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Byline: P. Shukla, M. Gairola, B. Mohanti, G. Rath Background and Aims: Radiation induced wet desquamation of skin in carcinoma breast patients is a painful condition. In this study topical [...]

In the year 2020 cancer was identified as the second leading cause of death globally with more than 19 million cancer cases and 10 million cancer deaths. As per GLOBOCAN 2020, the caseload of cancer in Bangladesh was 1,56,775 and the cancer death were 1,08,990. Radiation therapy (RT) is indicated for around 50% of cancer, achieving local control and overall survival benefit. Inadequate number of RT facilities and manpower, huge cancer patient burden, lack of trained manpower is the main barrier for optimum cancer care of Bangladesh. During the COVID pandemic a unique initiative for manpower training in the field of radiation therapy was taken by a private cancer center of Bangladesh, with the regional academic collaboration of a Cancer Institute and Research Center of India. "Virtual training on IGRT" was arranged mainly for radiation therapy technologists (RTT) also with the provision for radiation oncologists (RO) and medical physicists (MP) to attend. Retrospective record review of the IGRT training program arranged from 4 September to 9 October 2020 was done. The program was designed for five days on five week ends (4 September,11 September, 18 September, 25 September and 9 October 2021) for a duration of three-hours daily. First day was the introductory session which covered Setup, Fusion, Immobilization and Context Setting, followed by site specific discussion. On Day 2. Head and Neck Cancer, Brain Cancer, Day 3. Breast and Thoracic Cancer, Day 4. Upper and Lower Gastrointestinal Cancer, Day 5. Prostate and Cervical Cancer were covered. A number of 245 candidates completed the pre-program online registration (RO- 83, MP-43, RTT-87 and PG Students-32). Among them total 230 attended the virtual program (Day-1-64, Day 2-150, Day 3-100, Day 4-103 and Day 5-103) Total 22 faculties were engaged from the collaborative center of India for this virtual training program where 11 were RO, 4 MP and 9 were RTT. Out of 230 attendants,133 (58%) provided their online feedback. Majority of them (>90%) found the training contents relevant to their daily practice and they opined that this training will help to change their ongoing practice. This first ever initiative of a private Cancer center of Bangladesh with regional academic collaboration could create encouraging response among participants with significant impact on their everyday practice. Participants found the training useful and practice changing. Well-structured, need based more such virtual training program may be arranged in future. This model can be reproduced at other developing countries with the expectation of similar outcome. [ABSTRACT FROM AUTHOR]

To study the effect of radiation treatment delay due to COVID-19 infection. This study is a descriptive analysis. We studied all patients who were COVID-19 positive while undergoing radiation treatment. In addition, those COVID-19 positive patients before the start of radiation during their neoadjuvant treatment period or surgery were also analyzed. However, patients detected with COVID-19 infection after the radiation treatment course were excluded. The study period was from June 2020 to May 2021. A radiation treatment delay was defined as a delay in starting the treatment, a break in therapy during their scheduled radiation course, or treatment discontinuation. Patients who had a radiation treatment delay were followed-up till December 2021. Ninety-four patients who met the criteria were identified for the analysis. Seventy-seven of them had a mild infection, while 17 had a moderate or severe infection. Of the 94 patients identified, 83 patients had a treatment delay. The median treatment delay (MTD) was 18 (6 to 47) days and the median follow-up period was 13 months. In this cohort, 66 patients were treated with a curative intent, of which 51 are on follow-up {34 patients are disease-free (MTD – 18.5, 10 to 43), seven had either a residual disease or locoregional recurrence (MTD – 22, 10 to 32), seven had distant metastasis (MTD – 18, 15 to 47), and three patients died (MTD – 20, 8 to 27)}. Amongst the three patients who died, only one died of COVID-19 infection or sequel (Case Fatality Rate, CFR – 1.06%). The CFR due to COVID-19 infection amongst those who underwent radiotherapy was low. At the same time, higher MTD might have been the reason for residual or locoregional recurrences. However, a longer follow-up is required to confirm this. Till then, it will remain debatable whether it was worth delaying radiotherapy for mild to moderate COVID-19 infection for a significant time to cause a potential cancer treatment failure. [ABSTRACT FROM AUTHOR]

