A comparative study in left-sided breast cancer treated with moderate deep inspiratory breath hold versus free breathing.

BACKGROUND: The moderate deep inspiratory breath hold (mDIBH) is a modality famed for cardiac sparing. Prospective studies based on this are few from the eastern part of the world and India. We intend to compare the dosimetry between mDIBH and free-breathing (FB) plans. METHODS: Thirty-two locally advanced left breast cancer patients were taken up for the study. All patients received a dose of 50 Gy in 25 fractions to the chest wall/intact breast, followed by a 10-Gy boost to the lumpectomy cavity in the case of breast conservation surgery. All the patients were treated in mDIBH using active breath coordinator (ABC). The data from the two dose volume histograms were compared regarding plan quality and the doses received by the organs at risk. Paired t-test was used for data analysis. RESULTS: The dose received by the heart in terms of V5, V10, and V30 (4.55% vs 8.39%) and mean dose (4.73 Gy vs 6.74 Gy) were statistically significant in the ABC group than that in the FB group (all p-values < 0.001). Also, the dose received by the LADA in terms of V30 (19.32% vs 24.87%) and mean dose (32.99 Gy vs 46.65 Gy) were significantly less in the ABC group. The mean treatment time for the ABC group was 20 min, while that for the free-breathing group was 10 min. CONCLUSIONS: Incorporating ABC-mDIBH for left-sided breast cancer radiotherapy significantly reduces the doses received by the heart, LADA, and left and right lung, with no compromise in plan quality but with an increase in treatment time.

PD-L1 Expression in Colorectal Carcinoma Correlates with the Immune Microenvironment.

INTRODUCTION/BACKGROUND: Colorectal carcinoma (CRC) is a common malignancy, with its diverse clinical, pathological, and molecular features. The immune microenvironment of a tumor comprises of interplay between various cells and molecules, and has a significant role in deciding the tumor behavior and overall prognosis. PD-L1 (programmed cell death ligand-1) has been implicated in the regulation of the tumor immune microenvironment (TIME). There is limited data regarding the correlation of PD-L1 expression with immune cell profile in CRCs, especially in the Indian setting. The study aimed to assess the PD-L1 expression in CRC tumor cells and its association with TIME, mismatch repair (MMR), and various other clinicopathological parameters. METHODS: This is a hospital-based, cross-sectional observational study. PD-L1 expression was assessed at the protein level by immunohistochemistry and mRNA level by qRT-PCR. Immune cell markers (CD4, CD8, CD20, FOXP3, and CD163) were interpreted using the ImageJ Fiji platform. RESULTS: Of the 104 cases, 21% were PD-L1 positive and were more common in right-sided CRCs. PD-L1 positive cases showed significantly higher concentrations of all T-cell subsets (CD4+ , CD8+ , and FOXP3+), CD20+ B-cells, and CD163+ macrophages were noted. No statistical significance was seen between PD-L1 expression with clinical profile, pathological subtype, grade or stage, mismatch repair status (proficient vs deficient), and survival. CONCLUSIONS: The present study showed a relatively lower frequency of PD-L1 in CRC from the Eastern Indian cohort. The immune cell concentration in the present study was calculated using image analysis-based objectivised methods. Significant correlation of PD-L1 expression in tumor cells with the tumor-infiltrating immune cells indicated its crucial role in the pathobiology of CRC especially by regulating the TIME. Considering the therapeutic implication of PD-L1 in various malignancies, it may be one of the crucial therapeutic targets in a proportion of cases.

Role of Cyclin-Dependent Kinase 4/6 in Metastatic Breast Cancer: Real-World Data From a Tertiary Care Institute in Eastern India.

