Autodelineation of organ at risk in head and neck cancer radiotherapy using artificial intelligence.

Aim: The aim of this study is to check the practical feasibility of artificial intelligence for day-to-day operations and how it generalizes when the data have considerable interobserver variability. Background: Automated delineation of organ at risk (OAR) using a deep learning model is reasonably accurate. This will considerably reduce the medical professional time in manually contouring the OAR and also reduce the interobserver variation among radiation oncologists. It allows for quick radiation planning which helps in adaptive radiotherapy planning. Materials and Methods: Head and neck (HN) computed tomography (CT) scan data of 113 patients were used in this study. CT scan was done as per the institute protocol. Each patient had about 100-300 slices in Dicom format. A total number of 19,240 images were used as the data set. The OARs were delineated by the radiation oncologist in the contouring system. Of the 113 patient records, 13 records were kept aside as test dataset and the remaining 100 records were used for training the UNet 2D model. The study was performed on the spinal cord and left and right parotids as OARs on HN CT images. The model performance was quantified using the Dice similarity coefficient (DSC) score. Results: The trained model is used to predict three OARs, spinal cord and left and right parotids. The DSC score of 84% and above could be achieved using the UNet 2D Convolutional Neural Network. Conclusion: This study showed that the accuracy of predicted organs was within acceptable DSC scores, even when the underlying dataset has significant interobserver variability.

Evolution of Cancer Care in Karnataka.

Cancer care in Karnataka started in the nineteenth century with the foundation stone of Victoria Hospital in Bangalore. After that the regional cancer center Kidwai in Bangalore and now almost 44 AERB-approved Radiotherapy centers available all over Karnataka. Karnataka, especially Bangalore, have all the high-end cutting-edge technology for cancer care from robotic surgery, Tomotherapy, and CyberKnife Radiosurgery. With initiatives from the government, in all the medical colleges and private hospitals, poor patients are getting higher-end cancer treatment for free under the Ayushman Bharath scheme. We wish cancer care in Karnataka sees more and more new technologies and treatment to conquer the disease, which human battling for centuries.

Regional collaboration to improve quality of radiation therapy in Asia.

In Asia, several challenges hinder the delivery of high-quality cancer treatment, especially radiation therapy (RT). Many Asian countries face large-scale shortage of RT centres and treatment machines. Additionally, there is also a significant technological gap, with many RT centres in Asia still using outdated technology. There is an urgent need to improve radiation treatment quality in Asia. The Federation of Asian Organizations for Radiation Oncology (FARO) was set up to foster regional collaboration, which we believe can help to identify and solve some of these issues collectively. This report describes the background and rationale of starting FARO, and puts forth some of the early achievements of the group, including fact-finding and educational activities. Finally, we discuss future possibilities, including strategic proposals that may benefit the RT community and our patients in Asia.

Assessing radiation oncology research needs in India: Results of a physician survey.

BACKGROUND: In India, where the annual incidence of cancer is projected to reach 1.7 million by 2020, the need for clinical research to establish the most effective, resource-guided, and evidence-based care is paramount. In this study, we sought to better understand the research training needs of radiation oncologists in India. METHODS: A 12 item questionnaire was developed to assess research training needs and was distributed at the research methods course jointly organized by Indian College of Radiation Oncology, the American Brachytherapy Society, and Education Committee of the American Society of Therapeutic Radiation Oncology during the Indian Cancer Congress, 2017. RESULTS: Of 100 participants who received the questionnaire, 63% responded. Ninety percent (56/63) were Radiation Oncologists. Forty-two percent (26/63) of respondents had previously conducted research. A longer length of practice (>10 years) was significantly associated with conducting research (odds ratio (OR) 6.99, P = 0.031) and having formal research training trended toward significance (OR 3.03, P = 0.058). The most common reason for not conducting research was "lack of training" (41%, 14/34). The most common types of research conducted were Audits and Retrospective studies (62%, 16/26), followed by a Phase I/II/III Trial (46%, 10/26). Having formal research training was a significant factor associated with writing a protocol (OR 5.53, P = 0.016). Limited training in research methods (54%, 13/24) and lack of mentorship (42%, 10/24) were cited as reasons for not developing a protocol. Ninety-seven percent (57/59) of respondents were interested in a didactic session on research, specifically focusing on biostatistics. CONCLUSIONS: With research training and mentorship, there is a greater likelihood that concepts and written protocols will translate into successfully completed studies in radiation therapy.