Objective: To identify variables associated with a patients' ability to reproducibly hold their breath for deep-inspiration breath-hold (DIBH) radiotherapy (RT) and to develop a predictive model for DIBH eligibility., Methods: This prospective, single-institution, IRB-approved observational study included women with left-sided breast cancer treated between January 2023 and March 2024. Patients underwent multiple breath-hold sessions over 2-3 consecutive days. DIBH waveform metrics and clinical factors were recorded and analysed. Logistic mixed modelling was used to predict DIBH eligibility, and a temporal validation cohort was used to assess model performance., Results: In total, 253 patients were included, with 206 in the model development cohort and 47 in the temporal validation cohort. The final logistic mixed model identified increasing average breath-hold duration (OR, 95% CI: 0.308, 0.104-0.910. p = 0.033) and lower amplitude (OR, 95% CI: 0.737, 0.641-0.848. p < 0.001) as significant predictors of DIBH eligibility. Increasing age was associated with higher odds of being ineligible for DIBH (OR, 95% CI: 1.040, 1.001-1.081. p = 0.044). The model demonstrated good discriminative performance in the validation cohort with an AUC of 80.9% (95% CI: 73.0-88.8)., Conclusion: The identification of variables associated with DIBH eligibility and development of a predictive model has the potential to serve as a decision-support tool. Further external validation is required before its integration into routine clinical practice., (© 2024. The Author(s).)

Oligometastatic non-small cell lung cancer (OMD NSCLC) has been proposed to bridge the spectrum between non-metastatic and widely metastatic states and is perceived as an opportunity for potential cure if removed. Twelve clinical trials on local treatment have been reported, yet none are conclusive. These trials informed the development of a joint clinical practice guideline by the American & European Societies for Radiation Oncology, which endorses local treatment for OMD NSCLC. However, the heterogeneity between prognostic factors within these trials likely influenced outcomes and can only support guidance at this time. Caution against an uncritical acceptance of the guideline is discussed, as strong recommendations are offered based on expert opinion and inconclusive evidence. The guideline is also examined by a patient's caregiver, who emphasizes that uncertain evidence impedes shared decision making., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Institute of Radiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: To investigate the association between radiotherapy (RT) and cardiac biomarkers in women with left-sided breast cancer., Methods: This prospective observational study recruited patients with stage I-III left-sided breast cancer without coronary heart disease who required adjuvant RT. High-sensitivity troponin I(hsTnI), N-terminal pro-brain natriuretic peptide(NT-proBNP), and high-sensitivity C-reactive protein(hsCRP) levels were measured pre-RT, immediately after RT, and 3 months post-RT. Cardiac-sparing RT techniques were utilized (Field-in-Field IMRT/VMAT ± voluntary deep inspiration breath-hold). Statistical analyses were performed using non-parametric tests and multivariable quantile regression (QR)., Results: One hundred five patients completed the study, with 63 evaluable at three months post-RT. Pre- and post-RT biomarkers showed no significant differences. Median pre-RT and post-RT values were: hsTnI (0.012ng/mL; 0.012ng/mL), hsCRP (3.1 mg/L; 2.8 mg/L), and NT-proBNP (59pg/mL; 45pg/mL). Three months post-RT, hsTnI, hsCRP and NT-proBNP levels also showed no significant differences. Multivariable QR revealed no association between heart D mean [median(IQR): 2.87 Gy (2.05-3.94)] and post-RT biomarkers. Age and BMI were associated with hsCRP and NT-proBNP, respectively., Conclusions: hsTnI, NT-proBNP, and hsCRP are not correlated with contemporary low cardiac exposure in left-sided breast cancer patients treated with contemporary RT techniques., (© 2024. The Author(s).)