Introduction CDK4/6 inhibitors currently approved for patients with hormone-receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer include palbociclib, ribociclib, and abemaciclib. This study aims to report on the treatment outcomes and real-world data regarding the use of CDK4/6 inhibitors in the treatment of ER+/HER2- metastatic breast cancer at a tertiary care institute in Eastern India. Materials and methods The present study is a retrospective analysis of data from patients with metastatic HR+/HER2- breast cancer who were treated with CDK4/6 inhibitors at a tertiary care institute in Eastern India between 2015 and 2022. The data were collected from online records in the departmental files and analyzed for the primary baseline characteristics of the patients, tumors, and response rates, including partial response (PR), complete response (CR), progressive disease (PD), and stable disease (SD), as defined by the Response Evaluation Criteria in Solid Tumors (RECIST) criteria version 1.1. The treatment administered, progression-free survival (PFS), and toxicity were also evaluated. Results From 2015 to 2022, 24 eligible patients were treated with CDK4/6 inhibitors for metastatic HR+/HER2- breast cancer. The average duration of follow-up was 25 months. Out of the 24 patients, 15 (62.5%) were taking Tab. ribociclib, six (25%) were taking Tab. palbociclib, and three (12.5%) were taking Tab. abemaciclib. CDK4/6 was used as a first-line therapy for 16 patients, while eight patients received it as a second-line treatment. Out of the total number of patients, six (25%) had stable disease, 13 (54.2%) had a partial response, and four (16.7%) had progressive disease. In total, of the eligible patients, five (20.8%) had grade I neutropenia, seven (29.2%) had grade II neutropenia, and four (16.7%) had grade III neutropenia. At five years, the PFS rate estimated by the Kaplan-Meier method was 50% (95% CI: 47.89-69.31). Conclusion Ribociclib and palbociclib have improved PFS in patients with metastatic HR+/HER2- breast cancer. Both drugs have well-tolerated toxicity, allowing patients to continue taking them for an extended period of time. CDK4/6 inhibitors have a higher response rate than the other agents.

Margin to Depth of Invasion Ratio: A Significant Predictor of Survival in Patients With Oral Cancer.

PURPOSE: A common definition of a clear margin (≥5 mm) in oral squamous cell carcinoma (OSCC) for all stages is a subject of controversy. Studies have shown that even 1- and 2-mm margins are adequate, and few studies have identified dynamic resection margin as a criterion. We aimed to study the margin to depth of invasion ratio (MDR), margin to tumor thickness ratio (MTR), and margin to tumor size ratio (MSR) as prognostic markers for survival. Notably, to our knowledge, this is the first study to evaluate the role of MDR in OSCC. METHODS: A prospectively maintained head and neck cancer database was analyzed from January 2017 to February 2023. The MDR, MTR, and MSR were calculated for each patient. Survival outcomes were analyzed using the Cox proportional model and the Kaplan-Meier method. Akaike's information criterion (AIC) and Bayesian information criterion (BIC) were used to compare different ratio models. X-tiles software was used to identify the optimal cutoff value of MDR. RESULTS: Two hundred eighty patients in the database were assessed, of which 123 eligible patients were enrolled in the study. MDR was an independent predictor of disease-free survival (DFS) on multivariate analysis. The MDR model had the lowest values on AIC and BIC analyses. A cutoff value of 0.5 for MDR showed a significant correlation with DFS and overall survival. CONCLUSION: MDR was the best predictor of recurrence of all the three ratios studied. The minimum safe surgical margin can be calculated by multiplying the depth of invasion by 0.5. This study signifies the role of dynamic resection margin criteria on the basis of MDR in defining clear margins.

Mono iso-centric VMAT planning for SBRT of multiple liver metastasis- A case report.

INTRODUCTION: Hepatocellular carcinoma (HCC) is the second most common cause of cancer mortality worldwide. The risk factors associated with the development of HCC are chronic Hepatitis B, Hepatitis C, and alcoholic cirrhosis. The standard care for HCC is surgical resection but the scope is limited for some patients. Continuous advancement of radiation therapy enabled the technique of stereotactic body radiotherapy (SBRT) as an option for the treatment of those cases for which surgery cannot be done. According to recent literature and meta-analysis, SBRT is an optimum treatment method with high local control with low toxicity. In SBRT, radiation is delivered with a smaller number of fractions than conventional radiation and employs high-precision delivery and accuracy with the help of image guidance. From a series of retrospective and prospective studies, it has been confirmed that SBRT achieves excellent local control in patients with early-stage inoperable, intermediate-stage, and advanced diseases. BACKGROUND: A 42-year-old male patient related to HBeAg infection and high AFP levels developed HCC BCLC Stage A was admitted to our department. There were two lesions with PTV volumes of 41.07 cc and 9.573 cc with a distance between them of 3.51 cm. These two lesions were treated with a mono-isocentric VMAT planning with SBRT technique. In this case, we present an unusual clinical practice of mono-isocentric treatment planning for treating multiple liver lesions. Since radiation therapy was viewed as the primary form of treatment because the patient wasn't an ideal candidate for surgery, SBRT was selected as the patient's primary modality of treatment because of the tiny volume of the two lesions and the normal liver volume (>700cc). Triple-phase 4DCT was performed for simulation to account for the motion of target volume and normal structures. After delineating the target volume and other normal structures, treatment planning was done with a dose of 45 Gray which was to be delivered in 5 fractions. Two PTVs were created with a margin of 3.0 mm to IGTV. Considering the positions of the lesions, a single isocentre plan was created using a 6MV FFF photon beam for both the PTVs with the VMAT technique. The treatment was carried through with 3 arcs, one coplanar, and the other 2 non-coplanar. At the time of treatment, after the proper positioning of the patient, one CBCT image was taken to match with the planned CT image acquired at the time of the simulation. After applying the translational and rotational errors, the patient was treated. RESULTS: The patient was treated successfully. After treatment, the condition of the patient was normal, and no toxicities have been observed in follow-up. CONCLUSION: Mono isocentric VMAT planning can be used for closely spaced lesions considering the position of lesions and other normal structures in the vicinity.

