Adherence to Treatment, Response and Patterns of Failure in Pediatric Parameningeal Rhabdomyosarcoma: Experience From a Tertiary Cancer Care Center From India.

The study was aimed at evaluating adherence to treatment protocol and outcome in pediatric parameningeal rhabdomyosarcoma (PM-RMS). We analyzed the characteristics, treatment administered, outcomes and patterns of failure of pediatric PM-RMS, who were treated with multimodality therapy between January 2005 and December 2013.Univariate and multivariate analysis (MVA) was completed to evaluate the impact of various prognostic factors. Thirty-seven patients were treated at our institution. Majority of them had the primary disease in paranasal sinuses (n=13). Majority of the patients belonged to group III (n=30) and stage III (n=24). The overall response rate to treatment was 52.5% (n=21). At a mean follow-up of 19.1 months, 23 patients developed disease progression. The actuarial rates of failure-free survival and overall survival (OS) at 2 years were 40% and 67.5%, respectively. Patients who received >20 weeks of intended chemotherapy schedule (P=0.02) and had complete response to first-line treatment (P=0.0004) were found to have superior failure-free survival on MVA. Complete response was the lone determinant of superior OS on MVA (P=0.006). Majority of patients with PM-RMS present with advanced stage disease. Response to first-line treatment is a significant predictor of superior progression-free survival and OS in these patients.

Grieving the Loss of a Pet Needs the Health System Recognition.

Globally there is increased presence of pets in the households. This non-human relationship, with its dimensions of physical and emotional bonds, can get severely jolted on the death of the companion animal. It sets a feeling, 'our life is now left with a void and the house feels utterly empty'. Unlike the loss of a child, spouse or parent which become a shared tragedy; others may not understand the depth of sadness and a sense of void in a grieving pet owner. Emotional pain and physical distress due to the loss of a companion animal are likely to be pronounced. A big challenge for the medical community is to anticipate, identify and address physical and psychosocial symptom burdens in a timely manner.

Health impact is the invisible side of terrorism.

Since 201 4, there is a shift in terror targets, with a 1 72% increase in the deaths of common citizens. India ranks fourth in the global terrorism index. Intelligence, security and counter-terrorism conjointly form the contours of priority for governance and public engagement but the attendant aspects of health system remain neglected. Recurring acts of global terrorism have given rise to unique medical requirements that can be termed as 'terror medicine', geared towards managing health impacts of terrorism and not just a single patient. Health impacts of terrorism that affect vulnerable and non-combative citizens will need a well-developed healthcare delivery mechanism consisting of four components: medical preparedness, incident management, care of injuries and body functions, and intervention for psychological consequences. Terror medicine should not be considered a 'dangerous territory', as it can provide opportunities for healthcare to gain new strengths of knowledge and research, similar to the medical outcomes from the two world wars.

Development of peptide inhibitor as a therapeutic agent against head and neck squamous cell carcinoma (HNSCC) targeting p38alpha MAP kinase.

BACKGROUND: The p38alpha MAP kinase pathway is involved in inflammation, cell differentiation, growth, apoptosis and production of pro-inflammatory cytokines TNF-alpha and IL-1beta. The overproduction of these cytokines plays an important role in cancer. The aim of this work was to design a peptide inhibitor on the basis of structural information of the active site of p38alpha. METHODS: A tetrapeptide, VWCS as p38alpha inhibitor was designed on the basis of structural information of the ATP binding site by molecular modeling. The inhibition study of peptide with p38alpha was performed by ELISA, binding study by Surface Plasmon Resonance and anti-proliferative assays by MTT and flow cytometry. RESULTS: The percentage inhibition of designed VWCS against pure p38alpha protein and serum of HNSCC patients was 70.30 and 71.5%, respectively. The biochemical assay demonstrated the K(D) and IC50 of the selective peptide as 7.22 x 10(-9) M and 20.08 nM, respectively. The VWCS as inhibitor significantly reduced viability of oral cancer KB cell line with an IC50 value of 10 microM and induced apoptosis by activating Caspase 3 and 7. CONCLUSIONS: VWCS efficiently interacted at the ATP binding pocket of p38alpha with high potency and can be used as a potent inhibitor in case of HNSCC. GENERAL SIGNIFICANCE: VWCS can act as an anticancer agent as it potentially inhibits the cell growth and induces apoptosis in oral cancer cell-line in a dose as well as time dependent manner. Hence, p38alpha MAP kinase inhibitor can be a potential therapeutic agent for human oral cancer.

