Stage retained its prognostic significance (HR 5.501; 95% CI 2.076-14.573; p = 0.0006) on multivariate analysis. CONCLUSIONS: Multimodality management of locally advanced thymoma yields decent survival outcomes. Masaoka stage is an independent prognostic factor for survival and radical surgery should be contemplated in all cases of locoregionally limited thymoma.

The power of integration: radiotherapy and global palliative care.

Radiotherapy (RT) is a powerful tool for the palliation of the symptoms of advanced cancer, although access to it is limited or absent in many low- and middle-income countries (LMICs). There are multiple factors contributing to this, including assumptions about the economic feasibility of RT in LMICs, the logical challenges of building capacity to deliver it in those regions, and the lack of political support to drive change of this kind. It is encouraging that the problem of RT access has begun to be included in the global discourse on cancer control and that palliative care and RT have been incorporated into national cancer control plans in some LMICs. Further, RT twinning programs involving high- and low-resource settings have been established to improve knowledge transfer and exchange. However, without large-scale action, the consequences of limited access to RT in LMICs will become dire. The number of new cancer cases around the world is expected to double by 2030, with twice as many deaths occurring in LMICs as in high-income countries (HICs). A sustained and coordinated effort involving research, education, and advocacy is required to engage global institutions, universities, health care providers, policymakers, and private industry in the urgent need to build RT capacity and delivery in LMICs.

Recurrent posterior reversible encephalopathy syndrome after chemotherapy in hematologic malignancy-posterior reversible encephalopathy syndrome can strike twice!!!

Posterior reversible encephalopathy syndrome (PRES) is a neuro-radiological syndrome characterized by seizures, altered level of consciousness, visual disturbance, and hyperintense lesions on magnetic resonance imaging most commonly in the posterior regions. PRES is typically associated with a number of complex clinical conditions including: Preeclampsia/eclampsia, allogeneic bone marrow transplantation, solid organ transplantation, autoimmune diseases, and high-dose anti-neoplastic therapy. We herein describe a case of recurrent PRES in a 29-year-old lady of refractory anaplastic large-cell lymphoma who was on second-line chemotherapy with Ifosfamide-Carboplatin-etoposide regimen. We have also tried to illustrate the pathogenesis, radiological features, and management of PRES. Although reversible in most cases, PRES may be recurrent even in chemotherapy--induced cases and result in fatal outcomes despite appropriate intervention. This is the first--reported case of recurrent PRES with such a fatal outcome, as a complication of anti-neoplastic systemic therapy.