Utility of Mid-treatment DWI in Selecting Pathological Responders to Neoadjuvant Chemoradiotherapy in Locally Advanced Esophageal Cancer.

PURPOSE: Pathological complete response correlates with better clinical outcomes in locally advanced esophageal cancer (LA-EC). However, there is lack of prognostic markers to identify patients in the current setting of neoadjuvant chemoradiotherapy (NACRT) followed by surgery. This study evaluates the utility of mid-treatment diffusion-weighted imaging (DWI) in identifying pathological responders of NACRT. METHODS: Twenty-four patients with LA-EC on NACRT were prospectively recruited and underwent three MRI (baseline, mid-treatment, end-of-RT) scans. DWI-derived apparent diffusion coefficient (ADC) mean and minimum were used as a surrogate to evaluate the treatment response, and its correlation to pathological response was assessed. RESULTS: Mid-treatment ADC mean was significantly higher among patients with pathological response compared to non-responders (p = 0.011). ADC difference (ΔADC) between baseline and mid-treatment correlated with tumor response (p = 0.007). ADC at other time points did not correlate to pathological response. CONCLUSION: In this study, mid-treatment ADC values show potential to be a surrogate for tumor response in NACRT. However, larger trials are required to establish DW-MRI as a definite biomarker for tumor response.

Determining the Occurrence of Hypothyroidism Following Treatment With Radiation Therapy in Head and Neck Carcinoma Patients and the Associated Role of Risk Factors and Dose-Volume Histograms: A Prospective Study.

Background Head and neck carcinomas are one of the most common malignancies in developing countries including India. Most patients are treated with radiotherapy. Although post-radiotherapy hypothyroidism is a known complication, data regarding its incidence and factors influencing it are scarce. This study aimed to determine the incidence of post-radiotherapy hypothyroidism in head and neck carcinoma patients treated with radiotherapy and the factors influencing it. Methodology Patients with head and neck carcinomas treated with radiotherapy as one of the modalities were included in this study. Thyroid function tests were done, and quality of life questionnaires were completed before treatment and during follow-up. Dose-volume histogram (DVH), demographic data, and disease-related parameters were compared. Results Out of the 95 patients screened, 14 were found to be hypothyroid prior to the commencement of radiotherapy and were excluded. With a median follow-up duration of 34 weeks, 29.6% developed hypothyroidism, with 19% developing it in the first year. On univariate and multivariate analysis of the DVH of the thyroid gland, volume receiving 50 Gy (V50), dose received to 50% volume (D50), and the mean dose (more than 50 Gy) were found to be significantly associated with hypothyroidism. Conclusions Hypothyroidism is a significant comorbid factor in Indian patients with head and neck carcinomas. The incidence of post-radiotherapy hypothyroidism is significant and occurs early compared to the western population leading to significant deterioration in the quality of life. Parameters such as the volume of the thyroid gland, V50, D50, and mean dose to the thyroid gland influence the incidence of hypothyroidism. The use of appropriate constraints can significantly prevent radiotherapy-induced hypothyroidism.

End-of-Treatment FDG PET-CT (EOT-PET) in Patients with Post-Chemotherapy Masses for Seminoma: Can We Avoid Further Intervention?

Anjana JoelContext Patients with seminoma present with advanced disease. End-of-treatment (EOT) positron emission tomography-computed tomography (PET-CT) is done to assess response and direct management of post-chemotherapy residual masses. Purpose This article assesses the utility of EOT PET-CT in the management of post-chemotherapy residual lymph nodal masses seminoma. Materials and Methods We analyzed all patients with seminoma who underwent an EOT PET-CT from January 2015 to January 2020 at our center and calculated the positive predictive value (PPV) and negative predictive value (NPV) of EOT PET-CT in the entire cohort of patients and among subgroups. Results A total of 34 male patients underwent EOT PET-CT. Fourteen (41.2%) were stratified as good risk and 20 (58.8%) as intermediate risk. The median follow-up was 23 months (interquartile range: 9.75-53 months). In 23 patients there were residual masses of size more than 3 cm at the EOT PET scan. EOT PET was positive as per the SEMPET criteria in 18 (78%) out of 23 patients. None underwent retroperitoneal lymph node dissection. All four who underwent image-guided biopsy, showed only necrosis on pathology. One patient with positive mediastinal node (standardized uptake value 13.6) had granulomatous inflammation. There was no relapse or progression during this period of follow-up. The NPV for EOT PET-CT for the entire cohort, > 3 cm, and > 6 weeks cutoff were 100%, respectively. The PPV for EOT PET-CT for the entire cohort, > 3 cm residual mass, and > 6 weeks cutoff were 8.7, 11.11, and 6.67%, respectively. Conclusion EOT PET-CT has a low PPV and high NPV in predicting viable tumor in post-chemotherapy residual masses among patients with seminomatous germ cell tumors. If required, EOT PET positivity can be confirmed by a biopsy or reassessed with a repeat PET-CT imaging to document persistent disease prior to further intervention.

