Change in dysphagia and laryngeal function after radical radiotherapy in laryngo pharyngeal malignancies - a prospective observational study.

BACKGROUND: Intensity modulated radiotherapy (IMRT) has the perceived advantage of function preservation by reduction of toxicities in the treatment of laryngo-pharyngeal malignancies. The aim of the study was to assess changes in dysphagia from baseline (i.e. prior to start of treatment) at three and six months post treatment in patients with laryngo-pharyngeal malignancies treated with radical radiotherapy ± chemotherapy. Functional assessment of other structures involved in swallowing was also studied. MATERIALS AND METHODS: 40 patients were sampled consecutively. 33 were available for final analysis. Dysphagia, laryngeal edema, xerostomia and voice of patients were assessed at baseline and at three and six months after treatment. Radiation was delivered with simultaneous integrated boost (SIB) using volumetric modulated radiation therapy (VMAT). Concurrent chemotherapy was three weekly cisplatin 100 mg/m2. RESULTS: Proportion of patients with dysphagia rose significantly from 45.5% before the start of treatment to 57.6% at three months and 60.6% at six months post treatment (p = 0.019). 67% patients received chemotherapy and addition of chemotherapy had a significant correlation with dysphagia (p = 0.05, r = -0.336). Severity of dysphagia at three and six months correlated significantly with the mean dose received by the superior constrictors (p = 0.003, r = 0.508 and p = 0.024, r = 0.391) and oral cavity (p = 0.001, r = 0.558 and p = 0.003, r = 0.501). There was a significant worsening in laryngeal edema at three and six months post treatment (p < 0.01) when compared to the pre-treatment examination findings with 60.6% of patients having grade two edema at six months. Significant fall in the mean spoken fundamental frequency from baseline was seen at 6 months (p = 0.04), mean fall was 21.3 Hz (95% CI: 1.5-41 Hz) with significant increase in roughness of voice post treatment (p = 0.01). CONCLUSION: There was progressive worsening in dysphagia, laryngeal edema and voice in laryngo-pharyngeal malignancies post radical radiotherapy ± chemotherapy.

A study on presentation and behavior of colo-rectal carcinoma in young Indian patients.

BACKGROUND: Colorectal cancer is rare in younger age group. Most cases occur in the second decade of life and are clinically aggressive. The prognosis of these patients is generally poor. This is a retrospective study in which data of Indian patients was compared to standard literature. METHODS: Data on 32 young patients with colorectal cancer between ages of 10-25 years treated between January 2000 and December 2006 was reviewed. Clinical presentation, natural history and response to therapy were evaluated. RESULTS: Studied cases comprised 9.9% of the total number of colorectal cancer patients. The median age of presentation was 21.5 years. Four-fifths of the cases presented in late stage. Nodal involvement was seen in 38% cases and metastatic disease in 12% cases. The rectum was the most commonly involved site. A majority of the patients presented with pain (81%), altered bowel habits (72%) and bleeding per rectum (78%). Surgery was done in 16 cases; radiotherapy in 16 patients; while chemotherapy was used in 19 cases. Responses at completion of treatment were seen in 28% cases; while 1 year post treatment only 12% cases were alive and only 6% at 2 years. CONCLUSIONS: Colorectal cancer in younger age is rare and a high level of suspicion is necessary to diagnose it at an early and curable stage. Rectal bleeding therefore should not be ignored but evaluated further with at least a digital rectal examination and a sigmoidoscopy. Failure to do so results in late presentation with consequent dismal survival rates.

The patient-reported outcome measures in oropharyngeal, laryngeal and hypopharyngeal cancer patients treated with Volumetric Modulated Arc based simultaneous integrated boost radiotherapy.

OBJECTIVE: To assess the change in the quality of life (QOL) in head and neck cancer patients treated with Simultaneous Integrated Boost (SIB) by Volumetric Modulated Arc Therapy (VMAT) technique. METHODS: Thirty patients with localised head and neck cancers (Stage II- IVa) were treated with VMAT and SIB technique. The three-dose levels prescribed were 68.2 Gy at 2.2 Gy/fraction, 62 Gy at 2 Gy/fraction and 55.8 Gy at 1.8 Gy/fraction to the high, intermediate and low-risk volumes respectively. Concurrent chemotherapy with cisplatin 100 mg/m2 was administered once in three weeks. Acute toxicities were evaluated and scored according to the RTOG grading system. Quality of life (QOL) was assessed using European Organization of Research and Treatment of Cancer (EORTC) QLQC30 and HN35 questionnaires at baseline and in three instances (immediately, one month and three months after the radiotherapy). RESULTS: Out of the total 30, 80% patients had a complete response (CR) at the median follow up of 12 months, while three patients died because of progression, and the remaining 3 had stable disease. All planning objectives were achieved for organs at risk and planning target volume(PTV). There was a statiscally significant(p value < 0.001) reduction in global quality of life scores at the end of treatment when compared to baseline scores, but by three months, there was the return in the QOL scores in most scales similar to the baseline value. CONCLUSION: VMAT based Simultaneous boost radiotherapy is a feasible and safe strategy in terms of toxicity profile with an acceptable transient change in the quality of life and allows a faster return to baseline quality of life.