Metastatic Renal Cell Carcinoma Masquerading as a Laryngeal Tumor: A Case Report.

Renal cell carcinoma (RCC) commonly metastasizes to various organs such as the lungs, liver, bones, and brain. However, isolated metastases to the head and neck region, especially the larynx, are very rare. This report presents a case of laryngeal growth that was eventually confirmed to be a metastatic deposit from an undiagnosed RCC. We report a case of a 66-year-old male who presented to the clinic with painless neck swelling and a change in voice. The scan showed a soft tissue mass in the thyroid cartilage. Histopathology of the resected laryngeal tumor confirmed metastatic clear cell carcinoma. A metastatic workup revealed a renal mass, and the patient underwent laparoscopic adrenal-sparing left cytoreductive nephrectomy. The histopathological examination established the diagnosis of clear cell RCC. Subsequently, the patient was treated with pembrolizumab and lenvatinib. Follow-up imaging showed no residual or recurrent lesions. This case highlights the rarity of laryngeal metastasis from RCC and the importance of an accurate diagnosis through advanced imaging and histopathological examination.

A rare case of cavernous sinus thrombosis following oral squamous cell carcinoma - The etiology and management dilemma.

Intracranial cavernous sinus metastases of oral squamous cell carcinoma (OSCC) are rare, with a reported incidence of 0.4 %. Due to their extremely infrequent presentation the etiology and management modalities of such complications are not clearly represented in the literature. Here we present a case of a 58-year-old male diagnosed with OSCC of Right Lower Alveolus with underlying bone invasion, cT4aN1M0, Stage IV. He underwent Right Hemi-mandibulectomy with Modified Neck Dissection, Pectoralis Major Myocutaneous Flap, and 60 Gy/30# adjuvant radiotherapy. Six months later, the patient was diagnosed with recurrence involving the right infratemporal fossa with associated right cavernous sinus thrombosis. Immunohistochemistry block review showed PDL1 - Positive. The patient was subjected to Cisplatin and Pembrolizumab immunotherapy. After receiving 35 cycles of Pembrolizumab over a period of 2 years the patient is doing well with no recurrence.

Cutaneous Metastasis in a Treated Case of Cervical Cancer With Extraordinary Response to Chemotherapy: A Case Report of a Rare Event and Review of the Literature.

Cervical cancer usually metastasizes to the lung, liver, bone, and brain. Metastasis to the skin from cervical cancer is relatively uncommon. The management options are systemic therapy, palliative radiotherapy, or best supportive care. Here, we report the case of a female patient with cervical cancer, stage IIB, who received radical treatment with radiotherapy and chemotherapy and later presented with disseminated skin nodules. She was treated with combination chemotherapy (nano-dispersible paclitaxel and carboplatin), bevacizumab, and a bone-stabilizing agent (zoledronic acid). There was a complete metabolic response to the therapy. There was also a dramatic improvement in the general condition of the patient. Skin metastasis in cervical cancer often presents as non-tender skin nodules. A biopsy is mandatory to establish the diagnosis. There are no specific guidelines about management. The intention of management is palliative. The combination of chemotherapy and bevacizumab produces substantial clinical improvement.