Framework for Machine Learning of CT and PET Radiomics to Predict Local Failure after Radiotherapy in Locally Advanced Head and Neck Cancers.

CONTEXT: Cancer Radiomics is an emerging field in medical imaging and refers to the process of converting routine radiological images that are typically qualitatively interpreted to quantifiable descriptions of the tumor phenotypes and when combined with statistical analytics can improve the accuracy of clinical outcome prediction models. However, to understand the radiomic features and their correlation to molecular changes in the tumor, first, there is a need for the development of robust image analysis methods, software tools and statistical prediction models which is often limited in low- and middle-income countries (LMIC). AIMS: The aim is to build a framework for machine learning of radiomic features of planning computed tomography (CT) and positron emission tomography (PET) using open source radiomics and data analytics platforms to make it widely accessible to clinical groups. The framework is tested in a small cohort to predict local disease failure following radiation treatment for head-and-neck cancer (HNC). The predictors were also compared with the existing Aerts HNC radiomics signature. SETTINGS AND DESIGN: Retrospective analysis of patients with locally advanced HNC between 2017 and 2018 and 31 patients with both pre- and post-radiation CT and evaluation PET were selected. SUBJECTS AND METHODS: Tumor volumes were delineated on baseline PET using the semi-automatic adaptive-threshold algorithm and propagated to CT; PyRadiomics features (total of 110 under shape/intensity/texture classes) were extracted. Two feature-selection methods were tested for model stability. Models were built based on least absolute shrinkage and selection operator-logistic and Ridge regression of the top pretreatment radiomic features and compared to Aerts' HNC-signature. Average model performance across all internal validation test folds was summarized by the area under the receiver operator curve (ROC). RESULTS: Both feature selection methods selected CT features MCC (GLCM), SumEntropy (GLCM) and Sphericity (Shape) that could predict the binary failure status in the cross-validated group and achieved an AUC >0.7. However, models using Aerts' signature features (Energy, Compactness, GLRLM-GrayLevelNonUniformity and GrayLevelNonUniformity-HLH wavelet) could not achieve a clear separation between outcomes (AUC = 0.51-0.54). CONCLUSIONS: Radiomics pipeline included open-source workflows which makes it adoptable in LMIC countries. Additional independent validation of data is crucial for the implementation of radiomic models for clinical risk stratification.

In-vivo dose measurements with MOSFET dosimeters during MV portal imaging.

BACKGROUND: The purpose of this study was to investigate the feasibility of MOSFET dosimeter in measuring eye dose during 2D MV portal imaging for setup verification in radiotherapy. MATERIALS AND METHODS: The in-vivo dose measurements were performed by placing the dosimeters over the eyes of 30 brain patients during the acquisition of portal images in linear accelerator by delivering 1 MU with the field sizes of 10 × 10 cm2 and 15 × 15 cm2. RESULTS: The mean doses received by the left and right eyes of 10 out of 30 patients when both eyes were completely inside the anterior portal field were found to be 2.56 ± 0.2 cGy and 2.75 ± 0.2, respectively. Similarly, for next 10 patients out of the same 30 patients the mean doses to left and right eyes when both eyes were completely out of the anterior portal fields were found to be 0.13 ± 0.02 cGy and 0.17 ± 0.02 cGy, respectively. The mean doses to ipsilateral and contralateral eye for the last 10 patients when one eye was inside the anterior portal field were found to be 3.28 ± 0.2 cGy and 0.36 ± 0.1 cGy, respectively. CONCLUSION: The promising results obtained during 2D MV portal imaging using MOSFET have shown that this dosimeter is well suitable for assessing low doses during imaging thereby enabling to optimize the imaging procedure using the dosimetric data obtained. In addition, the documentation of the dose received by the patient during imaging procedure is possible with the help of an in-built software in conjunction with the MOSFET reader module.