Clival giant cell tumor presenting with isolated trigeminal nerve involvement.

Giant cell tumour (GCT) constitutes about 5 % of all skeletal tumors. They rarely occur in the skull. When involved, they preferentially involve the sphenoid or temporal bones. Skull-base GCTs generally present with multiple cranial nerves involvement, most commonly sixth followed by the third cranial nerve. We describe a case of clival GCT presenting with an isolated trigeminal nerve involvement in a 19-year-old man which was managed by surgery and adjuvant radiation. At 18 months of follow-up, the patient is clinically asymptomatic. Clival GCT should also be considered in the differential diagnosis of any isolated trigeminal nerve palsy. Adjuvant radiation has an important role to play in managing this tumour.

Outcome, pathologic findings, and compliance in orbital retinoblastoma (International Retinoblastoma Staging System stage III) treated with neoadjuvant chemotherapy: a prospective study.

PURPOSE: The present study prospectively evaluated outcome, pathologic findings, and compliance in orbital retinoblastoma patients (International Retinoblastoma Staging System [IRSS] stage III). DESIGN: Prospective study and case series. PARTICIPANTS: Twenty-eight consecutive IRSS stage III retinoblastoma patients were enrolled prospectively in the study after ethics committee approval and written informed consent. METHODS: Planned therapy for patients included treatment with a uniform protocol consisting of neoadjuvant chemotherapy followed by enucleation, adjuvant radiotherapy, and chemotherapy. Prospective computerized data entry and telephone contact were undertaken to improve compliance, a major issue in treatment of orbital retinoblastoma. MAIN OUTCOME MEASURES: Event-free survival (EFS) and overall survival (OS) were calculated using Kaplan-Meier survival analysis. The difference between groups was analyzed using the log-rank test. RESULTS: Median follow-up was 14.75 months (range, 2.23-26.3 months). The OS for all patients was 40.4% and the EFS was 33.33% at a follow-up of 26.3 months. The median EFS and OS were 10.37 months and 15.73 months, respectively. At baseline, bilateral retinoblastoma predicted inferior EFS (P = 0.0006) and OS (P = 0.0081). Twenty-two of 28 patients underwent enucleation, and viable tumor was present in 21 of 22 enucleated specimens (95%). Neoadjuvant chemotherapy prevented orbital exenterations. Presence of tumor in the cut end of the optic nerve significantly correlated with inferior EFS (P = 0.012) and OS (P = 0.0098). Central nervous system metastasis was the most common site of relapse and death. The overall rate of compliance with treatment was 67.8% (19/28), which was twice the compliance rate at the authors' center before initiation of the present study. CONCLUSIONS: There is a paucity of information in the literature on outcomes and pathologic findings after neoadjuvant chemotherapy in IRSS stage III retinoblastoma treated with a uniform treatment protocol, and as far as the authors are aware, there has been no prospective study. Neoadjuvant chemotherapy was able to avoid exenteration in all operated patients; however, residual viable tumor was present in 95% of enucleated specimens. Bilaterality and tumor in the optic nerve cut end after neoadjuvant chemotherapy were associated with inferior outcome. Compliance could be improved with computerized data entry and regular telephone contact.

PNET spine: morbid and mortal, but ignored till late.

Spinal primitive neuroectodermal tumor (PNET) is rare. We present clinical, radiologic profile and treatment outcome of 15 spinal PNET patients from June 2003 to March 2010 treated with chemoradiotherapy. Median duration of backache was 6.5 months; all had features of myelopathy and/or radiculopathy; 5/15 (33.3%) patients were diagnosed initially as spinal tuberculosis. The event-free survival (EFS) was 24.73% at a median follow-up of 22 months. Complete functional recovery to treatment significantly predicted better EFS; 4 patients discontinued treatment because of poor functional recovery. It is important to recognize spinal PNET early to prevent permanent neurological damage, which in turn would improve compliance, quality of life, and perhaps EFS.

Audit of radiation oncology practice: Lessons from a new private hospital in Delhi, India.

