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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 (D Body-PTV) to Body-PTV (D Body-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 D Body-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 D Body-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. [ABSTRACT FROM AUTHOR]

• A large number of patient migrate to other country for the cancer treatment. • 86.4% patients faces moderate to extreme financial toxicity post treatment. • Approximately 15% of migrated patients are having metastatic disease. • 35.4% of migrated patients only palliative radiotherapy. • Patients have travelled half of earth as long as 50h+ for very basic treatment. The purpose of this study is to analyze the challenges that overseas cancer patients face while receiving treatment in a Tier 1 city in India. A total of 2835 overseas patients from 55 countries received cancer treatment in two hospitals in Delhi, India between November 2013 and April 2019. Of these, 937 patients participated in a 30-point questionnaire on patient reported outcomes. The questionnaire included clinical information, difficulties, expenditure, financial toxicity (FT), education, profession/earning, family/emotional issues, and the reason for the choice of Delhi. Patient population consisted of 1149 and 1686 males and females with a mean age of 46.8 ± 18.7 years. Patients came from countries spread across four geographical regions, namely Asia (19 countries), Europe (4), Oceania (8), and Africa (23). The two most prominent reasons for overseas treatment were (1) unreliable medical service at home or in nearby countries and (2) non-availability of the medical services in the home country. 14.9% of the patients had metastatic disease. Of the 55 countries in total, 15 did not have any inland radiotherapy facility. The average number of caregivers was 1.3. The average treatment cost, travel cost, and one month accommodation cost for 2.3 people were 10.1 ± 9 thousand, 4.3 ± 2.9 thousand, and 1.6 thousand United States dollars, respectively. While 116 (13.4%) patients reported an ignorable financial burden, the rest (86.4%) reported moderate to extreme financial distress. Among the financially distressed patients, 35% had exhausted their lifetime savings. All patients in this category reported compromised lifestyle in terms of food and treatment of other chronic diseases for themselves and family. Patients from other countries coming to Delhi for cancer management travel long distances in search of reliable medical services. In the process, many patients and their families exhaust their finances, leading to lifetime financial distress. Traveling of cancer patients to another country for treatment (migration) is a worldwide problem. This is due to the lack of reliable medical facilities in the home and nearby countries, or the desire for better treatment. Cancer patient migration often produces several problems, which include family and emotional issues, financial difficulties, profession/earning and problems associated with travel to other countries. A total of 937 cancer patients from 55 countries belonging to four continents (Africa, Asia, Europe, and Oceania) were interviewed on a 30-point questionnaire about these difficulties and the reason for their choice of an overseas destination for cancer treatment. It was found that the most significant problems contributing to cancer patient migration were the lack of comprehensive cancer care facilities and reliability of the existing facilities. Around 15% of migrated patients had terminal diseases with limited life expectancy. This study, first of its kind, identifies problems associated with overseas cancer patients and quantify them. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: To compare quality of life (QOL) in breast cancer patients from a developing country after breast conservation surgery (BCS) or mastectomy and adjuvant radiotherapy (RT). Materials and methods: In a 6-month period, all consecutive early and locally advanced breast cancer patients treated with either BCS or mastectomy and treated with RT were analyzed. All patients who underwent mastectomy were treated with 45 Gray/20#/4weeks. Patients with BCS were treated with a dose of 45–50 Gray/25#/5weeks to whole breast followed by tumor bed boost (15 Gray/6#/6days with suitable energy electrons). Prospective evaluation of QOL using EORTC QLQ C30 and breast cancer specific QLQ BR23 was done before starting RT (baseline), at mid-RT and at RT conclusion for all patients. Results: One hundred and thirteen patients had mastectomy and 142 patients underwent BCS. Reliability test (Cronbach alpha) for questionnaire filling was 0.669–0.886. At pre-RT assessment, global QOL scores in mastectomy and BCS groups were 71.1 and 71.3, respectively. There was no significant difference in pre-RT EORTC QLQ C30 functional and symptom domains between mastectomy and BCS patients. However, social function domain score was higher in patients who underwent mastectomy (83 versus 73.9; p =0.018). In QLQ BR23 domains, body image and sexual functioning domains were similar between the two groups. However, sexual enjoyment (10.9 versus 47.6; p =0.006) and future perspective (7.4 versus 37.1; p =0.036) domains were significantly better in BCS arm. There was no difference between systemic side effect (BRSSE), breast symptom (BRBS) and arm symptom (BRAS) domain scores between the groups. There was no significant difference in change of QOL scores between mastectomy and BCS patients at RT completion as compared to baseline. Conclusions: There was no significant difference in quality of life in patients with BCS versus those with mastectomy. However, patients who underwent BCS had better sexual enjoyment and future perspective scores compared with mastectomy patients. There was no significant change of QOL domain scores after RT in mastectomy and BCS patients. [Copyright &y& Elsevier]