Primary mediastinal germ cell tumours: real world experience in the low middle income (LMIC) setting.

PURPOSE: Primary mediastinal germ cell tumours (PMGCTs) are rare; with limited data available about their outcomes and optimal treatment in the low middle income countries setting. We studied the clinical profile of patients with PMGCT treated at our centre in order to estimate their survival outcomes and to identify prognostic factors affecting the same. PATIENTS AND METHODS: Fifty-seven patients with PMGCTs treated between April 2001 and June 2019 were included. Baseline characteristics, details of first line chemotherapy, response rates, toxicity and surgical outcomes were noted. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS: Among 57 male patients (seminoma = 20 and nonseminomatous = 37), the median follow-up was 10 months (range: 1-120 months). For mediastinal seminoma, 9 (45%) and 11 (55%) patients had good and intermediate risk disease, respectively. Nineteen patients (95%) received BEP (Bleomycin, etoposide and cisplatin) chemotherapy. 94.7% had partial responses and median event-free survival was not reached. All patients were alive and disease free at 2 years. For primary mediastinal nonseminomatous germ cell tumours (PMNSGCTs), all patients were poor risk. Thirty-four (91.8%) received BEP/EP chemotherapy as first line. Responses were PRM+ (partial response with elevated markers) in 7 (20.5%) and PRM- in 12 (35.2%). The incidence of febrile neutropenia was 50% and 55.8% in seminole and PMNSGCT, respectively. The median OS was 9.06 months and median PFS was 4.63 months for PMNSGCT. The proportion of patients alive at 1 year and 2 years were 35% and 24.3%, respectively. CONCLUSION: Primary mediastinal seminomas are rarer and have better survival outcomes. Treatment of PMNSGCT is still a challenge and is associated with poorer survival outcomes.

Patterns of Recurrence in Locally Advanced Resectable Oesophageal Carcinoma: Retrospective Review from a Tertiary Cancer Centre in South India.

PURPOSE: The study aims to analyse patterns of recurrence following neoadjuvant treatment and surgery in carcinoma oesophagus with an intent to postulate optimal nodal radiation. METHODOLOGY: A retrospective review of patients who presented to our centre within a 5-year period (2014-2018), with recurrence following sequential neoadjuvant treatment and radical surgery, was conducted in this single-institution study. The patterns of recurrence and duration of disease-free survival were analysed. RESULTS: Twenty-one patients (14 men, 7 women) presented with recurrence, of which 13, 7, and 1 patient(s) had received NACT, NACTRT, or both, respectively. Six patients who did not receive neoadjuvant radiotherapy received adjuvant RT. Among the 10 patients who had nodal recurrence after RT (either neoadjuvant or adjuvant), 6 and 4 patients had in-field and out-of-field nodal recurrences, respectively-the latter were equally distributed within 5 cm and outside 5 cm of the PTV margin. CONCLUSION: Among the patients who presented with recurrence, more than half had not received neoadjuvant RT (treated in the 'pre-CROSS era' or due to long-segment disease), reasserting the therapeutic superiority of NACTRT. Increased regularity of recurrences in the draining nodal region was not noted in this study, but large-scale, prospective, randomised head-to-head comparative trials to determine optimal nodal irradiation in carcinoma oesophagus are required.

Effects of radiotherapy on olfaction and nasal function in head and neck cancer patients.

PURPOSE: Radiotherapy (RT) is a major component of treatment in head and neck malignancies and often the radiation field includes the nasal cavity and olfactory cleft region. We aimed to assess olfaction, mucociliary clearance time and quality of life (QOL) before RT and during the course of radiotherapy. METHODS: This prospective, observational, cohort study was conducted over a period of 1 year. The olfactory function, mucociliary clearance and QOL of patients with primary head and neck cancers undergoing radiation therapy as part of treatment were assessed prior to radiotherapy and followed up serially up to 3 months after radiotherapy. A total of 21 patients were enrolled. Assessment was done using noninvasive tests for better compliance and ease of examination. RESULTS: Among the 21 patients recruited, 18 completed radiotherapy and 13 were assessed 3 months post radiotherapy. Mean olfactory scores (including olfactory threshold and odor identification), using Connecticut Chemosensory Clinical Research Center (CCCRC) test, deteriorated significantly at the end of radiotherapy (p < 0.001) as compared to scores before irradiation. Subjective assessment of olfaction by Appetite, Hunger and Sensory perception (AHSP) questionnaire did not demonstrate significant impairment in nasal function (p < 0.319) although overall QOL significantly deteriorated (p 0.004). The mucociliary clearance time was prolonged in 72% of the patients at the end of radiotherapy. CONCLUSION: Deterioration in olfactory function was found to occur during the course of radiotherapy with gradual improvement after 3 months. However, patients did not notice olfactory dysfunction subjectively. Mucociliary dysfunction persisted even after 3 months following radiation.