Time, distance, shielding and ALARA; drawing similarities between measures for radiation protection and Coronavirus disease pandemic response.

The practice of radiation oncology requires stringent adherence to specific steps and principles designed to minimize exposure of an individual to unnecessary doses of radiation. The basic principles of such measures to reduce the risk of exposure and limit the doses of irradiation follow the "as low as reasonably achievable " or ALARA principle by using the concepts of time, distance and shielding. Potential exposures in radiation oncology are controlled through combination of optimal design and installation of radiation delivery equipment with well-defined standard operating procedures (SOPs). In the modern era of viral pandemics, similar principles can also be applied toward prevention of viral transmission and protection of populations at risk. In the ongoing COVID-19 pandemic, the probability of an individual getting infected is dependent on the viral load that an individual is exposed to in public spaces over a period of time. All prevention and control measures are based on preventing any such exposure to the virus, that can be achieved through limiting space for movement of the virus, using barriers and increasing distance to vulnerable surfaces, and limiting the duration of exposure. Apart from adhering to the laid-down provisions of a lock-down, preventive measures recommended for the general public include maintaining hand-hygiene, social distancing, and using facemasks to break the chain of transmission. Appropriate triage and customization of treatment protocols can help curtail hospital visits and time-spent by cancer patients during pandemic times, thereby reducing their risk of exposure as well as allowing efficient utilization of resources. The outbreak of the contagious COVID-19 pandemic threatens to disrupt healthcare systems globally with its unprecedented challenges. However, despite all the difficulties and hardships, it has also enabled new ways of learning and communication, which are likely to persist even in the post-COVID world.

Brachytherapy in head and neck malignancies: Indian Brachytherapy Society (IBS) recommendations and guidelines.

PURPOSE: Brachytherapy (BT) forms major treatment modality in squamous cell carcinoma of head and neck cancers (HNC). However, there is a dearth of literature and guidelines for the use in various indications. High-dose-rate brachytherapy (HDR-BT) in Indian scenario is an important treatment modality, and the recommendations in this guidelines aim to provide the necessary recommendations for the use of HDR-BT for uniform application across the country in patients with HNC. MATERIAL AND METHODS: A panel consisting of members of the Indian Brachytherapy Society (IBS), based on their clinical experience was invited. The process involved defining important steps, precautions, target volumes and indications, thorough literature review, and discussion with fellow members. The guidelines were established and formulated the recommendations for HDR-BT based on available evidences and individual experience for sites, relevant to Indian settings. RESULTS: The IBS recommends the use of HDR brachytherapy as a part of treatment of head and neck tumors. The scope of these guidelines and recommendations included practical suggestions, ensuring efficient use of brachytherapy treatment as radical with external beam radiotherapy (EBRT) boost, palliative and adjuvant as definitive, or re-radiation as salvage for HNC in India. The IBS has made specific site-wise recommendations for previously untreated and recurrent HNC patients on their selection criteria, implant techniques, target volume definition, and HDR treatment parameters, such as time, dose rate, total dose, and fractionation schedules. Limited experience exists with HDR-BT in patients with head and neck cancers in India and across the globe. CONCLUSIONS: IBS provided a consensus statement and guidelines for the head and neck brachytherapy and believed that these recommendations will overcome the fear of practicing radiation oncologists. This should generate interest amongst students and will help radiation oncologists all across the country to use the art of brachytherapy carefully in HNC patients, with better curative and salvage options.

Gastric Adenocarcinoma in a 16-Year-Old Female.