Aims: The objective of this audit was to analyze the radiotherapy (RT) practice in a newly established tertiary private hospital. With increasing radiation oncology (RO) facilities in private sector, this report is the first audit from a private health organization in India. Subjects and Methods: The audit of all consecutively registered patients in RO has focused to extract data from the time of RT simulation planning till the completion of RT course. The patient and disease characteristics,RT-related treatment factors and compliance were analyzed in-depth. Results: In this newly established RO department, the vendor-supplied equipment, e.g., RT planning system, treatment delivery (linear accelerator and brachytherapy), and RO information system (ROIS), are integrated with enterprise-wide hospital information system into unified paperless workflow management for the patient care records in a prospective manner. This analysis comprised consecutive 328 patients who consented for RT simulation and planning from April 20, 2018, to December 31, 2019. RT course compliance was 94.8% (311/328 patients), and treatment intent-wise: curative plus adjuvant in 60.2% and palliative RT in 36%. RT technique was conformal in all 100%, with volumetric arc radiotherapy (VMAT) delivered to 66.6% of patients. With overall median RT course duration of 29 days (range 1-81 days), the patients were delivered a median of 20 fractions. Conclusions: Compared to the previously published audit from an academic RO department in Delhi, this audit from a private hospital has shown (i) lesser waiting time, (ii) improved treatment compliance, (iii) utilization of higher techniques, and (iv) a lower duration of RT course.

Post-COVID-19 Assessment of Physical, Psychological, and Socio-Economic Impact on a General Population of Patients From Odisha, India.

AIM:  This prospective cross-sectional study evaluated the physical, psychological, and socioeconomic impacts of post-COVID-19 conditions (PCC) in a generalized population from Odisha, India. MATERIALS AND METHODS:  The study protocol and clinical record form (CRF) were approved by the Institutional Ethics Committee. Those above 18 years and of all genders who had recovered in the last six months, whether hospitalized or not hospitalized after the COVID-19 diagnosis, were included in our study. RESULTS:  A total of 198 persons with a median age of 41 years (18-87 years) were enrolled at the post-Covid clinic. For COVID-19 management, 91 persons (46%) were hospitalized, and the remaining 107 (54%) were non-hospitalized. Five dominant clusters of physical symptoms were present - fatigue (82.8%), cough (54%), breathing difficulty (54%), pain in the body (53%), and sleeplessness (51%). The psychological issues faced were fear (41.6%), worry (40.4%), depression (31.8%), and anger (30.3%). The median monthly income in Indian Rupees (INR) for pre-Covid versus post-Covid was 30,000 versus 25,000, effectively a loss of 16.6% in the family income. Adverse impacts on health and economic conditions were observed in 31.3% and 20.7%, respectively. CONCLUSION: Post-Covid clinics can be a resource-appropriate health system approach for nearly 20% of the pandemic survivors with a low gross domestic product (GDP) per capita.

The dogma of Cetuximab and Radiotherapy in head and neck cancer - A dawn to dusk journey.

Since the introduction of Cetuximab as a biological molecule against Epidermal Growth Factor Receptor (EGFR), its use in the cancers of head and neck region is widely explored. With the recognition that EGFR expression is associated with radioresistance and poor prognosis, incorporation of an anti-EGFR agent along with Radiotherapy (RT) is a logical and attractive option. Cetuximab in combination with RT as Bio-Radiotherapy (BRT) is considered one of the standard treatment modalities in Locally Advanced Head and Neck Squamous Cell Cancers (LA-HNSCC). Many important phase-III clinical trials were undertaken simultaneously, where the use of Cetuximab BRT was tested in various clinical scenarios with different hypothesis. With the studies still ongoing and the results awaited, its use was continued in clinical practice. Today the results are out and definitely not encouraging. After the initial success, Cetuximab has miserably failed to win over cisplatin based chemoradiation which is the current standard of care in LA-HNSCC. Hence, it is the need of the hour to re-evaluate and define the present role of Cetuximab in the definitive management of LA-HNSCC in the light of the latest clinical evidence..

Daily waiting and treatment times at an advanced radiation oncology setup: A 4-year audit of consecutive patients from single institution.

