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.

A Dosimetric Study Comparing 3D-CRT vs. IMRT vs. VMAT in Left-Sided Breast Cancer Patients After Mastectomy at a Tertiary Care Centre in Eastern India.

Introduction Post-mastectomy radiation in left-sided breast cancer in women continues to pose a significant risk to the underlying lungs and heart. This study analyzed the difference in planning target volume (PTV) coverage and dose to the organs at risk (OAR) by using three different planning methods for the same patient - three-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT), and volumetric-modulated arc therapy (VMAT). Material and methods Thirty-five left-sided breast cancer patients' post-mastectomy were included in this study, and three different plans for adjuvant radiation were created using 3D-CRT, IMRT, and VMAT. The prescribed dose was 50Gy in 25 fractions. Kruskal-Wallis analysis of variance (ANOVA) was done, followed by a pairwise t-test to establish a hierarchy of plan quality and dosimetric benefits. The plans were compared with PTV95, homogeneity index (HI), conformity index (CI), hotspot (V107%), left lung V20Gy, mean lung dose, heart V25Gy, mean heart dose, and integral dose (ID) to the body. Results Both VMAT and IMRT led to improved PTV95% coverage (95.63±1.82%, p=0.000 in VMAT; 93.70±2.16 %, p=0.000; 81.40±6.27% in 3D-CRT arm) and improved CI (0.91±0.06 in IMRT [p<0.05] and 0.96±0.02 for VMAT plans [p<0.05]) as compared to 3D-CRT (0.66±0.11), which was statistically significant on pairwise analysis. In contrast, the difference in HI and reduction in hotspots were not significantly different. Left lung V20 was statistically very different between the three arms with the highest values in IMRT (36.64±4.45) followed by 3D-CRT (34.80±2.24) and the most negligible value in VMAT (33.03±4.20). Mean lung dose was also statistically different between the three arms. There was a statistically significant difference in mean heart dose between the three arms on pairwise analysis. Both the inverse planning methods led to a statistically significant increase in low dose volume (V5 and V10) of the ipsilateral lung, opposite lung, and heart, and increased ID to the body excluding the PTV. Conclusion While both the inverse planning modalities led to increased coverage, better CI, and better HI and decreased high dose volumes in OARs, there was increased low volume irradiation of heart, lungs, and body with VMAT faring marginally better than IMRT in coverage and decreasing lung irradiation with comparable heart irradiation.

An unusual response of recurrent breast cancer axillary lymphadenopathy to palliative radiotherapy: A case report.

INTRODUCTION: Radiotherapy has played a pivotal role in palliation of symptoms in progressive incurable stages of malignancies. Ionizing radiation has been employed to decrease cancer induced bone pain, control bleeding and mass effects from inoperable tumor with significant success. The advent of new systemic anti-neoplastic drugs has broadened options available for management of cancers in palliative intent. The outcome of systemic anti-neoplastic therapy in the role of palliation has received variable acceptance while radiotherapy has generally remained the workhorse for palliation. CASE REPORT: A young female with a diagnosis of left-sided breast cancer who had received adjuvant anthracycline based chemotherapy, but not whole breast radiotherapy, following lumpectomy had an axillary lymphnode recurrence three years later. Though the recurrence was salvaged with a radical mastectomy and followed up with a combination of taxane and platin-based chemotherapy, there was a recurrence of axillary lymph nodes during the course. Following six cycles of combination chemotherapy, the mass progressed to form a large ulcer with pain and discharge. The recurrent malignancy was diagnosed to be triple negative subtype upon microscopic and immunohistochemical study. OUTCOME: The ulcerated mass not only responded to palliative radiotherapy by complete healing of the ulcer, but it also led to improvement in overall performance score and quality of life as measured objectively. DISCUSSION: In triple negative subtype of breast cancer [TNBC], axillary lymphnodal recurrence is not uncommon after loco-regional surgery and peri­operative chemptherapy; particularly when adjuvant radiotherapy is omitted. Chemotherapy refractory axillary lymphnodal recurrence showing good response to palliative radiotherapy signifies the differing molecular signatures within TNBC subtype. CONCLUSION: Radiotherapy is an effective modality for loco-regional palliation of recurrent breast cancer, particularly TNBC subtype. It holds potency even when the disease is chemotherapy refractory and can improve subjective as well as objective quality of life parameters significantly.