Inclusion of Perineural Invasion with AJCC-TNM Staging: Outcomes from a South Asian Cohort of Curatively Treated Gastric Cancer Patients.

BACKGROUND: The incidence of perineural invasion (PNI) in patients with gastric cancer (GC) is high, and patients with PNI positive disease have a poor prognosis compared to PNI-negative disease. The present study aims to study the incidence and evaluate the impact of PNI on the survival outcome of a cohort of South Asian GC patients. MATERIAL AND METHODS: All consecutive patients undergoing curative gastrectomy were included in the study. The incidence of PNI and correlation with different clinico-pathological features and overall survival was performed. RESULTS: A total of 59.54% had PNI-positive disease and the median OS of PNI + ve patients was 29.3 months, while it was not reached in PNI-ve patients. The PNI positivity was a significant prognostic factor for overall survival both on univariate and multivariate analysis. On TNM-PNI staging, those with TNM stage I/II patients with PNI + ve disease had similar OS to all stage III patients (p = 0.835) and were worse than that of PNI-ve patients (p < 0.05). CONCLUSION: The incidence of PNI in gastric cancer is high. The inclusion of PNI with AJCC-TNM staging may better stratify prognostic staging in curatively treated gastric cancer patients.

Bilateral Breast Cancer-Its clinicopathological profile and management: An experience from a tertiary care center from Eastern India.

Background: Bilateral breast carcinoma (BBC), though not rare, is quite an uncommon clinical situation and hence guidelines regarding its diagnosis and management are not clear enough. It can be synchronous or metachronous depending on the interval between the time of presentation in bilateral breasts. Materials and Methods: We retrospectively reviewed our experience with 18 cases of bilateral breast malignancies presented and treated between January 2014 and December 2019. We analyzed clinical, pathological, and immunohistochemical profiles with their management. All the patients were staged separately for both breasts and received treatment according to prescribed guidelines. Results: Among these 18 cases, 16 were synchronous and 2 were metachronous during the presentation. During the presentation of synchronous malignancies, eight patients had stage IV disease, whereas the other eight cases were nonmetastatic. Patients received combined modality treatment by surgery, chemotherapy, and radiotherapy depending on the stage of presentation. At a median follow-up period of 12 months, 10 (55.56%) patients were disease free, 2 (11.11%) patients had disease recurrence, and 5 (27.78%) patients succumbed to the disease, whereas 1 patient has lost follow-up. Conclusion: Diagnosis and management of bilateral breast malignancies pose a clinical challenge to the oncologist and hence should be vigilantly looked upon. The treatment decision is individualized according to the stage and molecular type of the particular patient. Regular follow-up and judicious use of clinical breast examination and mammography can help in the early detection of second breast carcinoma.

Chemotherapy-induced hand foot syndrome: comparative efficacy and safety of pharmacological prophylaxis - systematic review and Bayesian network meta-analysis.

BACKGROUND: Hand-foot syndrome (HFS) is one of the most common toxicities experienced by patients receiving systemic chemotherapy agents such as capecitabine and multikinase inhibitors such as sorafenib. Several randomised controlled trials (RCTs) have investigated the efficacy and safety of prophylactic agents such as pyridoxine, celecoxib, urea cream and cystine/theanine in managing HFS. This network meta-analysis (NMA) evaluated data from high-quality trials to provide strong evidence in forming recommendations to prevent systemic cancer therapy-induced HFS. OBJECTIVE: To examine the comparative efficacy and safety of interventions for preventing systemic chemotherapy-induced HFS in patients with cancer. METHODS: We searched PubMed, Embase and clinical trial registry for RCTs of interventions for preventing HFS. Bayesian NMA was performed to estimate the OR with 95% credible intervals (CrI) from both direct and indirect evidence. The outcome measures were the incidence of HFS (grade ≥1) and moderate to severe HFS (grade ≥2). Adverse drug reactions were discussed descriptively. RESULTS: A total of 15 RCTs with 2715 patients with 12 prophylactic strategies were included. The analysis showed only celecoxib could significantly prevent the incidence of moderate to severe HFS (grade ≥2) (OR 0.29, 95% CrI 0.13 to 0.68). But none of the preventive interventions could prevent the incidence of HFS (grade ≥1). CONCLUSION: Only celecoxib (200 mg two times per day) showed significant prevention of the incidence of moderate to severe HFS. Pyridoxine (400 mg once daily) and urea cream (10%) have to be evaluated further in larger randomised trials.