PURPOSE: We present our data for every single fraction for every patient treated at our center for the past 4 years, analyzing the waiting and treatment times. MATERIALS AND METHODS: Between January 2014 and February 2018, all patients and their corresponding recorded measurements of waiting time and machine treatment time were analyzed. Times recorded included actual arrival time, designated arrival time, linac entry time, and last beam treatment time. The complete waiting time information was divided into two categories (1) first day treatments and (2) subsequent day treatments. SPSS version 18 was used for statistical calculations, correlations, and assessing significance. RESULTS: First day treatments - of 1982 patients following treatments were carried out; 1557 volumetric-modulated arc therapy (78.6%), 88 three-dimensional conformal radiotherapy (RT) (4.4%), 14 electron (0.7%), 10 intensity-modulated RT (0.5%), 264 stereotactic irradiation (13.3%), 17 stereotactic body RT (0.7%), and 32 total body irradiation (1.6%). The mean (± standard deviation) times for early/late time, total spent time (TST), wait time gross (WTG), and wait time net (WTN) were 11.0 ± 49.6 min, 74.7 ± 44.8 min, 47.46 ± 43.9 min, and 24.1 ± 44.4 min, respectively. Subsequent day treatments - a total of 34,438 sessions of treatment delivery were recorded. Overall average WTG was 37.4 ± 32.7 min. Overall WTN was 12.1 ± 62.7 min. Overall mean total spent time (TST) was 52.4 ± 33.0 min, overall mean setup and treatment time was 15.1 ± 10.9 min. CONCLUSION: We have presented our results of patient-related times during RT. Our study covers the daily waiting times before RT as well as the actual treatment times during modern-day RT. This consecutive patient data from a large series shall be an important resource tool for future planners and policymakers.

Dosimetric comparison of short and full arc in spinal PTV in volumetric-modulated arc therapy-based craniospinal irradiation.

Since 2011 when it was first described, the volumetric-modulated arc therapy (VMAT) technique for craniospinal irradiation (CSI) has always seen the use of large arc lengths for the spine fields ranging from 200° to 360°. This study was aimed to do a dosimetric comparison between the large and shorter spinal arc for CSI. For a cohort of 10 patients, 2 VMAT CSI plans were created for each patient, one using the conventional full 360° arc (VMAT_FA) for the spine and the other using 100° posterior arc (VMAT_PA) for 23.4 Gy and 35 Gy prescriptions. In both the plans, 360° arc fields were employed for treating cranial volume. Spillage dose (DBody-PTV) to Body-PTV (DBody-PTV: dose to body excluding planning target volume) was compared with VMAT_FA and VMAT_PA plans. In addition to these VMAT plans, a 3-dimensional conformal radiotherapy plan was also created for all these patients to compare the DBody-PTV and target volume related dose constraints. Mean D95% difference between the two VMAT plans did not exceed 1.3% for cranial and spinal targets for both prescription levels. The conformity index (CI) was averaged over both prescription doses. Average CI shows a similar value for VMAT_FA (0.84 ± 0.04) and VMAT_PA (0.82 ± 0.05) plans. D95%, V110% and CI did not exhibit a statistically significant difference between partial and full-arc VMAT plans. However, the VMAT_PA plan exhibited a lower DBody-PTV compared to VMAT_FA plans (0.007 ≤ p < 0.05) in the 1 to 5 Gy range. Nevertheless, partial arc plans could not offer a statistically significant dose reduction for delineated organs compared to full arc plans, except for bilateral kidneys.

Treatment Outcome and Patterns of Failure in Patients with Maxillary Sinus Cancer: Clinical Experience from a Regional Cancer Centre in North India.

Treatment of maxillary sinus cancer poses several challenges because of its complex anatomy, close proximity to critical structures and majority of patients presenting at an advanced stage. Despite presence of several treatment approaches, the outcome in these cancers has remained dismal. This article examines its clinical behaviour and treatment outcome of these patients treated at our centre in past 7 years. In this retrospective study, 67 patients with carcinoma of maxillary sinus presented from January 2011 to December 2017 were analysed. All the patients reporting during this period were included except those who did not turn up after first visit. Of all the patients, 64.2% had squamous cell carcinoma. The majority of patients presented with advanced stage (IVA and IVB, 83.58%). Nodal disease at presentation was seen in seven patients (10.4%). Treatment to the primary site comprised of surgery and radiotherapy in 24 patients, radiotherapy alone in 22 patients and surgery alone in 12 patients. Statistical program for social sciences (SPSS) version 16 was used for all statistical analyses. The mean follow-up time was 25 months (range 3-72 months). Overall, 17 out of 41 patients who were treated with curative intent (41.5%) developed recurrence. Patients who underwent surgery followed by adjuvant radiotherapy did fairly better in terms of recurrence. Seven patients out of 17 (41.2%) could be salvaged by surgery or radiation. Only one patient developed distant metastasis to D8 vertebra. Patients who were treated with surgery and radiotherapy (either preoperative/adjuvant setting) had better disease-free survival. The results of the current study regarding the treatment of carcinoma of the maxillary sinus show feasibility and efficacy of multimodal therapy. Radical radiotherapy appears to be a feasible alternative in cases of inoperable tumours. Loco regional relapse remains a significant pattern of failure.