Effects of a Yoga Program on Mood States, Quality of Life, and Toxicity in Breast Cancer Patients Receiving Conventional Treatment: A Randomized Controlled Trial.

AIMS: The aim of this study is to compare the effects of yoga program with supportive therapy counseling on mood states, treatment-related symptoms, toxicity, and quality of life in Stage II and III breast cancer patients on conventional treatment. METHODS: Ninety-eight Stage II and III breast cancer patients underwent surgery followed by adjuvant radiotherapy (RT) or chemotherapy (CT) or both at a cancer center were randomly assigned to receive yoga (n = 45) and supportive therapy counseling (n = 53) over a 24-week period. Intervention consisted of 60-min yoga sessions, daily while the control group was imparted supportive therapy during their hospital visits. Assessments included state-trait anxiety inventory, Beck's depression inventory, symptom checklist, common toxicity criteria, and functional living index-cancer. Assessments were done at baseline, after surgery, before, during, and after RT and six cycles of CT. RESULTS: Both groups had similar baseline scores. There were 29 dropouts 12 (yoga) and 17 (controls) following surgery. Sixty-nine participants contributed data to the current analysis (33 in yoga, and 36 in controls). An ANCOVA, adjusting for baseline differences, showed a significant decrease for the yoga intervention as compared to the control group during RT (first result) and CT (second result), in (i) anxiety state by 4.72 and 7.7 points, (ii) depression by 5.74 and 7.25 points, (iii) treatment-related symptoms by 2.34 and 2.97 points, (iv) severity of symptoms by 6.43 and 8.83 points, (v) distress by 7.19 and 13.11 points, and (vi) and improved overall quality of life by 23.9 and 31.2 points as compared to controls. Toxicity was significantly less in the yoga group (P = 0.01) during CT. CONCLUSION: The results suggest a possible use for yoga as a psychotherapeutic intervention in breast cancer patients undergoing conventional treatment.

The nuances of brachytherapy taught by teachers from beyond: Questionnaire-based assessment of the first cadaveric hands-on brachytherapy workshop in India.

PURPOSE: A questionnaire-based assessment of a cohort of young radiation oncologists attending the first human cadaveric hands-on brachytherapy workshop in India. METHODS AND MATERIALS: The cadaveric workshop for hands-on training in head/neck and gynecologic cancers was a novel process conducted at M.S. Ramaiah Medical College and Hospital, for which 30 attendees from all regions of India took part with an opportunity to interact with experienced resource persons, individually perform the procedure, and indulge in all aspects of brachytherapy process. The questionnaire was part of the workshop and enquired on common practices for head/neck and gynecologic brachytherapy followed by the attendees at their hospitals and their opinion on avenues for learning the skill of brachytherapy and its future as a therapeutic modality. RESULTS: Twenty-seven of thirty attendees were practicing brachytherapy at their centers out of which only 14 (46%) were doing head/neck brachytherapy. In gynecologic procedures, 89% were performing only intracavitary brachytherapy. Twenty attendees (66%) felt lack of expertise was the primary reason for dwindling brachytherapy practice in India. Ten (33%) of them felt that advancements in external radiotherapy were the second major cause for it. Some less important reasons given were lack of suitable cases, fear of toxicity, and reduced remuneration. CONCLUSIONS: Cadaveric brachytherapy workshops may be a practical and cost-effective method to inculcate this unique skill set in the next generation of radiation oncologists. This questionnaire-based assessment has tried to validate this opinion.

Effects of an integrated Yoga Program on Self-reported Depression Scores in Breast Cancer Patients Undergoing Conventional Treatment: A Randomized Controlled Trial.