Impact of Comorbidity Scores on the Overall Survival of Patients With Advanced Non-small Cell Lung Cancer: A Real-World Experience From Eastern India.

Introduction Lung cancer is the most common cancer, and it is the leading cause of cancer-related death. Smoking is the most common risk factor for the development of lung cancer. There is a lack of data on the comorbidities and outcomes of advanced non-small cell lung cancer (NSCLC) in the eastern part of India. This prospective study evaluated the impact of comorbidity scores on overall survival (OS) in these patients. Method This prospective cohort study was conducted on newly diagnosed advanced NSCLC patients between June 2020 and April 2021. These patients were given platinum-based doublet chemotherapy guided by histology and targeted therapy based on molecular studies. Comorbidities were assessed using the Charlson Comorbidity Index (CCI), Simplified Comorbidity Score (SCS), and Adult Comorbidity Evaluation-27 (ACE-27). The outcome assessed was OS. Overall survival was calculated in days from the date of start of anticancer therapy to the date of last follow-up or date of death. All enrolled patients were followed at regular intervals whenever they visited the hospital and telephonically until April 2022. The patients who were alive on April 30, 2022, were censored. The survival probability and median OS were calculated by Kaplan-Meier analysis, and group differences in comorbidity scores were analyzed with the log-rank test. A Cox proportional hazard analysis was performed to look for factors affecting overall survival. Results A total of 114 patients were enrolled in the study period, and the mean age of patients was 56.54 ± 11.03 years. Most of the patients were males (68.4%), and 52.6% were smokers. Adenocarcinoma was the most common histology (73.7%), followed by squamous cell carcinoma (25.4%). The median OS was 127 days (95% CI, 60-193 days). 33.4% of the patients had a CCI score of 0, a CCI score of 1 was seen in 57%, and ≥2 scores in 9.6%. SCS scores ≤9 and >9 were seen in 92.1% and 7.9% of patients, respectively. The ACE-27 score was none in 41 subjects, mild in 59, moderate in 12, and 2 NSCLC subjects had severe ACE-27 scores. The median OS for patients with a CCI score of 0 was 275 days (95% CI, 7-543 days), 114 days (95% CI, 85-142 days) for subjects with a CCI score of 1, and 402 days (95% CI, 0-844 days) for patients with a CCI score ≥2 (log-rank p = 0.215). Individuals with an SCS score ≤9 had a median OS of 175 days (95% CI, 91-258 days), and the median OS was 92 days (95% CI, 80-103 days) for patients with an SCS score >9 (log-rank p = 0.302). Median OS of the patients with ACE-27 score 0,1,2,3 were 297 days (95% CI, 76- 517 days), 117 days (95% CI, 81-152 days), 87 days (95% CI, 49-124 days) and 66 days, respectively (log-rank p=0.457). There was no statistical significance between comorbidity scores and OS. Worse OS was independently associated with poor performance status Eastern Cooperative Oncology Group (ECOG) ≥2 (hazard ratio [HR] 3.266; 95% CI 1.785-5.978; p = 0.00), neutrophil-to-lymphocyte ratio (NLR) <3 (HR, 2.35 95% CI 1.18-4.702; p = 0.015) and patients who were given compassionate tyrosine kinase inhibitors (TKIs) (HR, 7.396 95% CI 3.531-15.490; p = 0.000). Conclusions In our study, the advanced NSCLC patients who were given chemotherapy or oral TKIs showed no significant influence of comorbidities on overall survival. Factors independently associated with the worst survival were poor performance status (ECOG ≥ 2), NLR < 3, and patients who were given TKIs on a compassionate basis.

Metronomic Therapy in Palliation of Oral Cancer Patients-A Home Based Approach at the End of Life.