Purpose: The metal present in the implant creates artifacts during the treatment simulation, which impacts the treatment planning and delivery of the prescribed dose to the target and sparing normal tissues. This retrospective study evaluated the uncertainties in the planning and delivery of doses for prosthesis cases with dedicated phantom., Materials and Methods: In this retrospective study, 11 patients with a hip prosthesis having cervix carcinoma were selected. Two treatment plans were generated on treatment planning system (TPS) for each case. Plan&#95;No&#95;Res was without any beam restriction, and Plan&#95;exit&#95;only was the plan with restricted beam entry through the metallic implant. An indigenous phantom was utilized to verify the accuracy of the treatment. In the phantom, some groves were present, which could be filled by implants that mimic the patient's geometries, like left, right and bilateral femur implants. The delivered doses were recorded using optically stimulated luminescence dosimeters (OSLDs), which were placed at different positions in the phantom. The plans were further calculated using megavoltage computed tomography (MVCT) scans acquired during treatment., Results: The patient data showed no significant dose changes between the two planning methods. The treatment time increases from 412.18 ± 86.65 to 427.36 ± 104.80 with P = 0.03 for Plan&#95;No&#95;Res and Plan&#95;exit&#95;only, respectively. The difference between planned and delivered doses of various points across phantom geometries was within ± 9.5% in each case as left, right, and bilateral implant. The variations between OSLDs and MVCT calculated doses were also within ± 10.8%., Conclusion: The study showed the competency of tomotherapy planning for hip prosthesis cases. The phantom measurements demonstrate the errors in dosimetry near the implant material, suggesting the need for precise methods to deal with artifact-related issues., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Medical Physics.)

With the advent of molecular immunohistochemistry and next generation sequencing, Switch/sucrose non-fermentable (SWI/SNF) chromatin remodeling complex altered tumors have gained recognition recently. SWI/SNF related, matrix associated, actin dependent regulator of chromatin subfamily B member 1 (SMARCB1) and SMARCA4 are the primary SWI/SNF components altered in several recently described undifferentiated malignancies in head and neck region with predilection for paranasal sinuses in SMARCB1-deficient tumors and nasal cavity in SMARCA4-deficient tumors. However, to the best of our knowledge, SMARCA4-deficient tumors of the oropharynx have not been described. We present an unusual case of SMARCA4-deficient carcinoma of the oropharynx (palatine tonsil) which is the first case in the literature, expanding the topographic distribution of SMARCA4-deficient tumors in the head and neck region and emphasizing the importance of BRG1 as an essential immunohistochemical marker for the diagnosis of this distinct entity., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Myxofibrosarcoma (MFS) is a rare subtype of soft tissue sarcoma that usually occurs in the extremities of the body. Its location in the head and neck region is unique. Surgery is the primary treatment for all non-metastatic MFS. It has high rates of local recurrence and metastasis. Like other soft tissue sarcomas, the aim of adjuvant treatment is to decrease the chances of local recurrence or metastasis in MFS. Due to its rarity, there is a lack of data showing the benefit of adjuvant treatment in MFS of the head and neck region. We are presenting a case report and literature review on MFS in the head and neck., (© Association of Otolaryngologists of India 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Purpose: Postconcurrent chemoradiotherapy (CRT) response assessment has been challenging in locally advanced head-and-neck squamous cell carcinoma (LA-HNSCC) due to prevailing postradiation changes. Molecular response methods have been encouraging, although further clarifications and validations were needed. We tested the effectiveness of a proposed semi-quantitative molecular response criterion in these patients., Materials and Methods: Two subspecialty-trained physicians evaluated 18 F-fluorodeoxyglucose positron emission tomography/computed tomography of LA-HNSCC patients ( n = 83) post 3 months CRT using a five points Head and Neck Molecular Imaging-Reporting and Data System (HAN-MI-RADS) criterion. Where available, histopathology examination with clinical and imaging interpretation was taken as a reference for the disease. A diagnostic accuracy comparison was done with the existing Hopkins score. Further effectiveness was analyzed with disease-free survival (DFI) and overall survival (OS)., Results: Metastasis was developed in 11/83 patients at 3 months of evaluation. Of 72 patients, 39, 2, and 31 patients had a complete response, equivocal response, and partial response as per HAN-MI-RADS. Per patient sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for predicting loco-regional disease up to 1 and 2 years was 93.3%, 92.5%, 90.3%, 94.9%, 92.9%, and 84.9%, 91.9%, 90.3%, 87.2%, and 88.6% respectively. One year and two years DFI for each HAN-MI-RADS score showed a statistically significant difference while it was not for OS. The receiver operating characteristic curve analysis showed significantly better outcome predictability of HAN-MI-RADS (area under the curve [AUC] 0.884) than Hopkins (AUC 0.699)., Conclusions: A five points HAN-MI-RADS criterion was found promising for response assessment with less equivocal results and statistically significant higher AUC than Hopkins for loco-regional recurrence prediction., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Nuclear Medicine.)