Abstract: Evaluation of dose distribution in a single plane (i.e., 2-dimensional [2D] planning) is simple and less resource-intensive than CT-based 3-dimensional radiotherapy (3DCRT) planning or intensity modulated radiotherapy (IMRT). The aim of the study was to determine if 2D planning could be an appropriate treatment in a subgroup of breast cancer patients based on their breast size. Twenty consecutive patients who underwent breast conservation were planned for radiotherapy. The patients were grouped in 3 different categories based on their respective chest wall separation (CWS) and the thickness of breast, as “small,” “medium,” and “large.” Two more contours were taken at locations 5 cm superior and 5 cm inferior to the isocenter plane. Maximum dose recorded at specified points was compared in superior/inferior slices as compared to the central slice. The mean difference for small breast size was 1.93 (standard deviation [SD] = 1.08). For medium breas size, the mean difference was 2.98 (SD = 2.40). For the large breasts, the mean difference was 4.28 (SD = 2.69). Based on our dosimetric study, breast planning only on the single isocentric contour is an appropriate technique for patients with small breasts. However, for large- and medium-size breasts, CT-based planning and 3D planning have a definite role. These results can be especially useful for rationalizing treatment in busy oncology centers. [Copyright &y& Elsevier]

Abstract: For the past 30 years, tamoxifen has saved millions of lives throughout the world. The same has been proven in randomized trials and metaanalyses. Recent trials have shown clinical superiority of aromatase inhibitors over tamoxifen in terms of disease free survival and reduction in complications. However, because of the unique mechanism of tamoxifen, intrinsic advantages and low cost, this wonderdrug may still be a reasonable choice for hormonal therapy in breast cancer. [Copyright &y& Elsevier]

Abstract: We describe a simple procedure of craniospinal irradiation in supine position. The procedure was carried out with a 100-cm isocenter linear accelerator and compatible simulator. Treatment was with a 1 or 2 posteroanterior (PA)-directed spinal fields abutting lateral-directed cranial fields. Abutment of the fields was established by placement of markers on the neck of the patient, which provided a measure of the divergence of the spinal field. The precision and reproducibility of this technique, including the placement of junctions, appeared to be as good as for treatment in the prone position. The same could be verified with port films. We conclude that this new technique of supine craniospinal treatment is a simple and convenient alternative to traditional treatment in the prone position. [Copyright &y& Elsevier]

Abstract: Radiotherapy (RT) has been established to improve both local control as well as overall survival rates in breast cancer. However, RT especially in left-sided breast cancer also irradiates a portion of the heart. Radiation associated toxicity to the heart assumes significance because of improval in survival of breast cancer patients. A circadian pattern has been reported in the myocardial oxygen demand and myocardial ischaemia with the cardiac tissue being more susceptible to injury between 6am and noon. Radiation damages blood vessels of all sizes causing an increase in capillary wall permeability and dilatation of vessels leading to the characteristic radiation erythema followed by an inflammatory cell infiltrate. Coronary artery spasm may be the reason behind some cases of sudden death occurring in patients after radiation therapy. Endothelial behaviour also has a circadian variation and vasodilation is significantly attenuated in the morning. Critical coronary artery disease occurs 10–15years after radiotherapy. Radiation in the morning hours may be one of the associated risk factor. The application of chrono-therapeutics with radiation therapy in carcinoma breast and in other chest wall irradiation, could possibly decrease the radiation associated cardiac toxicity. [Copyright &y& Elsevier]

Abstract: Proteins in tissue obtained from human skin and oral mucosa have shown a significant circadian rhythm, with the peak expression of p27 at 6:00 AM (early G1-phase marker), p53 at 10:50 AM (late G1-phase marker) and cyclin-E at 2:50 PM (S-phase marker). Patients irradiated in late afternoon/evening have shown a higher grade of mucositis and dermatitis. Studies evaluating the effect of EGFR blockade on cell cycle progression in several human cell types, including A431 squamous epithelial carcinoma cells, suggest that cetuximab leads to cell cycle arrest in G1 phase. On concurrent administration with radiation, mucositis and dermatitis are its main side-effects. So we can hypothesize that cetuximab administration after 11:00 AM would decrease these toxicities. In addition, its administration prior to late afternoon/evening (3:00 PM) can further reduce the radiation associated mucositis and dermatitis due to the occurrence of S-phase during this time and thus increase the therapeutic benefit. [Copyright &y& Elsevier]