A Randomized Phase 2 Study of ADXS11-001 Listeria monocytogenes-Listeriolysin O Immunotherapy With or Without Cisplatin in Treatment of Advanced Cervical Cancer.

OBJECTIVES: A global unmet medical need exists for effective treatments for persistent, recurrent, or metastatic cervical cancer, as patients have a short life expectancy. Recently, immunotherapies have shown promising survival benefits for patients with advanced forms of cancer. Axalimogene filolisbac (ADXS11-001), a Listeria monocytogenes immunotherapy with a broad effect on the immune system, is under investigation for treatment of human papillomavirus-associated cancers including cervical cancer. METHODS: This phase 2 study evaluated the safety and efficacy of ADXS11-001, administered with or without cisplatin, in patients with recurrent/refractory cervical cancer following prior chemotherapy and/or radiotherapy. A total of 109 patients were treated, and 69 were evaluable for tumor response at equal to or more than 3 months postbaseline. RESULTS: Median overall survival (OS) was comparable between treatment groups (ADXS11-001: 8.28 months; 95% confidence interval [CI], 5.85-10.5 months; ADXS11-001 + cisplatin: 8.78 months; 95% CI, 7.4-13.3 months). The 12- and 18-month milestone OS rates were 30.9% versus 38.9%, and 23.6% versus 25.9% for each group, respectively (34.9% and 24.8% combined). Median progression-free survival (6.10 vs 6.08 months) and the overall response rate (17.1% vs 14.7%) were similar for both groups. ADXS11-001 was generally well tolerated; adverse events were predominantly mild to moderate in severity and not related to treatment. More adverse events were reported in the combination group (429 vs 275). CONCLUSIONS: These promising safety and efficacy results, including the encouraging 12-month 34.9% combined OS rate, warrant further investigation of ADXS11-001 for treatment of recurrent/refractory cervical cancer.

Role of Functional Magnetic Resonance Imaging Derived Parameters as Imaging Biomarkers and Correlation with Clinicopathological Features in Carcinoma of Uterine Cervix.

INTRODUCTION: Magnetic Resonance Imaging (MRI) is emerging as a powerful tool in the evaluation and management of cervical cancer. The role of Diffusion Weighted Imaging (DWI) with Apparent Diffusion Coefficient (ADC) as a non-invasive imaging biomarker is promising in characterization of the tumour and prediction of response. AIM: The aim of this study was to evaluate the role of conventional MRI and diffusion weighted MRI in predicting clinicopathological prognostic factors. MATERIALS AND METHODS: This was a retrospective study. The data of 100 cervical cancer patients who had MRI with DWI was retrieved from the database and analysed. Clinico pathological details were collected from the computerized hospital information system. SPSS version 15.0 was used for statistical analysis. RESULTS: The mean tumour dimensions on MRI in x, y and z axes were 43.04 mm (±13.93, range: 17-85), 37.05mm (±11.83, range: 9-80) and 39.63 mm (±14.81, range: 14 -76). The mean T2W MRI based tumour volume (TV) was 48.18 (±34.3, range: 7-206) and on DWI images was 36.68(±33.72, range: 2.5-200). The mean ADC value in patients with squamous cell carcinoma was 0.694 (±0.125, n=88), adenocarcinoma was 0.989 (±0.309, n=6), adenosquamous was 0.894 (±0.324, n=4). There was statistical significant difference in mean ADC between squamous vs. non squamous histology (p = 0.02). The mean ADC values of well differentiated, moderately differentiated, and poorly differentiated tumours were 0.841(±0.227, n= 26), 0.729 (±0.125, n=28), 0.648 (±0.099, n=46) respectively. There was significant statistical difference of mean ADC between well differentiated, moderately differentiated (p=0.020) and poorly differentiated tumours (p=0.0001). Difference between the mean ADC values between the node positive and node negative disease was statistically significant (p=0.0001). There was no correlation between the tumour volumes on T2W and DWI images and ADC values. Sixteen patients had residual/recurrent disease at a median follow up of 12 months (range: 3-59 months). The mean ADC values in this group was 0.71 (n=16) and was not significantly different from the disease free group (mean ADC =0.72, n=74). CONCLUSION: Higher ADC values are associated with favourable histology and differentiation. Adenocarcinomas have higher ADC values followed by adenosquamous followed by squamous cell carcinomas. Well differentiated tumours had higher ADC values than moderately followed by poorly differentiated tumours. DWI with ADC have a potential role as an imaging biomarker for prognostication and needs further studies for routine clinical applications.

