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Objective: The objective of this study is to evaluate the diagnostic and prognostic ability of fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) scan in patients with squamous cell carcinoma of the head and neck treated with chemoradiotherapy or radiotherapy only. Materials and Methods: Fifty-nine patients with HNSCC planned for radical nonsurgical treatment were randomized to receive either three-dimensional conformal radiotherapy or intensity-modulated radiation therapy. In addition to routine clinical examination and staging investigations, patients had a FDG PET-CT scan at baseline and on the first follow-up for response assessment. No evidence of clinicopathological disease for at least 6 months after the completion of treatment was considered confirmation of complete response. The presence or absence of disease during the follow-up period was used to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET-CT for the primary site and node. Results: At a median follow-up of 52.5 months, 55.6% of patients were alive and disease free. Response assessment PET-CT was done at a median of 9 weeks (range: 5–18 weeks). PET-CT assessment of the primary had sensitivity, specificity, PPV, and NPV of 81.8%, 93%, 75%, and 95.2%, respectively; the corresponding figures at the node were 44.4%, 95.6%, 66.7%, and 89.6%. The median baseline maximum standardized uptake value (SUVmax) at primary and node was 14.9 and 8.1, respectively. When PET-CT was done after 10 weeks, no false-positive or false-negative findings were seen. Patients with negative PET at the first follow-up had a significantly better progression-free and overall survival. Conclusions: Disease evaluation using PET-CT has an overall accuracy of 80%. High baseline SUVmax correlates with worse clinical outcomes. Negative PET-CT at the first follow-up is a predictor for survival.

Aim : Prospective subjective evaluation of swallowing function and dietary pattern in locally advanced head and neck cancer patients treated with concomitant chemo-radiotherapy (CRT). Materials and Methods : Prospective evaluation of swallowing function with performance status scale for head and neck cancer patients (PSSHN) at pre-CRT, CRT completion and at subsequent follow-ups in adult with loco-regionally advanced head and neck squamous cell carcinoma (HNSCC) patients. Results : In 47 patients (40 male, seven females; mean age 53; 72% smoker 53%, oropharyngeal cancer), the mean total PSSHN score at pre-CRT was 258.5 and decreased to 225.2 and 219.2 at two and six months respectively. Understandability of speech, normalcy in diet and eating in public at pre-CRT and six months were 91.5 and 84.4; 80.4 and 63.1; 87.3 and 76.6 respectively. In univariate analysis, pre-CRT PSSHN scores were significantly lesser in patients with severe pre-CRT dysphagia (P = 0.001), hypopharyngeal cancer (P = 0.244) and advanced T-stage (T3/4) disease (P = 0.144). At CRT completion, there was significant reduction of PSSHN scores in patients with severe pre-CRT dysphagia (P = 0.008), post-CRT weight loss (>10%) and disease progression (P = 0.039). At two months and six months, 17 (57%) and 11 (73.5%) patients respectively showed change in dietary habit. Mean increase in meal time was 13% and 21% at two and six-month follow-up. Conclusions : HNSCC patients show deterioration in swallowing function after CRT with normalcy of diet in maximum and eating in public least affected. Pre-CRT severity of dysphagia, weight loss> 10% and disease progression have significant correlation with higher swallowing function deterioration after CRT.

