Comparative effectiveness of verbal instruction versus video-based education (VIVid) among family caregivers for improving the quality of life in advanced head and neck cancer patients receiving palliative care in Eastern India: a randomized controlled trial.

PURPOSE: To determine if video-based educational intervention compared to the standard verbal guidelines, provided to caregivers on home-based palliative care could enhance the quality of life (QoL) in advanced head and neck cancer (HNC) patients. METHODS: The study employed a prospective, two-arm parallel-group, randomized controlled trial design. Investigators prepared a real-world demonstrational video of ten minutes duration regarding home-based care for family caregivers, with voice-over in Odia language (Eastern India). The contents of the video addressed the management of common problems in palliative care among HNC patients. This study included 180 participants, 90 patient & caregiver dyads randomized to interventional (video-based education) or control (verbal instruction) groups. Patients' QoL was measured at baseline and 3 weeks follow-up using EORTC QLQ C30. Data were analyzed descriptively, and the Chi-square, Mann-Whitney U, T-test, spearman correlation, and multiple hierarchical regression analyses were employed for statistical analysis, with a significance level of p < 0.05. RESULTS: Seventy participant dyads completed the planned two assessments: baseline and at the end of 3rd week (Intervention = 37; Control = 33). The intervention group showed a significant improvement in the patient's health-related QoL, physical, emotional, and social functioning. Symptom burden reduction was observed for pain, nausea, and fatigue. A significant increase in the change in QoL with the video-based education group (VBE) compared to the verbal instruction (VI) group after adjusting for age, gender, physical functioning, and pain symptomology (adjusted R2 = 0.402) was noted. CONCLUSION: VBE intervention using smart-phone may offer caregivers a viable means of enhancing self-management while improving patients' QoL within the socio-cultural challenges for home-based palliative care in India. Further research on training caregivers using digital interventions and home-based visits is recommended. TRIAL REGISTRATION NUMBER: CTRI/2021/06/034473 [Registered on: 30/06/2021].

Efficient and Reliable Data Extraction in Radiation Oncology using Python Programming Language: A Pilot Study.

Background and Purpose: In recent years, data science approaches have entered health-care systems such as radiology, pathology, and radiation oncology. In our pilot study, we developed an automated data mining approach to extract data from a treatment planning system (TPS) with high speed, maximum accuracy, and little human interaction. We compared the amount of time required for manual data extraction versus the automated data mining technique. Materials and Methods: A Python programming script was created to extract specified parameters and features pertaining to patients and treatment (a total of 25 features) from TPS. We successfully implemented automation in data mining, utilizing the application programming interface environment provided by the external beam radiation therapy equipment provider for the whole group of patients who were accepted for treatment. Results: This in-house Python-based script extracted selected features for 427 patients in 0.28 ± 0.03 min with 100% accuracy at an astonishing rate of 0.04 s/plan. Comparatively, manual extraction of 25 parameters took an average of 4.5 ± 0.33 min/plan, along with associated transcriptional and transpositional errors and missing data information. This new approach turned out to be 6850 times faster than the conventional approach. Manual feature extraction time increased by a factor of nearly 2.5 if we doubled the number of features extracted, whereas for the Python script, it increased by a factor of just 1.15. Conclusion: We conclude that our in-house developed Python script can extract plan data from TPS at a far higher speed (>6000 times) and with the best possible accuracy compared to manual data extraction.

Calculation of set-up margin in frameless stereotactic radiotherapy accounting for translational and rotational patient positing error.