Ductal carcinoma in situ is a challenge for breast surgeons, beginning with its difficult radiological detection and continuing with its contentious multimodal treatment and management. It is becoming more common as a result of widespread screening mammography and usually manifests as a cluster of calcifications. Patients are usually asymptomatic or present with a small, palpable lump. It is, however, a premalignant lesion that has the potential to progress to invasive carcinoma and is treated similarly with multimodal therapy. Treatment options currently include total or simple mastectomy with sentinel lymph node biopsy or lumpectomy with radiation. Tamoxifen and human epidermal growth factor receptor two suppression therapy are examples of adjuvant therapy. A review of consensus guidelines and literature was performed, in which we included the available online literature on the concerned topic from 2000-2022. This article is not a complete review of all the available literature; rather, it is a comprehensive review of the topic and its current management guidelines., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kalwaniya et al.)

The advent of computed tomography-based planning coupled with modern tools for target delineation and hypofractionated treatment schedules has increased efficiency and throughput for patients with breast cancer. While the benefit of adjuvant radiation therapy (RT) in reducing locoregional recurrences is established, disentangling local versus regional recurrence risks with modern treatment protocols has become an area of active research to de-escalate treatment. Delineation guidelines for nodal regions either attempt to replicate results of conventional RT techniques by translating bony landmarks to clinical target volumes or use landmarks based on the fact that lymphatic channels run along the vasculature. Because direct comparisons of both approaches are implausible, mapping studies of nodal recurrences have reported on the proportion of nodes included in these delineation guidelines, and larger, bony, landmark-based guidelines appear intuitively appealing for patients with unfavorable risk factors. A pooled analysis of these studies is reported here, along with literature supporting the exclusion of the true chest wall from postmastectomy/breast-conserving surgery clinical target volumes and the selective (versus routine) use of bolus during postmastectomy RT. The risk-adapted approach suggested here accounts for the risk of recurrence as well as toxicity and endorses nuanced target volume delineation rather than a one-size-fits-all approach., (Copyright © 2022 American Society for Radiation Oncology. All rights reserved.)

Objective: To evaluate treatment outcomes in patients from a low-middle income country (LMIC) with esophageal carcinoma who underwent esophagectomy after neoadjuvant chemoradiation (NACRT/S)., Methods: Between 2010 and 2020, 254 patients (median follow-up: 53 months) met our inclusion criteria. Out-of-field nodal regions were determined by reviewing individual radiotherapy plans. Cox regression modelling was performed to analyze overall survival (OS) and recurrence-free survival (RFS), while pathological complete response (pCR) prediction utilized Poisson regression., Results: The median OS was 71.4 months (interquartile range: 19.6-∞), RFS did not reach the median and pCR rate was 46%. On multivariable Cox regression, BMI [0.93 (0.89-0.98); 0.94 (0.89-0.99)] and absence of out-of-field node with extranodal extension (ENE)[0.22 (0.09-0.53); 0.30 (0.12-0.75)] influenced OS and RFS, respectively. Age [1.03 (1.01-1.06)], nodal stage [cN2-3 vs cN0: 2.67 (1.08-6.57)] and adventitial involvement [2.54 (1.36-4.72)] also influenced OS, while involved margins [3.12 (1.24-7.81)] influenced RFS. On multivariable Poisson regression, non-CROSS-chemotherapy regimens [0.65 (0.44-0.95)] and residual primary disease on pre-surgical imaging [0.73 (0.57-0.93)] were significantly associated with pCR. The most frequently involved in-field and out-of-field nodal regions were the periesophageal and perigastric (greater and lesser curvature) regions, respectively., Conclusion: NACRT/S is feasible and effective in patients from LMIC. Out-of-field ENE merits further investigation as a prognostic factor since it significantly influenced both OS and RFS., Advances in Knowledge: The results of clinical trials are replicable in LMICs. Out-of-field ENE is an independent prognostic factor for OS and RFS., Competing Interests: Data Availability StatementThis study was based on institutional cancer registry data. The authors do not own these data and hence are not permitted to share them in the original form (only in aggregate form). Reasonable requests for access to data will be considered on an individual basis, by contacting the corresponding author.