AIM: To compare the effects of yoga program with supportive therapy on self-reported symptoms of depression in breast cancer patients undergoing conventional treatment. PATIENTS AND METHODS: Ninety-eight breast cancer patients with stage II and III disease from a cancer center were randomly assigned to receive yoga (n = 45) and supportive therapy (n = 53) over a 24-week period during which they underwent surgery followed by adjuvant radiotherapy (RT) or chemotherapy (CT) or both. The study stoppage criteria was progressive disease rendering the patient bedridden or any physical musculoskeletal injury resulting from intervention or less than 60% attendance to yoga intervention. Subjects underwent yoga intervention for 60 min daily with control group undergoing supportive therapy during their hospital visits. Beck's Depression Inventory (BDI) and symptom checklist were assessed at baseline, after surgery, before, during, and after RT and six cycles of CT. We used analysis of covariance (intent-to-treat) to study the effects of intervention on depression scores and Pearson correlation analyses to evaluate the bivariate relationships. RESULTS: A total of 69 participants contributed data to the current analysis (yoga, n = 33, and controls, n = 36). There was 29% attrition in this study. The results suggest an overall decrease in self-reported depression with time in both the groups. There was a significant decrease in depression scores in the yoga group as compared to controls following surgery, RT, and CT (P < 0.01). There was a positive correlation (P < 0.001) between depression scores with symptom severity and distress during surgery, RT, and CT. CONCLUSION: The results suggest possible antidepressant effects with yoga intervention in breast cancer patients undergoing conventional treatment.

A brachytherapy plan evaluation tool for interstitial applications.

Radiobiological metrics such as tumor control probability (TCP) and normal tissue complication probability (NTCP) help in assessing the quality of brachytherapy plans. Application of such metrics in clinics as well as research is still inadequate. This study presents the implementation of two indigenously designed plan evaluation modules: Brachy_TCP and Brachy_NTCP. Evaluation tools were constructed to compute TCP and NTCP from dose volume histograms (DVHs) of any interstitial brachytherapy treatment plan. The computation module was employed to estimate probabilities of tumor control and normal tissue complications in ten cervical cancer patients based on biologically effective equivalent uniform dose (BEEUD). The tumor control and normal tissue morbidity were assessed with clinical followup and were scored. The acute toxicity was graded using common terminology criteria for adverse events (CTCAE) version 4.0. Outcome score was found to be correlated with the TCP/NTCP estimates. Thus, the predictive ability of the estimates was quantified with the clinical outcomes. Biologically effective equivalent uniform dose-based formalism was found to be effective in predicting the complexities and disease control.

Quantification of uncertainties in conventional plan evaluation methods in Intensity Modulated Radiation Therapy.

PURPOSE: In Intensity Modulated Radiation Therapy (IMRT) dose distributions tend to be more complex and heterogeneous because of the modulated fluences in each beamlet of every single beam. These dose-volume (DV) parameters derived from the dose volume histogram (DVH) are physical quantities, thought to correlate with the biological response of the tissues. The aim of this study was to quantify the uncertainty of physical dose metrics to predict clinical outcomes of radiotherapy. METHODS: The radiobiological estimates such as tumor control probability (TCP) and Normal Tissue Complication Probability (NTCP) were made for a cohort of 40 cancer patients (10 brain;19 head & neck;11 cervix) using the DV parameters. Statistical analysis was performed to determine the correlation of physical plan quality indicators with radiobiological estimates. RESULTS: The correlation between conformity index (CI) and TCP was found to be good and the dosimetric parameters for optic nerves, optic chiasm, brain stem, normal brain and parotids correlated well with the NTCP estimates. A follow up study (median duration 18 months) was also performed. There was no grade 3 or 4 normal tissue complications observed. Local tumor control was found to be higher in brain (90%) and pelvic cases (95%), whereas a decline of 70% was noted with head & neck cancer cases. CONCLUSIONS: The equivalent uniform dose (EUD) concept of radiobiological model used in the software determines TCP and NTCP values which can predict outcomes precisely using DV data in the voxel level. The uncertainty of using physical dose metrics for plan evaluation is quantified with the statistical analysis. Radiobiological evaluation is helpful in ranking the rival treatment plans also.