Treatment of Advanced Carcinoma of the Larynx and Hypopharynx with Laser Followed by External Radiotherapy.

INTRODUCTION: Radical laryngeal surgeries for extensive laryngeal and hypopharyngeal tumors often require a permanent tracheostomy, which has an immense impact on the quality of life of patients. A minimally invasive technique such as transoral laser microresection (TLM) followed by radiotherapy can preserve the functions of the voice and swallowing. The aim of this study is to evaluate the role of laser debulking in the treatment of carcinoma of the larynx and hypopharynx, to evaluate the response of the tumor to subsequent radiotherapy, and also to assess the usefulness of laser in avoiding tracheostomy and functional preservation of the voice and swallowing. MATERIALS AND METHODS: This prospective cohort study included patients with carcinoma of the larynx and hypopharynx unwilling to have definitive surgery and those medically unfit for radical surgery. The clinical profile of patients at presentation, tumor status following laser debulking, immediately after radiotherapy (RT), 6 weeks post RT, 3 months post RT, and at the end of study; short term complications associated with laser surgery; and usefulness of laser in avoiding tracheostomy and in functional preservation of the voice were evaluated. RESULTS: There were 18 (90%) male patients and 2 (10%) female patients. Age ranged from 24 to 78 years with a mean age of 55. Hoarseness of voice was the most frequent presenting complaint (90%) followed by progressive dysphagia (45%), odynophagia (40%), otalgia (40%), and dyspnoea (25%). 11 (55%) patients had T3 tumors, while 6 (30%) were T2, and 3 (15%) were T4 lesions. 65% of patients were free of lymph node metastasis at presentation. 2 (10%) had N1 and 5 (25%) had N2 nodes. At presentation 10 (50%) patients had Stage III disease and 6 (30%) had stage IV disease. 13 patients (65%) had moderately differentiated squamous cell carcinoma. None of the risk factors and co-morbid illnesses showed any statistically significant difference among the tumor sites. Apart from the 2 (10%) patients who had residual disease, 2 (10%) patients developed a recurrent tumor in the course of their follow up. None had neck recurrence. Two patients underwent tracheostomy, before laser surgery, for compromised airway and both had recurrence of their tumor and continued to be on tracheostomy. CONCLUSION: Laser debulking followed by radiotherapy is a viable alternative in the management of malignancies of the larynx and hypopharynx for those who refuse radical surgery and for those patients in whom radical open surgery is impractical due to physiological reasons such as advanced age and poor pulmonary reserve.

Is the Deep Inspiration Breath-Hold Technique Superior to the Free Breathing Technique in Cardiac and Lung Sparing while Treating both Left-Sided Post-Mastectomy Chest Wall and Supraclavicular Regions?