Context: Rotation corrected set-up margins in stereotactic radiotherapy (SRT). Aims: This study aimed to calculate the rotational positional error corrected set-up margin in frameless SRT. Settings and Design: 6D setup errors for the steriotactic radiotherapy patients were converted to 3D translational only error mathematically. Setup margins were calculated with and without considering the rotational error and compared. Materials and Methods: A total of 79 patients of SRT each received >1 fraction (3-6 fractions) incorporated in this study. Two cone-beam computed tomography (CBCT) scans were acquired for each session of treatment, before and after the robotic couch-aided patient position correction using a CBCT. The postpositional correction set-up margin was calculated using the van Herk formula. Further, a planning target volume_R (PTV_R) (with rotational correction) and PTV_NR (without rotational correction) were calculated by applying the rotation corrected and uncorrected set-up margins on the gross tumor volumes (GTVs). Statistical Analysis Used: General. Results: A total of 380 sessions of pre- (190) and post (190) table positional correction CBCT was analyzed. Posttable position correction mean positional error for lateral, longitudinal, and vertical translational and rotational shifts was (x)-0.01 ± 0.05 cm, (y)-0.02 ± 0.05 cm, (z) 0.00 ± 0.05 cm, and (θ) 0.04° ± 0.3°, (Φ) 0.1° ± 0.4°, (Ψ) 0.0° ± 0.4°, respectively. The GTV volumes show a range of 0.13 cc-39.56 cc, with a mean volume of 6.35 ± 8.65 cc. Rotational correction incorporated postpositional correction set-up margin the in lateral (x), longitudinal (y) and vertical (z) directions were 0.05 cm, 0.12 cm, and 0.1 cm, respectively. PTV_R ranges from 0.27 cc to 44.7 cc, with a mean volume of 7.7 ± 9.8 cc. PTV_NR ranges from 0.32 cc to 46.0 cc, with a mean volume of 8.1 ± 10.1 cc. Conclusions: The postcorrection linear set-up margin matches well with the conventional set-up margin of 1 mm. Beyond a GTV radius of 2 cm, the difference between PTV_NR and PTV_R is ≤2.5%, hence not significant.

Peer reviewers from low- and middle-income countries(LMIC) for open access journals in oncology can improve the equity in cancer research and clinical trials.

Open access journals (OAJ) in biomedicine are promoted to improve the reach and distribution of global health research (GHR). However, in the last 20 years, article publishing charge (APC) is attracting and publishing the vast majority of papers from high-income countries (HIC) in "oncology" journals under OAJ. This paper outlines the impediments for cancer research and publication from low-and middle-income countries (LMIC): (a) existing disparities in cancer care facilities and survival outcomes between HIC and LMIC, (b) more than 70 % of OAJ in 'oncology' subject levy APC, becoming unaffordable for scientists and clinicians from LMIC, (c) impactful OAJ in oncology engage less than 10 % of members from LMIC in editorial board or as peer reviewer, whereas two-third of cancer diagnosis and management occur in these countries. Peer review serves the editors by recommending the relevant papers. Thus, peer reviewers from developing countries working for the OAJs in "oncology" can increase the diversity in publication, improving the GHR in cancer management. The cancer research and clinical trials which can bring to notice the challenges and hurdles faced by researchers, clinicians and cancer patients in LMIC will be served to some measure by engaging peer reviewers from those countries who understand the ecosystem.

An audit of Grade III or more skin reactions in consecutively assessed patients at a modern radiation oncology center.