Abstract: Medulloblastoma is the most common malignant brain tumor of childhood, with a propensity for neuraxial spread via the cerebrospinal fluid. However, systemic metastases can occur in a small minority of patients. Very rarely such metastases can involve the mandible and present with intra-oral swelling. One such occurrence in a patient with medulloblastoma in the setting of disseminated disease is reported with a review of the relevant literature. The treatment options for patients with extra-neuraxial metastases are limited and their prognosis continues to remain poor. [Copyright &y& Elsevier]

Abstract: A 36-year-old woman presented to our hospital with a short history of intermittent headaches. An MRI of the brain revealed a left temporal intracerebral cystic lesion with rim enhancement. Histopathology showed a malignant tumour with features of rhabdoid differentiation. Immunohistochemistry revealed that vimentin, epithelial membrane antigen and S-100 were positive, and that glial fibrillary acidic protein and the chromosome deletion 1p/19q were negative. The patient was diagnosed as having an intracerebral cystic rhabdoid meningioma. She was treated with surgery and post-operative radiotherapy. Cystic intracerebral rhabdoid meningiomas are rare. We discuss the clinical picture of this patient with reference to the published literature on this uncommon diagnosis. [Copyright &y& Elsevier]

Purpose To study the clinical outcomes of women with early breast cancer (EBC) treated with accelerated partial breast irradiation (APBI) with multicatheter interstitial brachytherapy (MIB) using 3 dimensional computerized tomography (3DCT) based planning. Materials and methods During August 2005 to January 2013, 140 women with EBC were treated prospectively with APBI using high dose rate (HDR) MIB. After 3DCT based planning patients were treated to a dose of 34 Gy/10 #/1 week with bid regimen. Results Median age was 57 years and tumor size 2 cm (range: 0.6–3.2 cm). Infiltrating duct carcinoma (IDC) was the most common histology; grade III tumors were seen in 82%. Median dose homogeneity index (DHI) was 0.76 (range: 0.49–0.85). The median coverage index (CI) of the cavity was 90% (61.4–100) and 80.5% (53.6–97.4) for planning target volume (PTV). Median follow up was 60 months (1–102 months). The 5 and 7 year local control rates (LC) were 97% and 92% respectively. Her2 positivity was the only prognostic factor which had an adverse impact on LC ( p = 0.01). Five and 7 year disease free survival (DFS) and overall survival (OAS) were 93%, 84%, 97.5% and 89% respectively. Good to excellent cosmetic outcomes at last follow up were seen in 87 (77%) women. Conclusions 3DCT based MIB results in excellent long term outcomes and good to excellent cosmesis. Her2 positivity has an adverse impact on LC rates. [ABSTRACT FROM AUTHOR]

Purpose: A feasibility study was performed to evaluate RapidArc (RA), and the potential benefit of flattening filter-free beams, on advanced esophageal cancer against intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT). Methods and Materials: The plans for 3D-CRT and IMRT with three to seven and five to seven fixed beams were compared against double-modulated arcs with avoidance sectors to spare the lungs for 10 patients. All plans were optimized for 6-MV photon beams. The RA plans were studied for conventional and flattening filter-free (FFF) beams. The objectives for the planning target volume were the volume receiving ≥95% or at most 107% of the prescribed dose of <1% with a dose prescription of 59.4 Gy. For the organs at risk, the lung volume (minus the planning target volume) receiving ≥5 Gy was <60%, that receiving 20 Gy was <20%–30%, and the mean lung dose was <15.0 Gy. The heart volume receiving 45 Gy was <20%, volume receiving 30 Gy was <50%. The spinal dose received by 1% was <45 Gy. The technical delivery parameters for RA were assessed to compare the normal and FFF beam characteristics. Results: RA and IMRT provided equivalent coverage and homogeneity, slightly superior to 3D-CRT. The conformity index was 1.2 ± 0.1 for RA and IMRT and 1.5 ± 0.2 for 3D-CRT. The mean lung dose was 12.2 ± 4.5 for IMRT, 11.3 ± 4.6 for RA, and 10.8 ± 4.4 for RA with FFF beams, 18.2 ± 8.5 for 3D-CRT. The percentage of volume receiving ≥20 Gy ranged from 23.6% ± 9.1% to 21.1% ± 9.7% for IMRT and RA (FFF beams) and 39.2% ± 17.0% for 3D-CRT. The heart and spine objectives were met by all techniques. The monitor units for IMRT and RA were 457 ± 139, 322 ± 20, and 387 ± 40, respectively. RA with FFF beams showed, compared with RA with normal beams, a ∼20% increase in monitor units per Gray, a 90% increase in the average dose rate, and 20% reduction in beam on time (owing to different gantry speeds). Conclusion: RA demonstrated, compared with conventional IMRT, a similar target coverage and some better dose sparing to the organs at risk; the advantage against conventional 3D-CRT was more evident. RA with FFF beams resulted in minor improvements in plan quality but with the potential for additional useful reduction in the treatment time. [Copyright &y& Elsevier]