Aims and Objectives: To study the geometric uncertainties in the treatment and evaluate the adequacy of the margins employed for planning target volume (PTV) generation in the treatment of focal conformal radiotherapy (CRT) for patients with brain tumors treated with different head support systems. Materials and Methods: The study population included 11 patients with brain tumors who were to be treated with CRT. Contrast-enhanced planning CT scan (5-mm spacing and reconstructed to 2 mm) of brain were performed. Five patients were immobilized using neck support only (NR-only) and six patients had neck support with flexion (NRF), the form of immobilization being decided by the likely beam arrangements to be employed for that particular patient. The data was transferred to the planning system (CadPlan) where three-dimensional conformal radiation therapy was planned. Digitally reconstructed radiographs (DRRs) were created for the orthogonal portals with the fixed field sizes of 10 x 10 taken at the isocenter. Treatment verification was done using an amorphous silicon detector portal imaging device for using orthogonal portals and the DRR was used as a reference image. An image matching software was used to match the anatomical landmarks in the DRR and the portal imaging and the displacement of the portals in x, y axis and rotation were noted in the anteroposterior (AP) and lateral images. Electronic portal imaging was repeated twice weekly and an average of 8-14 images per patient was recorded. The mean deviation in all the directions was calculated for the each patient. Comparison of setup errors between the two head support systems was done. Results: A total 224 images were studied in anterior and lateral portals. The patient group with NR-only had 100 images, while the NRF group had 124 images. The mean total error in all patients, NR-only group, and NRF group was 0.33 mm, 0.24 mm, and 0.79 mm in the mediolateral (ML) direction; 1.16 mm, 0.14 mm, and 2.22 mm in the AP direction; and 0.67 mm, 0.31 mm, and 0.96 mm in the superoinferior (SI) direction, respectively. The systematic error (S) in all patients, NR-only group, and NRF group in the ML direction was 0.31 mm, 0.28 mm, and 0.78 mm; 1.29 mm, 0.1 mm, and 2.24 mm in the AP direction; and 0.75 mm, 0.52 mm, and 0.94 mm in the SI direction, respectively. Random error (s) in all patients, NR-only group, and NRF group in the ML direction was 1.25 mm, 1.04 mm, and 1.41 mm; 1.31 mm, 1.36 mm, and 1.28 mm in the AP direction; 1.38 mm, 1.37 mm, and 1.39 mm in the SI direction, respectively. In all patients, the PTV margin with Stroom′s formula in the NR-only and NRF group was 1.29 mm and 2.55 mm in the ML, 1.15 mm and 5.38 mm in the AP, and 2.0 mm and 2.85 mm in the SI directions, respectively. Conclusion: A PTV margin of 5 mm appears to be adequate; further reduction to 3 mm may be considered based on our results. Errors were significantly higher in the AP direction with NRF when compared to NR-only. Differential PTV margin may therefore be considered, with more margin in the AP and less in other directions, especially with the use of flexion devices.

Background: Brain metastasis from primary head and neck squamous cell carcinoma (HNSCC) is infrequent and probably under-reported thereby leading to paucity of information. Methods: Archives of two institutes in India were studied from 2005 to 2013 and relevant information regarding patient demographics, treatment details, and follow-up was obtained for patients having brain metastasis (BM) from HNSCC. Data were analyzed using SPSS software version 20 (IBM Corporation, NY, USA). Results: Metastasis to the brain was detected in 17 patients with an HNSCC primary. The median age for diagnosis of index primary was 55 years (range (R) - 32–71 years) with 88% (15/17) being male. Oral cavity was the most common site of primary disease with 35% (6/17) followed by larynx (24%), oropharynx (18%), and hypopharynx (18%). The median stage at presentation was IVA (47%) and two (12%) were metastatic to the brain at presentation. Human papillomavirus analysis was not available for any of the patients. Neurological symptoms were complained of in 94% patients. The median BM-free-interval was 15 months (R - 1–67 months, SE ± 5.2). While 88% had multiple brain metastases, 82% also had extracranial metastasis and in 53% of patients, the index primary was not controlled. The median overall survival of all patients after the development of BM was 2 months (R - 0.5–6 months, SE ± 0.4). Conclusion: BM in HNSCC is mostly multiple, associated with extracranial metastasis and can occur in patients without locoregional relapse or residual disease and carries a dismal outcome.

Aim: This study aims to provide information on the accrual rate and to identify the reasons for non-enrollment of oral cancer patients into a clinical trial. Setting and Design: Prospective study conducted at the Tertiary Cancer Centre (India). Materials and Methods: Patients eligible and screened for the oral cancer adjuvant therapy (OCAT) were logged prospectively and reasons for non-enrollment were documented which were broadly divided into patient and trial related. Statistical Analysis Used: Demographic characteristics of the non-enrolees were compared with the enrolled. Factors predicting non-enrollment were analyzed using multivariate logistic regression test. Results: A total of 1335 patients with locally advanced cancer of the oral cavity were screened of whom 498 (37%) could be enrolled. Among non enrolled 837 patients, 182 (22%) had the trial-related reasons and 655 (78%) had patient-related reasons. Most important patient-related reasons were patients' preference of taking treatment closer to their native place (26.2%), lack of interest (16.8%) in trial participation. Anticipated poor compliance to treatment (5.9%) and follow-up (6.6%), inability to start treatment in time (6.2%) were important trial-related reasons for non-enrollment. Multivariate analysis identified the genders (female), education (illiterate), occupation (laborer) and non availability of support system in the city as significant predictors of non-enrollment. Conclusions: Both trial design and patient factors were important causes of non enrollment in eligible patients. Patients' need for being closer to home and refusal to participate were the most common reasons for non-enrollment.