Purpose: Radiation dermatitis is most common and debilitating side effects of radiotherapy leading to treatment interruption, thereby compromising the local control, and effecting quality of life. With the invent of modern imaging and recent advances in megavoltage radiotherapy, radiation-related side effects have reduced. In this audit, we report the risk factors associated with Grade III dermatitis in modern centers. Materials and Methods: We analyzed 172 patients treated with volume modulated arc therapy (VMAT) and static field intensity-modulated radiotherapy (SFIMRT) at our center. All head and neck, breast, gynecological, GU malignancies, and sarcoma patients treated with a dose of >45 Gy from April 2018 to December 2019 were included in the study. On couch, treatment verification was done with cone-beam computer tomography (CBCT). Slice-by-slice verification of planning target volume (PTV) with CBCT was done in the first three fractions and weekly thereafter. Skin evaluation was done using CTCAE v. 5. Statistical analysis was done using SPSS v. 22. Results: Of the 172 patients treated with VMAT and SFIMRT, 15 patients (8.7%) had Grade III dermatitis. Grade III dermatitis was mostly seen in breast cancer followed by head-and-neck patients. More reactions were observed in patients with advanced stage disease. Treatment verification is important at the later course of treatment, especially in head-and-neck cases where the treatment volume is large and PTV may extend outside skin. Contributing factors of radiation dermatitis at modern radiotherapy center are gene mutation, use of concurrent chemoradiotherapy, and bolus. Conclusion: We hereby conclude that PTV mismatch in weekly treatment verification, genetic mutations, concurrent chemo-radiotherapy, use of thermoplastic mask, and bolus are the contributing factors for Grade III dermatitis in modern radiotherapy centers.

Challenges faced by female radiation oncologists (FRO) in South Asia.

AIM: This study was designed to evaluate the personal challenges, work environment, and financial satisfaction of female radiation oncologists (FRO) in South Asia. MATERIAL AND METHOD: A 28-point online survey was answered by 296 FRO from south Asia. The study comprised of seven sections: personal, professional, family, economic, workplace burnout, research/academic components, and challenges exclusive to being a working woman. RESULTS: The distribution of the participants was 73.4%, 14.8%, 7.9%, and 3.9% from India, Bangladesh, Nepal, and Pakistan, respectively. Age distribution was>50 y 12.1%, 30-50 y 61.1%, and<30 y 26.8%. Out of 296 respondents 206 (69.6%) and 176 (59.5%) were married and mothers respectively. 43.8% (77) of all mothers were denied maternity leave partially.45.9% (136) of all respondents and 68.7% (121) of all mothers found motherhood the principal obstacle to career growth. Total 60.1% encounter a gender bias in the department, and 34.8% reported they were either gained or lost a job/training because of their gender. 43.3%, 36.9%, 30.6%, and 25.5% of responders felt they could have done well in professional, financial, social, and academic perspectives, respectively, had they been of the opposite gender. 28.5%, 31%, and 16.4% FRO have income ½, equal and>1.5 times than their partners. 58.9% of FRO have a similar income to male colleagues in the city, and 43% of participants are financially satisfied. CONCLUSION: This study shows a fraction of FRO in south Asia faces a substantial gender disparity in the workplace. They are partially satisfied as a woman, as RO, as mother, and as lone-earner in the family. FROs need well deserved support for optimum delivery in their professional and personal lives.

Opioid: Plenitude versus pittance.

The opioid crisis in the USA and in other developed countries can potentially affect low- and middle-income countries (LMICs). The licit medical use of opioids has two sides. The USA and high-income countries maintain abundant supply for medical prescription. Between 1990 and 2010, the use of opioids for cancer pain relief was overtaken by a dramatic rise in the opioid prescriptions for non-cancer acute or chronic pain. The surge led to the opioid epidemic, recognized as social catastrophe in the USA, Canada and in some countries in Europe. From 2016, the medical community, health policy regulators and law-makers have taken actions to tackle this opioid crisis. On the other side, formulary deficiency and low opioid availability exists for three-fourths of the global population living in LMICs. Physicians and nurses in Asia and Africa engaged in cancer pain relief and palliative care face a constant paucity of opioids. Millions of patients in LMICs, suffering from life-modifying cancer pain, do not have access to morphine and other essential opioids, due to restrictive opioid policies. Attention will be needed to improve opioid availability in large parts of the world, even though the opioid crisis has led to control the licit medical use in the USA.

Ida Belle Scudder and Ketayun Ardeshir Dinshaw: The two iconic women who shaped the face of radiation oncology in India.