Abstract: Purpose: To report the incidence of clinical, pathological and radiological fat necrosis (FN) in women treated with accelerated partial breast irradiation (APBI) using interstitial brachytherapy (BRT) for early-stage breast cancer and to study certain variables associated with it. Methods and materials: Between May 2000 and August 2008, 171 women were treated with APBI using high dose rate (HDR) BRT. Patients were treated to a dose of 34Gy/10 fractions/1week with two fractions/day after intraoperative/postoperative placement of catheters. Results: At a median follow up of 48months (SD: 28) 20 women developed FN with median time to detection being 24months (range: 4–62months, SD: 20). Actuarial 5 and 7year FN rate was 18% and 23%, respectively. Grade 1 FN was seen in 4, grade 2 in 8 and grade 4 in 8 women. Additional investigations such as aspiration/biopsy were done in 9 patients. Volume of excision was the only significant factor affecting FN (p =0.04). Conclusions: Actuarial FN rate of 18% at 5years in our study was comparable to other reported series of FN. Median time of detection of FN was 24months. Higher volume of excision resulted in an increased incidence of fat necrosis. [Copyright &y& Elsevier]

Purpose: To present the effect of radiotherapy doses to different volumes of normal structures on neurocognitive outcomes in young patients with benign and low-grade brain tumors treated prospectively with stereotactic conformal radiotherapy (SCRT). Methods and Materials: Twenty-eight patients (median age, 13 years) with residual/progressive brain tumors (10 craniopharyngioma, 8 cerebellar astrocytoma, 6 optic pathway glioma and 4 cerebral low-grade glioma) were treated with SCRT to a dose of 54 Gy in 30 fractions over 6 weeks. Prospective neuropsychological assessments were done at baseline before RT and at subsequent follow-up examinations. The change in intelligence quotient (IQ) scores was correlated with various factors, including dose–volume to normal structures. Results: Although the overall mean full-scale IQ (FSIQ) at baseline before RT remained unchanged at 2-year follow-up after SCRT, one third of patients did show a >10% decline in FSIQ as compared with baseline. Logistic regression analysis demonstrated that patients aged <15 years had a significantly higher chance of developing a >10% drop in FSIQ than older patients (53% vs. 10%, p = 0.03). Dosimetric comparison in patients showing a >10% decline vs. patients showing a <10% decline in IQ revealed that patients receiving >43.2 Gy to >13% of volume of the left temporal lobe were the ones to show a significant drop in FSIQ (p = 0.048). Radiotherapy doses to other normal structures, including supratentorial brain, right temporal lobe, and frontal lobes, did not reveal any significant correlation. Conclusion: Our prospectively collected dosimetric data show younger age and radiotherapy doses to left temporal lobe to be predictors of neurocognitive decline, and may well be used as possible dose constraints for high-precision radiotherapy planning. [Copyright &y& Elsevier]

Purpose: To present outcome data in a prospective study of radiotherapy (RT) with concurrent and adjuvant temozolomide (TMZ) in children with diffuse intrinsic pontine gliomas (DIPGs). Methods and Materials: Pediatric patients with newly diagnosed DIPGs were prospectively treated with focal RT to a dose of 54 Gy in 30 fractions along with concurrent daily TMZ (75 mg/m2, Days 1–42). Four weeks after completing the initial RT-TMZ schedule, adjuvant TMZ (200 mg/m2, Days 1–5) was given every 28 days to a maximum of 12 cycles. Response was evaluated clinically and radiologically with magnetic resonance imaging and positron emission tomography scans. Results: Between March 2005 and November 2006, 20 children (mean age, 8.3 years) were accrued. Eighteen patients have died from disease progression, one patient is alive with progressive disease, and one patient is alive with stable disease. Median overall survival and progression-free survival were 9.15 months and 6.9 months, respectively. Grade III/IV toxicity during the concurrent RT-TMZ phase included thrombocytopenia in 3 patients, leucopenia in 2, and vomiting in 7. Transient Grade II skin toxicity developed in the irradiated fields in 18 patients. During the adjuvant TMZ phase, Grade III/IV leucopenia developed in 2 patients and Grade IV thrombocytopenia in 1 patient. Patients with magnetic resonance imaging diagnosis of a high-grade tumor had worse survival than those with a low-grade tumor (p = 0.001). Patients with neurologic improvement after RT-TMZ had significantly better survival than those who did not (p = 0.048). Conclusions: TMZ with RT has not yielded any improvement in the outcome of DIPG compared with RT alone. Further clinical trials should explore novel treatment modalities. [Copyright &y& Elsevier]