AIMS: To evaluate the efficacy of the deep inspirational breath-hold (DIBH) technique and its dosimetric advantages over the free breathing (FB) technique in cardiac (heart and left anterior descending artery [LAD]) and ipsilateral lung sparing in left-sided post-mastectomy field-in-field conformal radiotherapy. DIBH is highly reproducible, and this study aims to find out its dosimetric benefits over FB. MATERIALS AND METHODS: Nineteen left-sided mastectomy patients were immobilized using breast boards with both arms positioned above the head. All patients had 2 sets of planning CT images (one in FB and another in DIBH) with a Biograph TruePoint HD CT scanner in the same setup. DIBH was performed by tracking the respiratory cycles using a Varian Real-Time Position Management system. The target (chest wall and supraclavicular region), organs at risk (OARs; ipsilateral lung, contralateral lung, heart, LAD, and contralateral breast), and other organs of interests were delineated as per the RTOG (Radiation Therapy Oncology Group) contouring guidelines. The single-isocenter conformal fields in the field treatment plans were generated with the Eclipse Treatment Planning System (Varian Medical Systems) for both FB and DIBH images, and the doses to the target and OARs were compared. The standard fractionation regimen of 50 Gy in 25 fractions over a period of 5 weeks was used for all patients in this study. RESULTS AND DISCUSSION: The target coverage parameters (V95, V105, V107, and D_mean) were found to be 97.8 ± 0.9, 6.1 ± 3.4, 0.2 ± 0.3, and 101.9 ± 0.5% in the FB plans and 98.1 ± 0.8, 6.1 ± 3.2, 0.2 ± 0.3, and 101.9 ± 0.4% in the DIBH plans, respectively. The plan quality indices (conformity index and homogeneity index) also showed 1.3 ± 0.2 and 0.1 for the FB plans and 1.2 ± 0.3 and 0.1 for the DIBH plans, respectively. There was a significant reduction in dose to the heart in the DIBH plans compared to the FB plans, with p values of nearly 0 for the V5, V10, V25, V30, and D_mean dosimetric parameters. The difference in ipsilateral lung doses between FB and DIBH showed statistically significant p values, and the differences in mean doses were found to be 7, 15.7, 11.8, and 10.7% for V5, V20, V30, and D_mean, respectively. There was a significant reduction in dose to the LAD in the DIBH compared to the FB plans. CONCLUSIONS: DIBH resulted in significant reductions in doses to the heart, LAD, and lungs, since with this technique there was an increase in the distance between the target and the OARs. With appropriate patient selection and adequate training, the DIBH technique is acceptable and achievable for radiotherapy to the chest, and therefore should be considered for all suitable patients, as this could result in fewer radiotherapy-related complications. However, this technique is time-consuming, since the setup is complex, results in an increased time for treatment delivery, and needs patient cooperation and technical expertise.

Outcome of radiotherapy for pituitary adenomas.

AIM: The aim of this study was to analyze the outcome and toxicities and its correlation to patient related and treatment related factors. BACKGROUND: Pituitary adenomas are treated by radiation therapy (RT) as one of the modalities along with surgery and medical therapy. RT to pituitary adenomas is a challenge due to adjacent dose limiting structures such as optic apparatus and hypothalamus. MATERIALS AND METHODS: Between January 2004 and December 2010, 94 patients treated for pituitary adenoma with RT who had hospital records of a minimum follow-up of 1 year were included in the analysis. Tests of correlation were done with regards to treatment factors. RESULTS: Male preponderance was noted in our patient population. Nonfunctioning and functioning tumors were equal in number in this series. Hypopituitarism was associated in 58.5% of patients prior to RT. Radiological tumor progression was seen in one patient (1/94) who had a nonfunctioning tumor. Among functioning tumors, biochemical remission was seen in 93.6% of patients at a median follow-up of 6 years. CONCLUSIONS: Visual complication was seen in 5.3% of patients and worsening or new onset hypopituitarism was seen in 6.4%. Conventional 3-field technique was associated with significantly more visual complication compared to Stereotactic Radiation Therapy (SRT) technique. Doses ≤50.4 Gy showed a trend of reduced rate of visual and endocrine complications with no compromise in efficacy.

Radiation dose measurements during kilovoltage-cone beam computed tomography imaging in radiotherapy.

OBJECTIVE: The use of image guidance during radiotherapy for accurate localization and setup has become the standard care of practice in radiotherapy. This mostly involves the use of kilovoltage-cone beam computed tomography (kV-CBCT) for verification of patient setup on the first few days and on a weekly basis. Some protocols require this to be performed daily and also before and after the treatment. Though the radiation due to this kV-CBCT is small, the repeated use could deliver a dose that could increase the probability of the stochastic effect. The main purpose of this work is to measure radiation dose during image guidance with kV-CBCT. MATERIALS AND METHODS: In this work, we have attempted to measure the dose during kV-CBCT for different sites both on a humanoid phantom and on patients undergoing image-guided radiotherapy with MOSFETs calibrated against an ion chamber. RESULTS: The dose measurement on patients during kV-CBCT resulted in mean doses of 0.19 and 0.3 cGy to the ipsilateral and contralateral eyes, 0.625 and 1.097 cGy to the surface of the ipsilateral and contralateral breasts, and 3.01 cGy to the surface of the pelvis. CONCLUSION: Radiation dose to the eye, breast, and the surface of the pelvis have been arrived at during CBCT. The doses measured on patients agreed closely with those measured on humanoid phantom and with published values.