Perfusion magnetic resonance imaging in contouring of glioblastoma patients: Preliminary experience from a single institution.

PURPOSE: T1-contrast and T2-flair images of magnetic resonance imaging (MRI) are commonly fused with computed tomography (CT) and used for delineation of postoperative residual tumor and bed after surgery in patients with glioblastoma multiforme (GBM). Our prospective study was aimed to see the feasibility of incorporating perfusion MRI in delineation of brain tumor for radiotherapy planning and its implication on treatment volumes. METHODS: Twenty-four patients with histopathologically proven GBM were included in the study. All patients underwent radiotherapy planning with a contrast CT scan. In addition to radiotherapy (RT) planning protocol, T1-perfusion MRI was also done in all patients in the same sitting. Perfusion imaging was processed on the in-house-developed JAVA-based software. The images of CT and MRI were sent to the iPlan planning system (Brainlab AG, GmbH) using a Digital Imaging and Communications in Medicine - Radiation Therapy (DICOM-RT) protocol. A structure of gross tumor volume (GTV)-perfusion (GTV-P) was delineated based only on the MRI perfusion images. Subsequently, GTV-P and GTV were fused together to make GTV-summated (GTV-S). Using existing guidelines, GTV-S was expanded to form clinical target volume-summated (CTV-S) and planning target volume-summated (PTV-S). The increment in each of the summated volumes as compared to baseline volume was noted. The common overlap volume (GTVO) between GTV and GTV-P was calculated using intersection theory (GTV n GTV-P = GTVO [Overlap]). RESULTS: Mean ± standard deviation (cc) for GTV, GTV-P, and GTVO was 46.3 ± 33.4 cc (range: 5.2 cc-108.0 cc), 26.0 ± 26.2 (range: 6.6 cc-10.3.0 cc), and 17.5 ± 22.3 cc (range: 10.0 cc-92 cc), respectively. Median volume (cc) for GTV, GTV-P, and GTVO was 40.8 cc, 17.2 cc, and 8.0 cc, respectively. Mean absolute and relative increments from GTV to that of GTV-S were 8.5 ± 8.2 cc and 27.2 ± 30.9%, respectively. Average CTV volume (cc) was 230.4 ± 115.3 (range: 80.8 cc-442.0 cc). Mean and median CTV-S volumes were 262.0 ± 126.3 cc (range: 80.8 cc-483.0 cc) and 221.0 cc, respectively. The increment in the mean CTV volume (with respect to CTV created from GTV-S) was 15.2 ± 15.9%. Mean and median PTV volumes created on the summated CTV were 287.1 ± 134.0 cc (range: 118.9 cc-576.0 cc) and 258.0 cc, respectively. Absolute and relative increments in PTV volume, while incorporating the perfusion volume, were 31.3 ± 28.9 cc and 12.5 ± 13.3%, respectively. Out of the total of 24 patients, perfusion scanning did not do any increment in GTV in five patients. CONCLUSIONS: Our study is the first to present the feasibility and the outcome of contouring on perfusion imaging and its overlay on regular MRI images. The implications of this on long-term outcome and control rates of glioblastoma patients need to be seen in future studies.

Radiotherapy in India: History, current scenario and proposed solutions.

The history and current status of a biomedical discipline in a country or region provide important health system indicators. During the last one hundred years, radiotherapy has established its position as a vital specialty in cancer management. It has proved to be one of the most cost effective ways of treating cancer providing both radical and palliative treatments depending on patient stage and performance status. However, access to radiotherapy for cancer patients in India is limited by several factors including physical proximity of centre, cost and availability of required technology. This article gives an outline of the history, existing radiotherapy facilities and future trends related to radiotherapy practice in India.