INTRODUCTION: Despite the development of targeted therapies for the management of oral cancer patients, the cost of treatment is a concern in middle- and low-income countries. The present study assessed the feasibility of low-cost metronomic therapy as an alternative treatment modality in patients with unresectable or inoperable oral cancers. METHODOLOGY: The study was a prospective, single-arm study. Unresectable, inoperable, and metastatic lip and oral cavity cancers were started on metronomic therapy, a combination of oral methotrexate 15 mg/m2 once a week and oral celecoxib 200 mg twice daily, as palliative therapy. The primary endpoint was overall survival. The secondary endpoints were a response to metronomic therapy, compliance, and toxicity. RESULTS: From June 2018 to May 2020, 25 patients were started on metronomic therapy. The median age was 60 years. The median overall survival was 8.8 months. At eight weeks of therapy, 11 patients (44%) had a partial response, ten patients had stable disease (40%), and four patients had progressive disease (16%). The compliance with the therapy was 100%, and one patient (4%) developed grade III toxicity. CONCLUSIONS: Considering the resource constraints and cost limitations in low and middle-income countries, oral metronomic therapy in the form of methotrexate and celecoxib should be regarded as a suitable regimen in the palliative treatment of patients with unresectable, metastatic, or advanced, recurrent cancers.

CRISPR-based kinome-screening revealed MINK1 as a druggable player to rewire 5FU-resistance in OSCC through AKT/MDM2/p53 axis.

Cisplatin, 5FU and docetaxel (TPF) are the most common chemotherapy regimen used for advanced OSCC. However, many cancer patients experience relapse, continued tumor growth, and spread due to drug resistance, which leads to treatment failure and metastatic disease. Here, using a CRISPR/Cas9 based kinome knockout screening, Misshapen-like kinase 1 (MINK1) is identified as an important mediator of 5FU resistance in OSCC. Analysis of clinical samples demonstrated significantly higher MINK1 expression in the tumor tissues of chemotherapy non-responders as compared to chemotherapy responders. The nude mice and zebrafish xenograft experiments indicate that knocking out MINK1 restores 5FU mediated cell death in chemoresistant OSCC. An antibody based phosphorylation array screen revealed MINK1 as a negative regulator of p53. Mechanistically, MINK1 modulates AKT phosphorylation at Ser473, which enables p-MDM2 (Ser 166) mediated degradation of p53. We also identified lestaurtinib as a potent inhibitor of MINK1 kinase activity. The patient derived TPF resistant cell based xenograft data suggest that lestaurtinib restores 5FU sensitivity and facilitates a significant reduction of tumor burden. Overall, our study suggests that MINK1 is a major driver of 5FU resistance in OSCC. The novel combination of MINK1 inhibitor lestaurtinib and 5FU needs further clinical investigation in advanced OSCC.

CMTM6 attenuates cisplatin-induced cell death in OSCC by regulating AKT/c-Myc-driven ribosome biogenesis.

CMTM6, a type 3 transmembrane protein, is known to stabilize the expression of programmed cell death ligand 1 (PD-L1) and hence facilitates the immune evasion of tumor cells. Recently, we demonstrated that CMTM6 is a major driver of cisplatin resistance in oral squamous cell carcinomas (OSCC). However, the detailed mechanism of how CMTM6 rewires cisplatin resistance in OSCC is yet to be explored. RNA sequencing analysis of cisplatin-resistant OSCC lines stably expressing Nt shRNA and CMTM6 shRNA revealed that CMTM6 might be a potential regulator of the ribosome biogenesis network. Knocking down CMTM6 significantly inhibited transcription of 47S precursor rRNA and hindered the nucleolar structure, indicating reduced ribosome biogenesis. When CMTM6 was ectopically over-expressed in CMTM6KD cells, almost all ribosomal machinery components were rescued. Mechanistically, CMTM6 induced the expression of C-Myc, which promotes RNA polymerase I mediated rDNA transcription. In addition to this, CMTM6 was also found to regulate the AKT-mTORC1-dependent ribosome biogenesis and protein synthesis in cisplatin-resistant lines. The nude mice and zebrafish xenograft experiments indicate that blocking ribosome synthesis either by genetic inhibitor (CMTM6KD) or pharmacological inhibitor (CX-5461) significantly restores cisplatin-mediated cell death in chemoresistant OSCC. Overall, our study suggests that CMTM6 is a major regulator of the ribosome biogenesis network and targeting the ribosome biogenesis network is a viable target to overcome chemoresistance in OSCC. The novel combination of CX-5461 and cisplatin deserves further clinical investigation in advanced OSCC.

Divided target optimization with volumetric modulated arc therapy planning to improve target coverage and homogeneity in lung radiation therapy.