Results of a Conservative Dose Plan Linear Accelerator-Based Stereotactic Radiosurgery for Pediatric Intracranial Arteriovenous Malformations.

OBJECTIVE: To evaluate the obliteration rate and clinical outcome following linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) for intracranial arteriovenous malformation (AVM) in pediatric patients (age ≤18 years). METHODS: Factors associated with the obliteration rate and neurologic complications were studied retrospectively in pediatric patients who underwent LINAC-based SRS for AVM between June 1995 and May 2014. RESULTS: The study cohort comprised 36 males and 33 females, with a median age at the time of SRS of 14 years (range, 7-18 years). The mean AVM volume was 8.5 ± 8.7 cc (range, 0.6-41.8 cc). The median marginal dose of radiation delivered was 15 Gy (range, 9-20 Gy). Magnetic resonance imaging (MRI) demonstrated complete obliteration of the AVM in 44 of the 69 patients (63.8%), at a mean follow up of 27.5 months (range, 12-90 months). On subgroup analysis, 41 of the 53 AVMs of ≤14 cc in volume (77.3%) were obliterated. AVMs with a modified AVM radiosurgery score <1 had significantly shorter obliteration times from the time of SRS (P = .006). On multivariate analysis, the mean marginal dose of radiation delivered to the AVM was the sole significant predictor of obliteration (odds ratio, 1.6; 95% confidence interval, 1 to 2.4). CONCLUSIONS: A modest median marginal dose of 15 Gy (16 Gy in the obliterated AVM group vs. 12 Gy in the nonobliterated group) resulted in an obliteration rate of 66.7% after LINAC-based SRS for intracranial AVM, with low rate.

Management of Locally Advanced Carcinoma Oesophagus with Radiation/Chemoradiation: Single Institute Experience.

PURPOSE: Oesophageal malignancy is the fourth commonest cancer which has a very poor outcome. In the management of oesophageal malignancy, radiation therapy is underutilized by many physicians due to feared complications though its role is well proven in literature. This study brings the role of radiation therapy in terms of loco-regional and distant relapse. This study characterizes demographic characteristics, treatment modality and the impact of these on recurrence-free survival of locally advanced carcinoma oesophagus. METHOD: In a retrospective analysis over a period of 24 months, 28 patients diagnosed to have locally advanced oesophageal malignancy were included. Neoadjuvant chemotherapy was carried out in 4 patients and concurrent chemoradiotherapy in 18 patients. Among the 28 patients, 7 patients who were operable and fit underwent surgery 6-8 weeks after completion of the planned neoadjuvant therapy. All patients received concurrent chemoradiation for a period of 5 weeks with platinum and/or taxane-based chemotherapy. RESULTS: With a median follow-up of 12 months, loco-regional recurrence and distant relapse were substantially less with 14 and 10 %, respectively. The Kaplan-Meier recurrence-free survival was 60 % at 24 months. All patients who had surgery as a part of the multimodality management were disease free at the last follow-up. CONCLUSION: In locally advanced oesophageal malignancy, radiation therapy plays an important role in downsizing the tumour for operability or can also be utilized as the sole modality of management.

Role of conventional and diffusion weighted MRI in predicting treatment response after low dose radiation and chemotherapy in locally advanced carcinoma cervix.