Introduction: The number of patients for carcinoma cervix with implanted hip prostheses has been increasing worldwide during the past several decades. Technological advancements are useful for delivering higher doses, i.e., dose escalation to the target, but the presence of high-density implanted hip prosthesis creates challenges for the planner., Materials and Methods: A population of 25 patients was selected for the study. Plans were generated using the MONACO treatment planning system keeping the isocenter same. The parameters evaluated for planning target volume (PTV) were D 98% , D 50% , D 2% , D max , D mean , V 107%, and V 110% . Similarly, the parameters D max , D mean , and D 2cc were evaluated for the delineated critical organs. Average monitor units (TMU mean ) were also assessed., Results: D 98% of PTV was 44.51 (standard deviation [SD]: 0.13) Gy, 44.41 (SD: 0.38) Gy, 44.58 (SD: 0.14) Gy, 44.08 (SD: 0.41) Gy and 44.46 (SD: 0.32) Gy for 4F, intensity-modulated radiation therapy (IMRT), IMRT&#95;WP, volumetric-modulated arc therapy (VMAT), and VMAT&#95;WP techniques, respectively, where WP stands for "without prosthesis". Volume of bowel receiving 45 Gy was 86.82 (SD: 66.38) cm 3 , 6.97 (SD: 5.77) cm 3 , 14.11 (SD: 14.29) cm 3 , 13.31 (SD: 6.57) cm 3 , and 10.31 (SD: 10.94) cm 3 for 4F, IMRT, IMRT&#95;WP, VMAT and VMAT&#95;WP techniques, respectively., Discussion: Radiotherapy is standard care of practice for known cases of cervical malignancies. As per our investigations, VMAT has generated comparable plans in terms of target coverage (D 98% ) as compared to IMRT and 4F techniques (P = 0.015 and P = 0.002) and with prosthesis also (P = 0.024). The mean dose to the bladder was significantly lesser with IMRT and VMAT. Our results highlight that VMAT has reduced the mean dose to the rectum (P = 0.001) in presence of high-density implant. The mean dose to femoral heads was also reduced when compared with the 4-field technique., Conclusion: VMAT has an edge over other techniques in terms of target coverage and sparing of critical organs in the presence of metallic prosthesis. Information about the geometry and density of prosthesis will be beneficial for treatment planning., Competing Interests: None

Objective: To analyze the outcomes of patients receiving immunotherapy (IO) with advanced non-driver mutated non-small-cell lung cancer (NSCLC) after progression on systemic treatment. Methods: The overall survival (OS), progression-free survival (PFS) and best response to IO of 64 patients who met our inclusion criteria were analyzed. Results: Median follow-up, OS and PFS were 35.9, 7.1 and 3.2 months, respectively. On uni- and multi-variable analysis, better ECOG PS and fewer extra-thoracic metastases were associated with prolonged OS and PFS. Response to IO was associated with prolonged OS, while thoracic radiotherapy and isolated CNS involvement were associated with prolonged PFS. ECOG PS, thoracic radiotherapy and PDL1 status significantly influenced the likelihood of response to IO. Overall, 30% patients experienced any grade toxicity. Conclusion: Our results are concordant with reported trial outcomes and support the application of IO in Indian patients.