The early twentieth century India saw profound paucity in health care delivery and education, and the beliefs of people were ruled mainly by ignorance, superstitions and myths. Diseases like cancer and its treatment were totally unknown during that time in India. Dr Ida Belle Scudder, American woman, came to India to break all norms and sacrificed her entire life to work in a missionary hospital. Gradually she trained herself to treat cancer patients and established a fully equipped radiotherapy centre to treat such patients. Later, the field of radiation oncology was transformed and modernised by another influential woman, Dr Ketayun Ardeshir Dinshaw, who with her leadership attributes left no stone unturned to firmly establish the role of radiation in the management of cancer and bringing its benefits to the people of India.

A mathematical formulation for volume expansions in contouring for radiotherapy planning.

CONTEXT: This research describe the characteristic volume expansion of a moving target as a function of differential margins. AIM: We aimed to ascertain the volume change after giving margin for clinical and set up uncertainties including generating internal target volume (ITV) for moving target. MATERIALS AND METHODS: Settings and Design - Spheres of diameter (0.5-10 cm) with differential expansion of 1-15 mm were generated using a mathematical formula. Moving targets of radius 1-5 cm were generated, and the resultant volume envelopes with incremental motion from 1 to 20 mm were obtained. All relative volume change results were fitted with mathematical functions to obtain a generalized mathematical formula. STATISTICAL ANALYSIS USED: None. RESULTS: The percentage increase in volume (%ΔVp) was much more pronounced for smaller radius target. For moving target with relatively smaller radius, %ΔVp is predominant over the absolute volume change and vice versa in case of larger radius. Mathematical formulae were obtained for %ΔVp as a function of radius and expansion and for %ΔVp in ITV volume as a function of radius and tumor movement. CONCLUSIONS: This study provides an idea of volume change for various expansions for various size targets and/or moving target for different range of movements. It establishes a correlation of these volume changes with the changing target size and range of movements. Finally, a clinically useful mathematical formulation on volume expansion has been developed for rapid understanding of the consequence of volume expansion.

Collusion: The Facade and its Implications on Total Pain Management in Palliative Care.

Collusion is an unharmonious bond between the doctor and a patient or between patients and caregivers. This case report exemplifies one such experience and highlights the hurdles we face when dealing with collusion. A 31-year-old woman was diagnosed with rectal carcinoma during her pregnancy and underwent diversion colostomy (for intestinal obstruction) followed by neoadjuvant chemoradiation after delivery. Later, she was diagnosed with metastatic disease and was under palliative care. The family always had a negative association with cancer and chose to withhold information from the patient throughout the treatment trajectory. Collusion and lack of information can be a factor for persisting total pain. While caregivers desire to protect the patient from the distress of a life-limiting diagnosis, invariably it causes more anguish than comfort. Oncology professionals need to consider collusion as part of our sociocultural fabric and develop a strategy to negotiate and improve the care.

Metastatic colo-rectal cancer: real life experience from an Indian tertiary care center.

BACKGROUND: No data exist for the long-term outcome of metastatic colorectal cancer (mCRC) from the Southern part of Asia. The primary objective of the study is to evaluate the survival outcome of mCRC from an Indian tertiary care center. The study also aims to highlight the treatment pattern practiced and the unique clinico-pathologic characteristics. METHODS: This is a single-center retrospective observational study done at a large referral tertiary care center in North India. All patients with synchronous or metachronous mCRC who received at least one dose of chemotherapy for metastatic disease, registered between 2003 to 2017 were included. Primary outcome measures were overall survival and progression-free survival and prognostic factors of overall survival. Descriptive analysis was done for the clinicopathological characteristics and treatment patterns. Kaplan Meier method for overall survival and progression-free survival. Cox regression analysis was performed for the determination of the prognostic factors for overall survival. RESULT: Out of 377 eligible patients, 256 patients (68%) had de novo metastatic disease and the remaining 121 (32%) progressed to metastatic disease after initial treatment. The cohort was young (median age, 46 years) with the most common primary site being the rectum. A higher proportion of signet (9%) and mucinous histology (24%). The three common sites of metastasis were the liver, peritoneum, and lung. In the first line, most patients received oxaliplatin-based chemotherapy (70%). Only 12.5% of patients received biologicals in the first-line setting. The median follow-up and median overall survival of study cohort were 17 months and 18.5 months. The factors associated with poor outcome for overall survival on multivariate analysis were ECOG performance status of > 1, high CEA, low albumin, and the number of lines of chemotherapy received (< 2). CONCLUSION: The outcome of mCRC is inferior to the published literature. We found a relatively higher proportion of patients with the following characteristics; younger, rectum as primary tumor location, the signet, and mucinous histology, higher incidence of peritoneum involvement. The routine use of targeted therapies is limited. Government schemes (inclusion of targeted therapies in the Ayushman scheme), NGO assistance, and availability of generic low-cost targeted drugs may increase the availability.

