Practice of Tumor Bed Boost in Patients after Oncoplastic Breast-Conserving Surgery.

The practice of boost to the tumor bed after treatment with oncoplastic breast-conserving surgery (BCS) remains variable. Using a survey, the present study evaluated the current practice of tumor bed boost administered in women after oncoplastic BCS. Actively practicing radiation oncologists across India were sent a questionnaire on the practice of adjuvant whole-breast radiotherapy and tumor bed boost after oncoplastic BCS via email and encouraged to participate. Of the 54 radiation oncologists who participated, most (98.1%) used a linear accelerator for radiotherapy. Hypofractionation was preferred by 59.26%, standard fractionation by 7.41%, and the remaining selected the fractionation strategy based on various patient factors. In addition, 83.33% participants reported that they always planned tumor boost, 51.85% preferred photons for the boost, and 75.93% administered sequential boost. The most common dose for the boost was 12.5 Gy in five fractions (40.74%). Most participants (77.78%) revealed that they used a combination of methods for identifying the tumor bed. With respect to clip placement, most surgeons (96%) at the participants' centers placed ≥ 4 clips at the tumor site, with both the base and margins being preferred by surgeons (81.48%) for placement. Finally, 12.96% participants revealed that the surgeons always involved them during surgical planning, whereas 7.4% participants reported that they always included the surgeons during radiotherapy planning, suggesting that radiation oncologists and oncoplastic surgeons do not involve each other during surgical and radiotherapy planning, possibly leading to suboptimal treatment. This may be attributed to the absence of guidelines regarding boost practices after oncoplastic BCS.

Radiotherapy management of rectal cancer in the backdrop of the COVID pandemic.

BACKGROUND: COVID-19 outbreak was declared as a pandemic by the World Health Organization in March 2020. Over the last 3 months, the pandemic has challenged the diagnosis and treatment of all cancer, including rectal cancer. Constraints in resources call for a change in the treatment strategy without compromising efficacy. RECENT FINDINGS: Delivery of shorter treatment schedules for radiotherapy offers advantages like short overall treatment time, improved throughput on the machine, improved compliance and reduced risk of transmission of COVID 19. Other strategies include delaying surgery, reducing the intensity of chemotherapy and adoption of organ preservation approach. CONCLUSION: The curative treatment of rectal cancer should not be hindered during the COVID pandemic, and modifications in the multi-modality treatment will help achieve quality care.

An advisory by the association of radiation oncologists of India for radiation therapy patients and staff among COVID 19 pandemic.

Covid19 has become a major public health problem in India and the rest of the world. The dramatic rise in the incidence of COVID 19 cases has severely challenged our healthcare system and forced us to work with limited infrastructure, resources, and workforce. However, even in this time of adversity, we as oncologists cannot neglect the seriousness of cancer care and the utmost attention it requires for the timely management of our patients. Hence, the Association of Radiation Oncologists of India has come up with an advisory for radiation therapy keeping in mind such aspects.

Stereotactic body radiotherapy for lung tumors: Dosimetric analysis and clinical outcome.

INTRODUCTION: Stereotactic body radiotherapy (SBRT) has emerged as an important modality in malignant lung tumor treatment both in early localized primary and oligometastatic setting. This study aims to present the results of lung SBRT both in terms of dosimetry and clinical outcome. MATERIALS AND METHODS: Twenty-seven patients were assessed from 2012 to 2016. Both the primary and oligometastatic lung tumors were evaluated. Respiratory motion management was done employing ANZAI (Siemens, Germany) based four-dimensional computed tomography (CT). Commonly used fractionations were 60 Gy/5 fractions for peripheral tumors and 48 Gy/6 fractions for central tumors. Radiation Therapy Oncology Group toxicity criteria were used for toxicity and whole-body positron emission tomography-CT scan was done at follow-up for response evaluation. RESULTS: Twenty-seven patients were evaluated, 18 (66.7%) patients had a primary, and 9 (33.3%) patients had metastatic lung tumors. The male-to-female ratio for the entire cohort was 2:1. The median age at diagnosis was 65.8 years. Mean planning target volume (PTV) D2cc was 54.9 ± 9.04 Gy and mean internal target volume diameter was 3.0 ± 1.07 cm. Mean V20 Gy, V10 Gy, and V5 Gy of (lungs total-PTV) and (Lung ipsilateral - PTV) were 5.4 ± 4% and 10.9 ± 7.9%, 11.7 ± 5.8% and 24.2 ± 14.0%, and 22.05 ± 12.4% and 33.2 ± 15.3%, respectively. In total 21 (84%) patients and 4 patients (16%) showed a complete and partial response, respectively. One (3%) patient developed Gr 3 radiation pneumonitis. One year local control was in 18 (81%) patients whereas 4 (14%) patients progressed and three patients did not report. A higher prescribed dose significantly correlated with 1 year tumor control (P = 0.036). CONCLUSION: This study infers the feasibility and a favorable outcome for lung cancer amenable to SBRT in addition to being one of the largest clinical experiences for lung stereotactic treatment in our country.