PURPOSE: To investigate and evaluate the feasibility of a simple modified Divided Planning Target Volume (DPTV) optimization method in radiation therapy planning of lung cancer patients. METHODS: A cohort of 15 patients of Non-Small Cell Lung Cancer (13 patients stage III and two patients of stage II) who were previously treated with Concurrent Chemo Radiation Therapy were included in the study. The planning modality was Volumetric Modulated Arc Therapy, and the dose prescription was 60 Gray in 30 fractions. In this study, we attempted to replan by dividing the previous Single Planning Target Volume (SPTV) into a DPTV. All the treatment plans were revised and again optimized for DPTV with required dose constraints as in SPTV. The dosimetric parameters that were achieved for target and normal structures were recorded in both the optimization methods. RESULTS: Dosimetric target coverage (D95%) (p-value = 0.0001), dose homogeneity (p-value =0.0001) and conformity (p-value = 0.044) were improved by the DPTV optimization. The volume of the oesophagus receiving 35 Gy was found to be higher in the DPTV arm (p-value = 0.02) compared to the SPTV arm, but the volume of the oesophagus receiving 50 Gy was found to be similar (p-value = 0.122). CONCLUSION: In radiation therapy planning of lung cancer, the DPTV optimization method has better dose coverage to the target volume, homogeneity, as well as conformity than the stsndsrd SPTV method. Therefore, the DPTV optimization method can be a simple and efficient alternative to the SPTV method in lung cancer.

Effect of treatment interruptions and outcomes in cancer patients undergoing radiotherapy during the first wave of COVID-19 pandemic in a tertiary care institute.

INTRODUCTION: COVID-19 patients with cancer had poorer outcomes due to immunosuppression during cancer care, poor general condition, and other comorbidities. The study was conducted to present the real-world analysis of the effect of treatment interruptions on the outcomes of patients treated with radiation therapy during the first wave of the COVID-19 pandemic in a tertiary care institute in India. MATERIALS AND METHODS: The study is a retrospective observational cohort study on cancer patients undergoing radiation therapy from March 2020 to January 2021. The study's primary outcome was to analyze the effect of treatment interruptions on the outcomes of patients treated with radiation therapy during the first wave of COVID-19 pandemic. RESULTS: Between March 2020 to January 2021, 218 eligible patients undergoing radiation therapy were found for the study. Among the 218 patients, 25 patients (11.47%) were found positive for COVID-19, while 193 patients (88.53%) were negative for COVID-19. Among COVID-19-positive patients, ten patients had < 3 weeks of treatment interruption, while 15 patients had > 3 weeks of treatment interruptions. After recovering from COVID-19, treatment was resumed and completed for 15 (60.00%) of the COVID-19-positive patients. In comparison, 13 patients (52.00%) were lost to follow-up. Three of the COVID-19-positive patients died. The disease was clinically controlled in 12 (48.00%) of the COVID-19-positive patients, and the patients reported locoregional disease progression in 10 (40.00%). Among the 193 COVID-19-negative patients, 32 patients (16.58%) had treatment interruption. Twelve patients (37.50%) had treatment interruptions for less than 1 week. There was a significant difference in the delay of radiation treatment delivery by 2 weeks (11 fractions) in COVID-19-positive patients compared to only two fractions delay in COVID-19-negative patients. CONCLUSION: COVID-19 impacted the treatment outcomes in both COVID-19-positive and COVID-19-negative cohorts of patients. There was a longer duration of treatment interruptions in the COVID-19-positive patients, leading to fewer patients completing the radiation treatment and thereby increased locoregional disease progression. There was a significant difference in the delay in treatment between the two groups.

Metastatic primary gastric melanoma: a rare clinical presentation and a review of literature.

Primary gastric melanoma is a rare clinical finding. It presents with upper gastrointestinal symptoms like abdominal pain, weight loss and melaena. It is often difficult to differentiate a primary gastric melanoma from primary cutaneous melanoma with gastric metastasis. Upper gastrointestinal endoscopy and biopsy of the lesion for histopathology and immunohistochemistry help to reach a definite diagnosis. We report a case of primary gastric melanoma with metastases to the liver and bone. The patient was treated with palliative radiotherapy, palliative chemotherapy and a bone-stabilising agent.