Background: The objective of the study was to assess and evaluate the practice patterns of locoregional treatment of early and advanced breast cancer among radiation oncologists (ROs) in India. Materials and Methods: This questionnaire-based survey was served to practicing ROs through electronic mails and personal communication between November 2006 and March 2008. Patterns of practices with respect to locoregional treatment of breast cancer in patients with ductal carcinoma in situ, early breast cancer (EBC), locally advanced and metastatic breast cancer (MBC) were studied. Results: We analyzed sixty completed forms from ROs in India. The median number of breast cancer patients evaluated per year by the treating oncologist was 130, wherein EBC comprised 30%; locally advanced breast cancer (LABC), 50%; and MBC, 20%. A median 46% of the ROs favored breast-conserving therapy (BCT) in EBC and 92% of this subgroup advised adjuvant radiation therapy (RT) in BCT. For LABC, a majority 90% of the respondents advocated a modified radical mastectomy, whereas 42% chose to include the axilla in their RT portals. Conclusions: The survey highlights the prevalent varied treatment policies followed across the country and encourages us to understand and adopt a uniform consensus for the management of breast cancer.

Introduction: The present study identifies the prognostic factors influencing oral cancers in a large cohort of patients treated at a single institute. Materials and Methods: This is an audit of 1180 patients treated from 1990 to 2004 in the service setting with prospective data collection. Patients were treated with radical radiotherapy or were planned for surgery and post operative radiotherapy (PORT). None of the patients received postoperative concurrent chemoradiation. For analysis, patients were divided into Group 1 and Group 2 based on the oral cavity subsite. Results: Of the entire cohort, 810 patients had tumors of the Gingivo-alveolo-buccal complex, lip and hard palate (Group 1) and 370 patients had primaries in tongue and floor of mouth (Group 2). Three year locoregional control for the entire cohort was 58%. The three year local control (LC), locoregional control (LRC) and disease free survival (DFS) for PORT group were 74%, 65% and 60%, respectively, with pathological nodal status, perinodal extension and cut margin status showing statistical significance (P Conclusion: The results indicate superior outcomes with PORT particularly in advanced stages of oral cancer and inferior outcomes in tongue and floor of mouth subsites. There is scope for improving outcomes by adopting treatment intensification strategies.

Background: Linear Accelerator-based Intensity Modulated Radiation Therapy (IMRT), either as step-and shoot (SS) or in dynamic mode, is now considered routine in the definitive management of head and neck squamous cell carcinoma (HNSCC). Helical TomoTherapy (HT) is a new platform to deliver IMRT. This study aims to compare step-and-shoot Intensity Modulated Radiation Therapy (SS IMRT) with dynamic Helical TomoTherapy (HT) dosimetrically in patients with head and neck squamous cell carcinoma (HNSCC). Materials and Methods: Twelve patients with HNSCC, previously treated with SS IMRT, were re-planned on HT using the same CT dataset. Plans were compared for target coverage and organs-at-risk (OARs) sparing. Sparing of parotids was assessed after stratifying for side (contralateral vs. ipsilateral) and site of disease (laryngopharynx vs. oropharynx). Normal tissue complication probabilities (NTCP) were also compared for the parotid glands. Results: All HT plans showed improvement in target coverage and homogeneity, and reduction in OAR doses as compared to SS IMRT plans. For PTV 66, the mean V 99 improved by 14.65% ( P = 0.02). Dose Homogeneity (D 10-90 ) was significantly better in the HT plans (mean 2.07Gy as compared to 4.5Gy in the SS IMRT plans, P = 0.02). HT resulted in an average reduction of mean parotid dose of 12.66Gy and 18.28Gy for the contralateral and ipsilateral glands ( P = 0.003) respectively. This translated into a 24.09% and 35.22% reduction in Normal Tissue Complication Probability (NTCP) for the contralateral and ipsilateral parotids respectively ( P < 0.01). Site of disease (laryngopharynx vs. oropharynx) did not have any significant impact on parotid sparing between SS IMRT and HT. The maximum dose to the spinal cord showed a mean reduction of 12.07Gy in HT plans ( P = 0.02). Conclusion: Helical Tomotherapy achieved better target coverage with improved OAR sparing as compared to SS IMRT. The significant reduction in mean parotid doses translated into meaningful reduction in NTCP, with potential clinical implications in terms of reduction in Xerostomia and improved quality of life in patients with HNSCC.