Human papillomavirus in head and neck cancer in India: Current status and consensus recommendations.

Human papillomavirus (HPV) associated head and neck squamous cell cancers (HNSCC) have become increasingly common in the West, but the same cannot be said about India. These cancers have a different biology and confer a better prognosis, however, its current role in the management of patients in India is not clearly defined. At the 35th Indian Cooperative Oncology Network conference held in September 2016, a panel of radiation, surgical and medical oncologists, pathologists, and basic scientists from across the country having experience in clinical research with respect to HPV in HNSCC reviewed the available literature from India. All the ideas and facts were thereafter collated in this report. Various topics of controversy in dealing with the diagnosis and management of HPV-associated HNSCC have been highlighted in this report in context to the Indian scenario. Furthermore, the prevalence of the same and its association with tobacco and high-risk sexual behavior has been touched on. Conclusively, a set of recommendations has been proposed by the panel to guide the practicing oncologists of the country while dealing with HPV-associated HNSCC.

Oncology Gold Standard® practical consensus recommendations for the use of monoclonal antibodies in the management of squamous cell carcinoma of head and neck.

We present the 2017 Oncology Gold Standard Practical Consensus Recommendation for use of monoclonal antibodies in the management of advanced squamous cell carcinoma of head neck region.

Superior vena cava syndrome: A radiation oncologist's perspective.

Superior vena cava syndrome is referred to as a constellation of symptoms and signs caused by obstruction of superior vena cava. It can occur due to both benign and malignant causes with the latter being the predominant. There is a paradigm shift in the approach to manage this condition. It is no longer considered a medical emergency and histological diagnosis is necessary before treatment. This article reviews the causes, symptoms, pathophysiology, and overall management policy which have changed over decades.

Critical neurological structure sparing radiosurgery of vestibular schwannoma: dosimetric comparison of different techniques and dose prescription methods.

AIM: To investigate potential sparing of critical neurological structures (CNSs) during radiosurgery of vestibular schwannoma (VS) employing different techniques and dose prescription methods. MATERIALS AND METHODS: Fused CT and MRI datasets of eight patients with unilateral VS representing a wide range of target volume (0.48 to 12.08 cc; mean = 3.56 cc), shape and proximity to CNSs such as cochlea, trigeminal nerve and brainstem were re-planned employing static conformal field (SCF), dynamic conformal arc (DCA) and intensity modulated radiosurgery (IMRS) techniques. For every patient, five plans were created for a fixed margin dose of 12 Gy prescribed at 80% in three plans (SCF_80%, DCA_80%, and IMRS_80%) and 50% in another two plans (SCF_50% and DCA_50%). All plans were compared using standard dosimetric indices. RESULTS: Primary goal of every plan to cover ≥99% of target volume with 12 Gy was fulfilled for all patients with minimum significant dose to target (D99) ≥11.99 Gy. Best conformity index (CI Paddick = 0.62 ± 0.12) was observed in SCF_80% and DCA_80% plans whereas; sharpest dose gradient index of 3.40 ± 0.40 was resulted from DCA_50%. All five plans resulted similar maximum dose to brainstem (11.04 ± 2.23 to 11.53 ± 1.10 Gy), cochlea (9.02 ± 1.79 to 10.15 ± 1.26 Gy) and trigeminal nerve (11.55 ± 1.38 to 12.19 ± 2.12 Gy). Among 80% prescription plans, IMRS_80% reduces mean and D5 (P < 0.05) to all CNSs. Prescription of dose at 50% isodose sharpened the dose gradient and significantly (P < 0.05) reduced mean dose and D5 to all CNSs at the cost of target conformity (P = 0.01). Mean dose to cochlea and trigeminal nerve were least at 4.53 ± 0.86 and 6.95 ± 2.02 Gy from SCF_50% and highest at 6.65 ± 0.70 and 8.40 ± 2.11 Gy from DCA_80% plans respectively. CONCLUSION: This dosimetric data provides a guideline for choosing optimum treatment option and scope of inter institutional dosimetric comparison for further improvement in radiosurgery of Vestibular Schwannoma (VS).

Portal dosimetry for pretreatment verification of IMRT plan: a comparison with 2D ion chamber array.