BACKGROUND AND PURPOSE: To assess the diagnostic performance of conventional and diffusion weighted (DWI) magnetic resonance imaging (MRI) in predicting response in locally advanced cervical cancer. MATERIALS AND METHODS: Total 24 patients with stage IIB-IIIB squamous cell carcinoma cervix were treated with initial two cycles of paclitaxel and carboplatin and concurrent low dose radiotherapy prior to standard chemoradiation. Response was assessed clinically and radiologically after 3 weeks of initial treatment. Volumetric and functional parameters derived from conventional and diffusion weighted MRI, due to treatment were measured. RESULTS: Significant reduction of GTV was noted in MRI (54 cm(3) vs. 11 cm(3), p < 0.01) and DWI (44 cm(3) vs. 6 cm(3), p < 0.01, ΔADC = 0.49 × 10(-3)mm(2)/sec, p < 0.01) after treatment. Tumor volume reduction rate (TVRR) in DWI was significantly higher in pathological good responders (p = 0.03). In this group both mean post treatment apparent diffusion coefficient (ADC) value and ΔADC were significantly higher (p = 0.01 and p = 0.03). ADC was a good predictor for pathological response (area under receiver operating characteristic curve (ROC) 0.814). CONCLUSION: TVRR (DWI) and ΔADC can be used as a predictor of early pathological response. Complete response based on DWI, could be a useful predictor of long term disease control.

Radiobiological Response of Cervical Cancer Cell Line in Low Dose Region: Evidence of Low Dose Hypersensitivity (HRS) and Induced Radioresistance (IRR).

BACKGROUND: Purpose of the present study was to examine the response of cervical cancer cell line (HeLa cell line) to low dose radiation using clonogenic assay and mathematical modeling of the low dose response by Joiner's induced repair model. MATERIALS AND METHODS: Survival of HeLa cells following exposure to single and fractionated low doses of γ (gamma)-ray, 6 MV, and 15 MV photon was measured by clonogenic assay. RESULTS: HeLa cell line demonstrated marked low dose response consisting of an area of HRS and IRR in the dose region of <1 Gy. The two gradients of the low dose region (αs and αr) were distinctly different with a transition dose (Dc) of 0.28-0.40 cGy. CONCLUSION: HeLa cell line demonstrates marked HRS and IRR with distinct transition dose. This may form the biological basis of the clinical study to investigate the chemo potentiating effect of low dose radiation in cervical cancer.

Feasibility and response of concurrent weekly docetaxel with radical radiotherapy in locally advanced head and neck squamous cell carcinoma.

OBJECTIVE: (1) To study the feasibility, adverse effects and response of concurrent weekly Docetaxel with radical radiotherapy in inoperable locally advanced head and neck squamous cell carcinoma. (2) To assess the compliance and tolerance of weekly Docetaxel with radiotherapy. MATERIAL AND METHODS: Twenty one patients with stage III and IV head and neck squamous cell carcinoma satisfying inclusion criteria were selected and treated with conventional external radiotherapy of 70Gy in 35 fractions with weekly concurrent Docetaxel (15mg/sqm), administered one hour before radiotherapy. Assessment of toxicities and evaluationof response was carried out. RESULTS: Majority of patients had stage IV diseaseand 17/21 (81%) received the planned radiotherapydose of 70Gy and ≥4 cycles of weekly chemotherapy. Duration of treatment ranged from 7.1to 11.2 weeks. The toxicities noted were Grade III mucositis in 57% and grade III skin reaction in 23%, grade III dysphagia in 38% and grade II weight loss in 23% of patients. Systemic toxicities associated with chemotherapy were minimal and there was no dose limiting toxicities. The overall locoregional response at first follow up was 85%, with complete response of 70% and partial response of 15%. CONCLUSION: Concurrent Docetaxel is a feasible and suitable alternate to Cisplatin and 5-Fluorouracil chemotherapy with good patient compliance. The late toxicities and survival need to be followed up.

End-of-life care perspectives of patients and health professionals in an Indian health-care setting.

AIM: This descriptive study set out to explore the end-of-life care perspectives both of patients with advanced carcinoma and of health-care professionals in a tertiary health-care setting in India. METHOD: A descriptive approach was undertaken to assess the end-of-life care perspectives from a sample of 140 patients and 40 health-care professionals. Data was collected through structured interviews with the patients and by self-administered questionnaire from the health-care professionals. RESULTS: There was a significant association in attitudes to artificial prolongation of life with age and religion. Patients placed a higher degree of importance on emotional, social, physical and spiritual dimensions of care compared to the health-care professionals. CONCLUSION: There is an urgent call for formulating an end-of-life care policy and advance directives for patients with terminal illness in India. Nurses and physicians should be proactive in offering key supportive services to ensure patient autonomy and facilitate good death.