Rotational positional error-corrected linear set-up margin calculation technique for lung stereotactic body radiotherapy in a dual imaging environment of 4-D cone beam CT and ExacTrac stereoscopic imaging.

OBJECTIVE: Accurate calculation of set-up margin is a prerequisite to arrive at the most optimal clinical to planning target volume margin. The aim of this study was to evaluate the compatibility of different on-board and in-room stereoscopic imaging modalities by calculating the set-up margins (SM) in stereotactic body radiotherapy technique accounting and unaccounting for rotational positional errors (PE). Further, we calculated separate SMs one based on residual positional errors and another based on residual + intrafraction positional errors from the imaging data obtained in a dual imaging environment. MATERIALS AND METHODS: A total of 22 lung cancer patients were included in this study. For primary image guidance, four-dimensional cone beam computed tomography (4-D CBCT) was used and stereoscopic ExacTrac was used as the auxiliary imaging. Following table position correction (TPC) based on the initial 4-D CBCT, another 4-D CBCT (post-TPC) and a pair of stereoscopic ExacTrac images were obtained. Further, during the treatment delivery, a series of ExacTrac images were acquired to identify the intrafraction PE. If a, b and c were the observed translational shifts in lateral (x-axis), longitudinal (y-axis) and vertical direction (z-axis) and α, ß and γ were the rotational shifts in radians about the same axes, respectively, then the resultant translational vectors (A, B and C) were calculated on the basis of translational and rotational values. Set-up margins were calculated using residual errors post-TPC only and also using intrafraction positional errors in addition to the residual errors. RESULTS: Residual and residual + intrafraction SM were calculated from a dataset of 82 CBCTs and 189 ExacTrac imaging sessions. CBCT-based mean ± SD shifts in translational and rotational directions were 0.3 ± 1.8 mm, 0.1 ± 1.8 mm, - 0.4 ± 1.6 mm, 0.1 ± 0.4°, 0.0 ± 1.0° and 0.3 ± 0.7°, respectively, and for ExacTrac - 0.1 ± 1.8 mm, 0.2 ± 2.4 mm, - 0.6 ± 1.8 mm, 0.1 ± 1.2°, - 0.2 ± 1.3° and - 0.1 ± 0.6°, respectively. Residual SM without considering the rotational correction in x, y and z directions were 5.0 mm, 4.5 mm and 4.4 mm; rotation-corrected SM were 4.4 mm, 4.0 mm and 5.5 mm, respectively. Residual plus intrafraction SM were 5.5 mm, 6.6 mm and 6.2 mm without considering the rotational corrections, whereas they were 5.0 mm, 6.3 mm and 6.2 mm with rotational errors accounted for. CONCLUSION: Accurate calculation of set-up margin is required to find the clinical to planning target volume margin. Primary and auxiliary imaging margins fall in the range of 4.0 to 5.5 mm and 5.0 to 7.0 mm, respectively, indicating a higher SM for X-ray-based planar imaging techniques over three-dimensional cone beam images. This study established the degree of mutual compatibility between two different kinds of widely used set-up imaging modalities, on-board CBCT and in-room stereoscopic imaging ExacTrac. It also describes the technique to calculate the residual and residual plus intrafraction SM and its variation in a dual imaging environment accounting for rotational PE in stereotactic body radiotherapy of lung.