Portal dosimetry (PD) was performed for 181 fields from 14 IMRT plans of various clinical sites at gantry zero and source-to-detector distance (SDD) of 100 cm. PD was realized using aSi1000 electronic portal imaging device (EPID) and portal dose prediction (PDP) algorithm implemented in Eclipse treatment planning system (TPS). Agreement of PDP predicted and EPID measured photon fluence/dose distribution were evaluated using gamma (γ) index set at 3% at 3 mm distance to point agreement (DTA). Three gamma scaling parameters, maximum γ (γ(max)), average γ (γ(avg)) and percentage of points with γ ≤ 1 (γ% ≤ 1) were estimated for each field. An independent measurement was carried out using MatriXX 2D ion chamber array with detector plane at 100 cm and γ(max), γ(avg) and γ% ≤ 1 were estimated using OmniPro IMRT analyzing software. Effect of extended SDD and gantry rotation on portal dosimetry outcome was also investigated for another 45 IMRT fields. PDP predicted and EPID measured photon fluence agrees well with overall mean values of γ(max), γ(avg) and γ% ≤ 1 at 2.02, 0.24 and 99.43%, respectively. γ(max) value was lower in 15 MV compared to 6 MV IMRT plan. Independent verification using MatriXX showed comparable overall mean values of γ(avg) and γ% ≤ 1 at 0.25 and 99.80%. However, in all plans, MatriXX showed significantly lower γ(max) (p < 0.05) with an overall mean value of 1.35. In portal dosimetry, compared to gamma values at 100 cm SDD, γ(max), γ(avg) and γ% ≤ 1 values improve from a mean of 0.16, 0.03 and 0.26 at 110 cm SDD to 0.35, 0.05 and 0.29 at 140 cm SDD. PD outcome was independent of gantry rotation. In conclusion, both MatriXX 2D ion chamber array and portal dosimetry showed comparable results and can be use as an alternative to each other for relative photon fluence verification.

AIDS: a radiation oncologist's perspective.

While HIV is often associated with tuberculosis and a number of opportunistic infections, the spectrum of diseases of patients with HIV infection encompasses a number of malignancies as well. Typically, these are the AIDS-defining malignancies, though other malignancies also comprise a significant caseload. Radiotherapy plays an integral part in anti-cancer treatment and its tolerance and efficacy in HIV+ patients are therefore important. The patient's level of immunity as manifested by the CD4 count has a significant bearing on treatment outcomes. In some cases, like primary central nervous system lymphoma (PCNSL), the occurrence of the malignancy itself is tied to the patient's immunity with increased incidence in patients with CD4 counts less than 50/mm 3. The success of highly active antiretroviral therapy (HAART) has allowed administration of standard doses of radiotherapy and even chemotherapy in recent times leading to improved outcomes. In general, standard radiotherapy and concomitant chemo-radiotherapy protocols should be used wherever possible, so as not to compromise disease control. Local control and disease-specific survival rates in HIV patients are no worse than in HIV? patients, but this is only true for CD4 counts above 200/mm 3. In certain situations like cervical intraepithelial neoplasia CIN, HAART itself is associated with disease regression. The question of increased radiosensitivity in HIV patients remains unresolved in most diseases and there are sparse data with regard to non-HIV associated malignancies in these patients. Greater caution and emphasis on good supportive care and HAART would appear to be essential when treating the malignancies in HIV+ patients with standard anti-cancer regimens.

Spinal epidermoid cyst with sudden onset of paraplegia.

Spinal epidermoid cysts, whether congenital or iatrogenic, are relatively uncommon in the spinal cord. When they occur, the typical location is in the subdural, extramedullary space of the lumbo-sacral region. We describe an unusual presentation in a 3-year-old male child which mimicked astrocytoma clinicoradiologically. The child developed sudden onset of inability in walking and weakness of both lower limbs after a fall. There was a dramatic reversal of symptoms after surgery. Histopathology revealed an epidermoid cyst of the spine. On the first follow-up visit at 3 months, the child was asymptomatic.

Chest wall metastasis from hepatocellular carcinoma in the absence of a primary: An unusual presentation.

Metastatic hepatocellular carcinoma (HCC) has an aggressive course with a very poor outcome. The common hematogenous metastatic sites are the lungs, bones, and adrenal glands. The chest wall is an extremely rare site of metastasis from HCC. We report a rare presentation in a gentleman, where the chest wall metastasis kept progressing in spite of treatment, without any evidence of a detectable primary.

Embryonal rhabdomyosarcoma of the biliary tree mimicking a choledochal cyst.

Embryonal rhabdomyosarcoma (ERMS) of biliary tree is a rare type of mesenchymal neoplasm diagnosed at surgery or by preoperative liver biopsy. We present a one year eight months old child who mimicked a choledochal cyst and was eventually treated with surgery, chemotherapy with IRS IV protocol and adjuvant postoperative radiotherapy to surgical bed with 6 MV photons to a dose of 5040 cGy in 28 fractions.

Recurrent episodes of hematuria: a rare presentation of leiomyosarcoma of prostate.

Leiomyosarcoma of the prostate is an extremely rare entity. Sarcomas account for about 1% of all malignant tumors and less than 5% of them arise from the genitourinary tract. Majority of patients present with urinary obstructive symptoms. The outcome is generally poor. Surgery with or without radiotherapy/chemotherapy forms the mainstay of treatment for patients with operable tumors. We report a patient presenting with recurrent episodes of hematuria.