Treatment planning methods in high dose rate interstitial brachytherapy of carcinoma cervix: a dosimetric and radiobiological analysis.

Treatment planning is a trial and error process that determines optimal dwell times, dose distribution, and loading pattern for high dose rate brachytherapy. Planning systems offer a number of dose calculation methods to either normalize or optimize the radiation dose. Each method has its own characteristics for achieving therapeutic dose to mitigate cancer growth without harming contiguous normal tissues. Our aim is to propose the best suited method for planning interstitial brachytherapy. 40 cervical cancer patients were randomly selected and 5 planning methods were iterated. Graphical optimization was compared with implant geometry and dose point normalization/optimization techniques using dosimetrical and radiobiological plan quality indices retrospectively. Mean tumor control probability was similar in all the methods with no statistical significance. Mean normal tissue complication probability for bladder and rectum is 0.3252 and 0.3126 (P = 0.0001), respectively, in graphical optimized plans compared to other methods. There was no significant correlation found between Conformity Index and tumor control probability when the plans were ranked according to Pearson product moment method (r = -0.120). Graphical optimization can result in maximum sparing of normal tissues.

How common is hypothyroidism after external radiotherapy to neck in head and neck cancer patients?

PURPOSE: To identify the occurrence of clinical and subclinical hypothyroidism among head and neck cancer patients receiving radiation to the neck and to justify routine performing of thyroid function tests during follow-up. MATERIALS AND METHODS: This is a prospective nonrandomized study of 45 patients of head and neck cancer, receiving radiotherapy (RT). Thyroid stimulating hormone and T4 estimations were done at baseline and at 4 months and 9 months following RT. RESULTS: Of the 45 patients, 37(82.2 %) were males and eight (17.8 %) were females. All patients received radiation to the neck to a dose of >40Gy. 35.6% received concurrent chemotherapy. Two patients underwent prior neck dissection. Fourteen patients (31.1%) were found to have clinical hypothyroidism (P value of 0.01). Five (11.1%) patients were found to have subclinical hypothyroidism with a total 19 of 45 (42.2%) patients developing radiation-induced hypothyroidism. Nine of 14 patients with clinical hypothyroidism were in the age group of 51 to 60 years (P=0.0522). Five of 16 patients who received chemoradiation and nine of 29 who received RT alone developed clinical hypothyroidism. Above 40 Gy radiation dose was not a relevant risk factor for hypothyroidism. CONCLUSION: Hypothyroidism (clinical or subclinical) is an under-recognized morbidity of external radiation to the neck which is seen following a minimum dose of 40 Gy to neck. Recognizing hypothyroidism (clinical or subclinical) early and treating it prevents associated complications. Hence, thyroid function tests should be made routine during follow-up.

Role of palliative radiotherapy in brain metastases.

BACKGROUND: Brain metastases are a common manifestation of systemic cancer and exceed primary brain tumors in number and are a significant cause of neurologic problems. They affect 20-40% of all cancer patients. Aggressive management of brain metastases is effective in both symptom palliation and prolonging the life. Radiotherapy has a major role to play in the management of brain metastases. AIM: The aim of the study was to know the outcome of palliative radiotherapy in symptomatic brain metastases in terms of improvement in their performance status. MATERIALS AND METHODS: This is a retrospective study of 63 patients diagnosed to have brain metastases and treated with palliative whole brain radiotherapy to a dose of 30 Gy in 10 fractions over two weeks between June 1998 and June 2007. Diagnosis was done in most of the cases with computed tomography scan and in a few with magnetic resonance imaging. Improvement in presenting symptoms has been assessed in terms of improvement in their performance status by using the ECOG scale. RESULTS: Fifty-four patients completed the planned treatment. Eight patients received concurrent Temozolamide; 88% of patients had symptom relief at one month follow-up; 39/54 patients had a follow-up of just one to three months. Hence survival could not be assessed in this study. CONCLUSION: External beam radiotherapy in the dose of 30 Gy over two weeks achieved good palliation in terms improvement in their performance status in 88% of patients. Addition of concurrent and adjuvant Timozolamide may improve the results.