Integrating psycho-oncology services in cancer care in India.

Psychological distress is often an under-diagnosed problem in cancer care. Addressing psychosocial issues would enhance treatment compliance, physician-patient relationship, treatment efficacy and quality of life. This article emphasizes the importance of integrating psycho-oncology services in cancer care and attempts to define the various roles that a psycho-oncologist can play across the entire trajectory. It also highlights the indispensable role played by the oncologists' referrals in maximizing the benefits of psycho-oncology services received by patients and their caregivers.

Lessons from narrative medicine: Cancer care will improve with narrative oncologyLessons from narrative medicine: Cancer care will improve with narrative oncology.

Narrative medicine (NM) is a new discipline in healthcare that helps the patients and physicians to tell and listen to the accounts of disease, illness, and suffering. In the last 20 years, NM has moved into the realms of biomedical education, research, and training. The complexity of cancer management can gain from the medical humanism of NM. A new model of cancer care called narrative oncology (NO) with NM-based skill sets of attention, representation, and affiliation can build narrative competence, therapeutic relationship, and clinical trust. The oncologists, patients, and their family caregivers, and the cancer care health system will create an inclusive and empathetic eco-system. This paper outlines the broad framework of NM, which becomes narrative oncology for cancer medicine. The clinicians, nurses, health workers, and scientists should learn and implement this new discipline alongside their biomedical activities.

Adjuvant radiation therapy for malignant tumours of the eyelid: Experience from a tertiary cancer centre in India.

Background: . Tumours of the eyelid are a rare subgroup of neoplasms with varied histology and inherent differences in clinical behaviour. Surgery is the standard of care, and adjuvant radiation therapy (RT) is given in the presence of features suggesting a high risk of local recurrence. The treatment of lymph nodes in the neck is debatable. We reviewed the utility of RT for lymph nodes in the neck in patients with malignant tumours of the eyelid. Methods: . We reviewed medical records of all patients with tumours of the eyelid treated at our centre from July 2006 to December 2014 for their demographic, clinical profile, treatment details and outcome. Results: . The records of 37 patients were included for analysis, of these 34 underwent surgery and 21 received adjuvant RT. Their median age was 60 (range 30-85) years. Sebaceous cell carcinoma was the most common (50.4%). The median disease-free survival (DFS) was 35 months (95% CI 17.9-52.0). The 1- and 3-year DFS were 82.7% and 45%, respectively. Univariate analysis showed a superior outcome with early stage (T1) tumours (p=0.01), RT dose of ≥60 Gy and those underwent lymph node dissection (p=0.03). The presence of high-risk factors including close or positive margin had an inferior outcome with a trend towards statistical significance (p=0.06). Conclusion: . We found a favourable outcome with early T stage, RT dose of ≥60 Gy and lymph node dissection. High-risk histopathological features including close margins and positive lymph nodes merit adjuvant RT including regional lymph nodes.

Standardization of volumetric modulated arc therapy-based frameless stereotactic technique using a multidimensional ensemble-aided knowledge-based planning.