Tweaking of radiation and chemotherapy schedules is the new normal during the COVID-19 crisis: perspective from oncologists at a tertiary care health institute.

Patients with cancer are at a higher risk of infection with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) than the general population. In India, it has become a significant health problem of utmost importance, and India's Government has issued health advisories. Lockdown brought many unforeseen problems for patients and hospitals, leading to confusion and chaos. The aim of this article is to identify various issues related to our hospital, follow-up, nutrition, treatment and psychosocial issues. Multiple changes were made in the hospital, departmental and treatment policy for cancer patients' convenience and safety. As India is in the peak of COVID-19, these types of modifications and modifications of treatment schedules will be the 'New Normal'.

Comparison of two hypofractionated radiotherapy schedules in locally advanced postmastectomy breast cancer patients.

INTRODUCTION: The role of hypofractionated radiotherapy (HFRT) in postmastectomy breast cancer patients is not well established. This study was done to establish the role of two different HFRT schedules in the treatment of chest wall and regional lymph nodes after mastectomy. MATERIALS AND METHODS: Between 2012 and 2016, consecutively registered patients of locally advanced breast cancer patients having undergone mastectomy and adjuvant radiotherapy (RT) at a tertiary cancer center were analyzed. Locoregional recurrence (LRR) was the primary endpoint, whereas overall survival (OS), disease-free survival (DFS), and both acute and late adverse events were secondary endpoints. RESULTS: A total of 34 patients who were treated with 39 Gy in 13 fractions over 2½ weeks and 35 patients who were treated with 40 Gy in 15 fractions over 3 weeks were identified. The median follow-up period was 47 months and 63.5 months in the 39 Gy and 40 Gy arms, respectively. LRR was seen in 11.8% and 8.6% of patients in the 39 Gy and 40 Gy arms, respectively. OS at 4 years was 66% and 71.5% in the 39 Gy and 40 Gy arms, respectively. The mean DFS for 39 Gy and 40 Gy arms was 43.6 months and 66.4 months, respectively (P = 0.822). Acute skin toxicity was similar in the two groups. Arm edema was significantly more in the 40 Gy arm. CONCLUSION: The two HFRT schedules are equivalent to each other in terms of survival outcomes. Arm edema is higher with 40 Gy arm as compared to 39 Gy arm.

Prevalence of Pain and Its Characteristics in Hospitalized Patients in an Indian Teaching Hospital.

BACKGROUND: Pain has a great impact on the physical and mental condition of hospitalized patients, reduces quality of life, and increases economic burden. AIMS: The study aimed to determine pain prevalence, its characteristics, analgesic treatment, and associated factors for severity and chronicity of pain in hospitalized patients. METHODS: A cross-sectional study was carried out including 847 eligible adult in-patients, aged ≥18 years, admitted to the All India Institute of Medical Sciences, Bhubaneswar, India, from June to August 2018. Pain severity was evaluated by visual analog scale (VAS) at the time of interview and after 1 week/completion of pain treatment. RESULTS: The prevalence of pain during the 24 hours preceding the interview was 70.6%. The duration of pain was ≥4 weeks in 162 (27.1%) patients and severe (VAS ≥ 7) in 144 (24.1%) patients. The mean VAS score was 6.27 ± 1.97 at the time of interview and 3.31 ± 1.89 after 1 week/completion of pain treatment (p < .001). Use of opioid analgesics (adjusted odds ratio [aOR]: 3.18; confidence interval [CI]: 2.23-4.55) was significantly related to pain severity, whereas patients ≥60 years (aOR: 1.64; CI: 0.99-2.70), patients in a nonsurgical ward (aOR: 1.78; CI: 1.21-2.60), and patients using opioid analgesics (aOR: 2.63; CI: 1.73-3.98) had prolonged pain, defined as ≥4 weeks. CONCLUSION: Pain prevalence and intensity in this Indian hospital were high and pain treatment was adequate in many cases. Timely assessment and appropriate management of pain in hospitalized patients is needed to prevent further pain and its complications in these patients.