Pilar tumor is a rare neoplasm arising from the external root sheath of the hair follicle and is most commonly observed on the scalp. These tumors are largely benign, often cystic, and are characterized by trichilemmal keratinization. Wide local excision has been the standard treatment. Recent reports have described a rare malignant variant with an aggressive clinical course and a propensity for nodal and distant metastases which, therefore, merits aggressive treatment. In this report, we present a case of malignant pilar tumor of the scalp with multiple nodal metastases at presentation. Diagnostic and therapeutic considerations, in the form of adjuvant radiotherapy, are subsequently discussed.

Locally advanced breast cancer (LABC) accounts for a sizeable number (30-60%) of breast cancer cases and is a common clinical scenario in developing countries. The treatment of LABC has evolved from single modality treatment, consisting of radical mutilating surgery or higher doses of radiotherapy in inoperable disease to multimodality management, which along with the above two included systemic therapy. Neoadjuvant chemotherapy (NACT) has made a tremendous impact on the management of LABC. NACT was initiated to institute systemic therapy upfront at the earliest in this group of patients with a high risk of micrometastasis burden. While NACT did not yield a survival advantage, it has however made breast conservation possible in selected group of cases. Large number of studies and many randomised trials have been done in women with LABC in order to improve the therapeutic decisions and also the local control and survival. With this background we have reviewed various treatment options in patients with LABC which should possibly help in guiding the clinicians for optimal management of LABC.

Aim: To translate and validate the European Organisation for Research and Treatment for Cancer (EORTC) brain cancer module (BN-20) into Hindi to make it available for patients and scientific community. Methods and Results: The EORTC BN-20 was translated into Hindi using standard guidelines by EORTC. The process included forward translation by two translators, discussion with the translators in case of discrepancies and formation of first intermediate questionnaire. This questionnaire was then given to two more translators who translated this questionnaire back into English. These 2 questionnaires were then compared with the original EORTC questionnaire and the second intermediate questionnaire was formed. The second intermediate questionnaire was subsequently administered in 10 patients with brain tumors who had never seen the questionnaire before, for pilot-testing. Each of these 10 patients after filling up the questionnaire themselves was then interviewed for any difficulty encountered during the filling up of the questionnaire. These were in the form of specific modules including difficulty in answering, confusion while answering and difficulty to understand, whether the questions were upsetting and if patients would have asked the question in any different way. There were major suggestions in three questions, which were incorporated into the second intermediate questionnaire to form the final Hindi BN-20 questionnaire. Conclusion: The final Hindi BN-20 has been approved by EORTC and can be used in clinical practice and studies for patients with brain tumors.

Radiotherapy-induced damage in the oral mucosa is the result of the deleterious effects of radiation, not only on the oral mucosa itself but also on the skin, adjacent salivary glands, bone, dentition, and masticatory apparatus. From basic skin care to dental and oral health maintenance, several ointments and lotions, oral and parenteral medications, biological response modifiers, cytoprotective drugs, newer radiation techniques and surgery have been introduced to combat and more importantly to prevent the development of these complications. Radiotherapy-induced oral complications involve complex and dynamic pathobiological processes. This in the immediate- and long-term course lowers the quality of life and predisposes patients to serious clinical disorders. Here, we focus on these oral complications of radiotherapy, highlight preventive and therapeutic developments, and review the current treatment options available for these disorders.

Background: Breast conservative therapy (BCT) is a standard treatment option in early operable breast cancers (OBC) and a select group of large or locally advanced tumors. The present study deals with prospective evaluation of quality of life (QOL) score in consecutive patients treated with BCT employing adjuvant RT treated with either a cobalt machine or a linear accelerator (LA). Material and Methods: Patients of carcinoma breast who underwent BCT were taken into the study. Patients with larger breasts (inter-field separation >18-20 cm) were treated on LA and those with smaller breasts were treated on cobalt machine. All patients received a uniform RT dose (45-50 Gy/25#/5 weeks) to whole breast followed by tumor bed boost with suitable energy electrons. Prospective evaluation of QOL was done using EORTC QLQ C30 and breast cancer-specific EORTC QLQ BR23. QOL evaluation was done at pre-RT, at half completion of RT treatment (at 20-23 fractions) and at completion of RT. Results: Pre-RT evaluation GQOL scores in patients treated with cobalt and LA were 71.6 and 71.7, respectively (P = 0.8). QLQ C30 functional and symptom domain scores were also similar in the groups. At RT completion, Global quality of life (GQOL) scores were 67.7 in patients treated with cobalt as compared to 77.7 in patients treated with LA (P = 0.75). Physical function domain scores in cobalt and LA patients were 70.8 and 80.3, respectively (P = 0.26). Fatigue score was higher in patients treated with cobalt (39.1 versus 29.7; P = 0.9). However, there was no difference in other functional and symptom domains. There was no significant change in any of the EORTC QLQ C30 domains at RT completion as compared to the pre-RT scores. Conclusion: There is no significant difference in QOL domains between appropriately selected patients treated with cobalt and LA. There are no significant changes in QOL domain scores at RT conclusion as compared to pre-RT baseline in patients treated with cobalt or LA source. A cobalt machine may be effectively used to deliver adjuvant RT in appropriately selected BCT patients especially in developing countries with limited resources.