Melphalan and dexamethasone for patients with multiple myeloma who are not candidates for autologous stem cell transplantation.

BACKGROUND: Multiple myeloma is a disease for which a number of treatment options are available. The choice of therapy is often based on factors such as cost, ease of administration and faster response as the survival rates are similar with most of the regimens. We assessed the efficacy of a combination of melphalan and dexamethasone as first-line therapy in patients with multiple myeloma who were not candidates for autologous stem cell transplantation. METHODS: Thirty-four patients with multiple myeloma were included in the study. Patients received a maximum of 12 cycles of chemotherapy consisting of oral melphalan 8 mg/m2 on days 1-4 and oral dexamethasone 40 mg on days 1-4 and days 9-12 every 4 weeks. Patients were assessed for response on the basis of M proteins and a bone marrow biopsy with touch preparation. RESULTS: The median follow up of surviving patients was 40 months. Nine patients (26.1%) had complete response/near complete response (5 had negative immunofixation) and 15 (44%) had partial response. The regimen was well tolerated and there were no therapy-related deaths. The 3-year overall and progression-free survival rates using the Kaplan-Meier method were 53% and 34%, respectively. The median duration of overall and progression-free survivals were 58 and 28 months, respectively. CONCLUSION: The combination of melphalan and dexamethasone is safe and effective in patients with multiple myeloma who are not candidates for autologous stem cell transplantation.

Postoperative radiotherapy dose requirement in standard combined-modality practice for head and neck squamous cell carcinoma: Analysis of salient surgical and radiotherapy parameters in 2 cohorts.

BACKGROUND: This study compared 2 sequential cohorts to identify the postoperative radiotherapy (PORT) dose requirement for head and neck squamous cell carcinoma (HNSCC). METHODS: Two distinct PORT dose regimens were prescribed over 11 years; group 1 received 56 Gy or less, and group 2 received 60 Gy or more. The 2D and 3D techniques were used. RESULTS: Two sequential cohorts consisted of 478 patients, with mean and median follow-up for group 1 and 2 as: 37.0 versus 28.5 months and 13.8 versus 13.1 months, respectively. Grades 3-4 mucosal toxicities (11.4% vs 28.3%), hospitalization (3.2% vs 17.4%), and nasogastric feeding (11.9% vs 29.7%) were higher in group 2. The 2-year disease-free survival (DFS) was higher with PORT >60 Gy for the following factors: age ≤ 50 years (P = .041); ≥ 4 positive nodes (P = .029); and overall treatment time (OTT) ≥ 100 days (P = .042). CONCLUSION: Except for the benefit of doses >60 Gy for limited parameters, a lower PORT dose did not compromise the results and can potentially reduce the morbidities and healthcare costs.

Compliance and outcomes of concurrent Chemo-radiation in patients with peri-ampullary cancer undergoing curative resections.

OBJECTIVES: We aimed to study the compliance and treatment outcome of patients who received adjuvant treatment following curative resection for periampullary cancers periampullary cancers. MATERIALS AND METHODS: Institute medical records of PAC treated during 2007-2014 were retrieved. Demographics, treatment, and outcome in patients who were intended to receive adjuvant chemoradiation after curative resection were analyzed. Patients received first cycle chemotherapy with 5-fluorouracil folinic acid/capecitabine, followed by external radiotherapy 45 Gy/25 fractions/5 weeks and second and third cycle concurrent chemotherapy. Fourth and fifth cycle chemotherapy were administered after radiotherapy). Various prognostic factors, disease-free survival (DFS), and overall survival (OS) were evaluated. RESULTS: Sixty-five patients were evaluated. Median age was 50 years. 96.9% patients completed the intended course of radiation and overall adherence to chemotherapy was 86.2%. Median follow-up and DFS were 20 and 29.64 months, respectively (range: 1.9-97.3 months). Estimated 1-, 2-, 5-year DFS was 77.8%, 59.3%, and 37.6%, respectively. One-year estimated OS was 92.7%. Median DFS for node-negative and node-positive patients was 88.6 and 24.33 months (P = 0.06). Grade ≥III hematological toxicity was 20%. CONCLUSION: Positive node indicated a trend toward poor survival. The study highlights high compliance to multimodal management of PAC with acceptable toxicity in and out of clinical trial setting in a tertiary cancer center in India.