BACKGROUND: Primary gastric adenocarcinoma commonly occurs in the elderly in the sixth to seventh decade of life but is exceedingly rare in children and adolescents, accounting for only 0.05% of pediatric gastrointestinal malignancies. Because of the nonspecific clinical presentation, gastric adenocarcinomas in children and adolescents are often metastatic when they are discovered. CASE REPORT: We describe a case of gastric adenocarcinoma in a 16-year-old female who was diagnosed early and successfully treated with surgery and chemoradiation by volumetric modulated arc technique. CONCLUSION: The possibility of gastric adenocarcinoma should be considered in children and adolescents with persistent nonspecific symptoms of vomiting and upper abdominal pain so that the diagnosis can be made at early stages and radical treatment can be offered.

Malignant soft tissue sarcoma of the shoulder treated by surface mould brachytherapy boost in an adjuvant setting.

PURPOSE: Soft tissue sarcomas of the extremities account for half of all soft tissue sarcomas. Radiotherapy and surgery have been the standard modalities in the treatment of this type of cancer. Brachytherapy can be used as the sole therapy, if the target volume is localized and easily accessible. This work reports three cases of shoulder soft tissue sarcomas with positive deep resected margins, treated with a combination of external beam radiotherapy and surface mould brachytherapy boost technique. MATERIAL AND METHODS: Between January and June 2014, three patients received brachytherapy with sites close to the shoulder, and post-surgery involved deep resected margins. Each mould was made on a base of thermoplastic, over which dental wax was coated and catheters implanted. The target volume was defined as the tissue covering the tumor bed with lateral margins of 2-2.5 cm and depth of 1-1.5 cm. Treatment planning was computed tomography-based and dose prescribed was 85-100% isodose. Treatments has been delivered twice daily, six hours interval, and a review of reactions evaluated. RESULTS: Volume receiving more than 150% of the prescribed dose has been limited to less than 2%, and that above 200% to be inside the mould. Brachytherapy equivalent dose at 2 Gy per fraction (EQD2) of these patients was 24 and 28.6 Gy. Maximum dose to organ at risk (OAR) (2 cc of OAR) ranged between 55-87% of prescribed dose, with a median dose being 80%. All cases had only grade 1 post-radiotherapy skin immediate reactions, which resolved within four weeks. In all patients, no treatment failures were noted at nearly 2-years post-irradiation. CONCLUSIONS: Surface mould brachytherapy in soft tissue sarcomas could be a useful alternative to interstitial brachytherapy, especially where the target volume is superficially extensive with underlying critical structures, and where catheter placement may be difficult, such as the shoulder.

Dosimetric analysis and clinical outcomes in CT-based mould brachytherapy in early oral cancers in patients unfit for surgery.

PURPOSE: Brachytherapy in the oral cavity is an important alternative to conventional treatment, and provides a high localized dose and short overall treatment time. A rapid fall of dose beyond radioactive source makes it possible for increased tumour control and sparing surrounding tissue, while short overall treatment duration reduces risk of tumour repopulation. Moulds are fabricated to hold the catheters in position as closely as possible to tumour surface to provide adequate dose coverage of tumour volume and increase distance to other normal surrounding structures. Image based planning and dose optimisation help in better defining target volume and dose coverage. MATERIAL AND METHODS: A retrospective analysis of patients of early squamous cell carcinomas of lip and buccal mucosa from September 2011 to June 2014 to study response to mould brachytherapy. Double plane moulds were prepared for all lip cancer cases and single plane for buccal mucosa cases. Patients are being followed up till disease recurrence. In this study evaluation was done of the technique used, planning details, response to therapy, and reactions encountered. RESULTS: Nine patients treated by mould therapy were reviewed; seven cases were of lip and two of buccal mucosal cancers. Dose delivered ranged from 12.5-48 Gy in fraction sizes of 2.5-3.5 Gy. Equivalent dose in 2 Gy fractions (EQD2) ranged from 18-64 Gy. Maximum dose to organs at risk (OAR) was 91% of prescribed dose. Local mucositis was only reaction in all cases, which resolved in 3-6 weeks. Median follow-up was 19 months. Eight out of nine patients are in remission at a minimum of 7 months (1 case, rest over 14 months) post therapy and only patient had nodal recurrence at 18 months. CONCLUSIONS: Mould therapy is an effective treatment method for selected early and superficial squamous cell carcinomas of the oral cavity, although indications are limited.

Carcinoid of the trachea in a young adult male responsive to chemo-radiation.

Carcinoid of the trachea is an extremely rare entity with very few cases reported in literature. The standard of treatment is complete surgical excision with limited role for chemotherapy and also a limited role for radiotherapy as this type of tumour has very low metastatic potential. We describe a case of a tracheal carcinoid which was surgically unresectable, but which showed excellent response to combined modality treatment with sequential multi-agent chemotherapy followed by radiotherapy with complete resolution of disease.