PURPOSE: Aim of this article is to describe a new knowledge-based planning (KBP) methodology using volumetric modulated arc therapy (VMAT) for stereotactic radiosurgery (SRS) and radiotherapy (SRT) assisted by an ensemble mapping technique for use in a Monte Carlo planning system. METHODS: Libraries of 121 stereotactic patients were assembled on the basis of eight different parameters (a) tumor laterality, (b) whether planning target volume (PTV) dose coverage challenged by the presence of the organ at risk (OAR), (c) prescription dose and number of fractions, (d) number of PTVs, (e) tumor volume, (f) shortest distance between OAR and PTV (edge to edge distance, or EED), (g) center to center distance between OARs and PTV (CCD), and (h) lateral dimension of external contour (brain). For new patients, the most appropriate library plan was selected on the basis of the above categorization. A KBP plan was created based on this selected library plan with all parameters unchanged keeping the isocenter at the center of PTV. Using the same beam configuration, another independent treatment plan (IP) was generated by an experienced dosimetrist for comparison. IP and KBP were compared for 76 new patients. RESULTS: Of 197 patients (121 library and 76 new), 103 (52.3%) were placed in the OAR-challenged category and 94 were placed in the OAR unchallenged category. The ensemble mapping technique shows that, for an OAR-challenged patient, picking up the library plan is appropriate. IP was marginally better than KBP in PTV coverage and dose conformity (PCI). Library plans, IP, and KBP offer a mean PCI of 0.77 ± 0.2, 0.79 ± 0.2, and 0.78 ± 0.4, mean PTV-V99% of 97.3 ± 22.0%, 98.9 ± 14.1%, and 98.2 ± 13.2%, and mean MU of 2403.8 ± 2403.8, 2344.0 ± 2423.6, and 2473.6 ± 2296.8, respectively. Statistically significant differences were observed in the planning time between the IP and KBP plans for both OAR-challenged (P < 0.001) and -unchallenged (P < 0.002) categories. Comparison of optimization and dose calculation time showed a much lower average planning time of 111.0 ± 84.1 min for KBP as against 248.2 ± 96.6 min for IP. CONCLUSION: Validation results for KBP plans indicate the multidimensional ensemble mapping mechanism can accurately pick up the most appropriate library plan. KBP plans, although slightly inferior in their dosimetric quality, fulfill all the required clinical conditions and dose constraints. KBP plans save considerable planning time and are nearly independent of the skill and knowledge of the treatment planner. KBP works well with a Monte Carlo planning system like Monaco.

Primary CNS Lymphoma in India: A 17-Year Experience From the All India Institute of Medical Sciences.

PURPOSE: The information about the outcome of primary CNS lymphoma (PCNSL) in India is scarce, because there is no population-based or large hospital-based data. MATERIALS AND METHODS: This is a retrospective study that spanned 17 years (2001 to 2017) to study the outcome of PCNSL at the All India Institute of Medical Sciences (AIIMS), which is a tertiary care center in Northern India. RESULTS: Only one of 99 patients was positive for HIV serology. Diffuse large B-cell lymphoma was the most common histology (97.7%). The median patient age was 50 years (range, 13 to 70 years), and the ratio of men to women was 1.9. The median duration of symptoms before diagnosis was 3.5 months (range, 0.5 to 48 months), and 58.5% had a performance status (PS) of 3 or more. Multiple intracranial lesions were present in 81.8% of patients. Surgical resection was performed in 45%, and approximately 22% of patients were ineligible for treatment. Most patients (n = 73) were treated with high-dose methotrexate (HDMTX)-based regimens (ie, methotrexate, vincristine, and procarbazine with or without rituximab). Pharmacokinetic monitoring of methotrexate was not available at our center. HDMTX-related mortality was 3.9%. The median follow-up duration, event-free survival (EFS), and overall survival (OS) were 34 months, 20.4 months, and 31.7 months, respectively. Addition of rituximab (n = 27) to MVP resulted in a higher objective response rate (88.9% v 73.9% without rituximab; P = .12), complete remission (81.5% v 56.5%; P = .03), 2-year EFS (57.3% v 40.4%; P = .02), and 2-year OS (61.6% v 53.4%; P = .056). CONCLUSION: This is the largest study of PCNSL from India. The patients were immunocompetent and young but presented with a high-burden disease that precluded treatment in approximately 22%. The treatment with HDMTX appears safe without pharmacokinetic monitoring. The outcome is comparable to those observed in the West, and rituximab use showed additional benefit. There are notable barriers with respect to management of PCNSL in the real world, and efforts are required to improve the outcome more.