Introduction: An ongoing institutional randomized clinical trial comparing three-dimensional conformal radiotherapy (3D CRT) and intensity-modulated radiotherapy (IMRT) provided us an opportunity to document and compare the time-manpower burden with these high-precision techniques in head and neck cancers. Materials and Methods: A cohort of 20 consecutive patients in the ongoing trial was studied. The radiotherapy planning and delivery process was divided into well-defined steps and allocated human resource based on prevalent departmental practice. Person-hours for each step were calculated. Results: Twelve patients underwent IMRT and eight patients had 3D CRT. The prerandomization steps (upto and including approval of contours) were common between the two arms, and expectedly, the time taken to complete each step was similar. The planning step was carried out postrandomization and the median times were similar for 3D CRT (312 min, 5.2 person-hours) and IMRT (325.6 min, 5.4 person-hours). The median treatment delivery time taken per fraction varied between the two arms, with 3D CRT taking 15.2 min (0.6 person-hours), while IMRT taking 27.8 min (0.9 person-hours) (P< 0.001). The total treatment time was also significantly longer in the IMRT arm (median 27.7 versus 17.8 person-hours, P< 0.001). The entire process of IMRT took 48.5 person-hours while 3D CRT took a median of 37.3 person-hours. The monitor units delivered per fraction and the actual "beam-on" time was also statistically longer with IMRT. Conclusions: IMRT required more person-hours than 3D CRT, the main difference being in the time taken to deliver the step-and-shoot IMRT and the patient-specific quality assurance associated with IMRT.

Context: Accelerated partial-breast irradiation (APBI) using various approaches is being increasingly employed for selected women with early breast cancer (EBC). Aims: To conduct a case-control study comparing disease control, cosmesis, and complications in patients with EBC undergoing APBI using multicatheter interstitial brachytherapy vs those receiving conventional whole breast radiotherapy (WBRT). Settings and Design: Women with EBC fulfilling the American Brachytherapy Society (ABS) criteria were selected as ′cases′ if treated with APBI or as ′controls′ if offered WBRT during the period from May 2000 to December 2004. Materials and Methods: APBI patients were treated with high-dose-rate brachytherapy (HDR) to a dose of 34 Gy/10#/6-8 days. WBRT was delivered to the whole breast to a dose of 45 Gy/25# followed by tumor bed boost, either with electrons (15 Gy/6#) or interstitial brachytherapy (HDR 10 Gy/1#). Results: At the median follow-up of 43.05 months in APBI and 51.08 months in WBRT there was no difference in overall survival (OS), disease-free survival (DFS), late arm edema, and symptomatic fat necrosis between the two groups. However, APBI resulted in increase in mild breast fibrosis at the tumor bed. Telangiectasias were observed in three patients of the APBI group. The cosmetic outcome was significantly better in the APBI group as compared to the WBRT group (P = 0.003). Conclusions: This study revealed equivalent locoregional and distant disease control in the two groups. APBI offered better overall cosmetic outcome, though at the cost of a slight increase in mild breast fibrosis and telangiectasias.

Altered fractionation schedules are being increasingly investigated in the treatment of breast cancer. Two such schedules that are frequently compared are hypofractionated external beam radiation therapy (HERT) and accelerated partial breast irradiation (APBI). Though these two modalities are considered separately, APBI is an actually an advanced form of hypofractionation, where acceleration of the treatment is possible due to the smaller volume being irradiated. HERT as well as APBI are investigational at present and are being tested in randomized trials. This article looks at the advantages of APBI as a hypofractionation schedule.