Locally advanced cervical cancer - neoadjuvant chemotherapy followed by concurrent chemoradiation and targeted therapy as maintenance: A phase II study.

AIM: The survival in locally advanced cervical cancer remains low. We evaluated the role of neoadjuvant chemotherapy (NACT), chemoradiotherapy (CRT), followed by gefitinib maintenance in locally advanced cervical cancer. MATERIALS AND METHODS: Twenty-five patients with locally advanced carcinoma cervix were enrolled between July 2012 and May 2013. Patients received 6 weekly doses of NACT Paclitaxel (60 mg/m2) and carboplatin (AUC 2), followed by CRT and brachytherapy. The analysis of epidermal growth factor receptor (EGFR) expression was carried out by immunohistochemistry. Gefitinib (250 mg daily) was given as maintenance therapy for 1 year after completion of chemoradiation. Comparison of EGFR expression and survival outcomes was done. RESULTS: Twenty-four of 25 patients completed the neoadjuvant chemotherapy and concurrent chemoradiotherapy. Post-CRT, all patients were started on gefitinib maintenance, and twenty patients completed the intended 1 year of gefitinib maintenance. Nineteen (76%) patients had a radiological complete response to NACT. EGFR was moderately or strongly expressed in 86.3% of the patients. The 3-year overall survival was 69.8%, and 3-year progression-free survival was 51.4%. Expression of EGFR was not found to be a significant factor affecting overall survival or progression-free survival. CONCLUSIONS: Weekly neoadjuvant chemotherapy is associated with a good response rate in locally advanced cervical cancer. Neoadjuvant chemotherapy, chemoradiation, followed by gefitinib maintenance gives good survival outcome in patients with locally advanced cervical cancer.

4π Radiotherapy Using a Linear Accelerator: A Misnomer in Violation of the Solid Geometric Boundary Conditions in Three-Dimensional Euclidean Space.

PURPOSE: The concept of 4πc radiotherapy is a radiotherapy planning technique receiving much attention in recent times. The aim of this article is to disprove the feasibility of the 4π radiotherapy using a cantilever-type linear accelerator or any other external-beam delivery machines. MATERIALS AND METHODS: A surface integral-based mathematical derivation for the maximum achievable solid angle for a linear accelerator was carried out respecting the rotational boundary conditions for gantry and couch in three-dimensional Euclidean space. The allowed movements include a gantry rotation of 0-2πc and a table rotation of . RESULTS: Total achievable solid angle by cantilever-type linear accelerator (or any teletherapy machine employing a cantilever design) is , which is applicable only for the foot and brain radiotherapy where the allowed table rotation is 90°-0°-270°. For other sites such as pelvis, thorax, or abdomen, achievable solid angle as the couch rotation comes down significantly. Practically, only suitable couch angle is 0° by avoiding gantry-couch-patient collision. CONCLUSIONS: Present cantilever design of linear accelerator prevents achieving a 4π radian solid angle at any point in the patient. Even the most modern therapy machines like CyberKnife which has a robotic arm also cannot achieve 4π geometry. Maximum achievable solid angle under the highest allowable boundary condition(s) cannot exceed 2πc, which is restricted for only extremities such as foot and brain radiotherapy. For other parts of the body such as pelvis, thorax, and abdomen, the solid angle is reduced to 1/5th (maximum value) of the 4πc. To obtain a 4πc solid angle in a three-dimensional Euclidean space, the patient has to be a zero-dimensional point and X-ray head of the linear accelerator has a freedom to rotate in every point of a hypothetical sphere of radius 1 m. This article establishes geometrically why it is not possible to achieve a 4πc solid angle.