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The opioid crisis in the USA and in other developed countries can potentially affect low- and middle-income countries (LMICs). The licit medical use of opioids has two sides. The USA and high-income countries maintain abundant supply for medical prescription. Between 1990 and 2010, the use of opioids for cancer pain relief was overtaken by a dramatic rise in the opioid prescriptions for non-cancer acute or chronic pain. The surge led to the opioid epidemic, recognized as social catastrophe in the USA, Canada and in some countries in Europe. From 2016, the medical community, health policy regulators and law-makers have taken actions to tackle this opioid crisis. On the other side, formulary deficiency and low opioid availability exists for three-fourths of the global population living in LMICs. Physicians and nurses in Asia and Africa engaged in cancer pain relief and palliative care face a constant paucity of opioids. Millions of patients in LMICs, suffering from life-modifying cancer pain, do not have access to morphine and other essential opioids, due to restrictive opioid policies. Attention will be needed to improve opioid availability in large parts of the world, even though the opioid crisis has led to control the licit medical use in the USA.

This study was designed to evaluate the personal challenges, work environment, and financial satisfaction of female radiation oncologists (FRO) in South Asia.A 28-point online survey was answered by 296 FRO from south Asia. The study comprised of seven sections: personal, professional, family, economic, workplace burnout, research/academic components, and challenges exclusive to being a working woman.The distribution of the participants was 73.4%, 14.8%, 7.9%, and 3.9% from India, Bangladesh, Nepal, and Pakistan, respectively. Age distribution was50 y 12.1%, 30-50 y 61.1%, and30 y 26.8%. Out of 296 respondents 206 (69.6%) and 176 (59.5%) were married and mothers respectively. 43.8% (77) of all mothers were denied maternity leave partially.45.9% (136) of all respondents and 68.7% (121) of all mothers found motherhood the principal obstacle to career growth. Total 60.1% encounter a gender bias in the department, and 34.8% reported they were either gained or lost a job/training because of their gender. 43.3%, 36.9%, 30.6%, and 25.5% of responders felt they could have done well in professional, financial, social, and academic perspectives, respectively, had they been of the opposite gender. 28.5%, 31%, and 16.4% FRO have income ½, equal and1.5 times than their partners. 58.9% of FRO have a similar income to male colleagues in the city, and 43% of participants are financially satisfied.This study shows a fraction of FRO in south Asia faces a substantial gender disparity in the workplace. They are partially satisfied as a woman, as RO, as mother, and as lone-earner in the family. FROs need well deserved support for optimum delivery in their professional and personal lives.

Accurate calculation of set-up margin is a prerequisite to arrive at the most optimal clinical to planning target volume margin. The aim of this study was to evaluate the compatibility of different on-board and in-room stereoscopic imaging modalities by calculating the set-up margins (SM) in stereotactic body radiotherapy technique accounting and unaccounting for rotational positional errors (PE). Further, we calculated separate SMs one based on residual positional errors and another based on residual + intrafraction positional errors from the imaging data obtained in a dual imaging environment. A total of 22 lung cancer patients were included in this study. For primary image guidance, four-dimensional cone beam computed tomography (4-D CBCT) was used and stereoscopic ExacTrac was used as the auxiliary imaging. Following table position correction (TPC) based on the initial 4-D CBCT, another 4-D CBCT (post-TPC) and a pair of stereoscopic ExacTrac images were obtained. Further, during the treatment delivery, a series of ExacTrac images were acquired to identify the intrafraction PE. If a, b and c were the observed translational shifts in lateral (x-axis), longitudinal (y-axis) and vertical direction (z-axis) and α, β and γ were the rotational shifts in radians about the same axes, respectively, then the resultant translational vectors (A, B and C) were calculated on the basis of translational and rotational values. Set-up margins were calculated using residual errors post-TPC only and also using intrafraction positional errors in addition to the residual errors. Residual and residual + intrafraction SM were calculated from a dataset of 82 CBCTs and 189 ExacTrac imaging sessions. CBCT-based mean ± SD shifts in translational and rotational directions were 0.3 ± 1.8 mm, 0.1 ± 1.8 mm, − 0.4 ± 1.6 mm, 0.1 ± 0.4°, 0.0 ± 1.0° and 0.3 ± 0.7°, respectively, and for ExacTrac − 0.1 ± 1.8 mm, 0.2 ± 2.4 mm, − 0.6 ± 1.8 mm, 0.1 ± 1.2°, − 0.2 ± 1.3° and − 0.1 ± 0.6°, respectively. Residual SM without considering the rotational correction in x, y and z directions were 5.0 mm, 4.5 mm and 4.4 mm; rotation-corrected SM were 4.4 mm, 4.0 mm and 5.5 mm, respectively. Residual plus intrafraction SM were 5.5 mm, 6.6 mm and 6.2 mm without considering the rotational corrections, whereas they were 5.0 mm, 6.3 mm and 6.2 mm with rotational errors accounted for. Accurate calculation of set-up margin is required to find the clinical to planning target volume margin. Primary and auxiliary imaging margins fall in the range of 4.0 to 5.5 mm and 5.0 to 7.0 mm, respectively, indicating a higher SM for X-ray-based planar imaging techniques over three-dimensional cone beam images. This study established the degree of mutual compatibility between two different kinds of widely used set-up imaging modalities, on-board CBCT and in-room stereoscopic imaging ExacTrac. It also describes the technique to calculate the residual and residual plus intrafraction SM and its variation in a dual imaging environment accounting for rotational PE in stereotactic body radiotherapy of lung.

Background Prognosis of metastatic colorectal cancer (mCRC) is poor and goal of treatment is mainly palliative unless there is limited metastatic disease which is surgically resectable. Here, we report a case series of long-term survivors treated predominantly with chemotherapy. Methods This is a single-center retrospective analysis of patients of mCRC. Records of metastatic colorectal cancer patients registered at Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, between the year 2005 and 2015 were retrieved and reviewed. Inclusion criteria were patients who survived 5 years or more, treated mainly by chemotherapy, with either initial presentation as metastatic disease or those who progressed after initial surgery with or without adjuvant therapy. The details about the patient characteristics, treatment, and outcome were collected. The data were censored on September 30, 2020. Results Records of 370 mCRC patients were reviewed. Thirty-one patients with all the available details fulfilled the criteria for inclusion in the study. Median age was 53 years (range, 22–74 years). Sixteen were women (51.6%). Twenty-four (77%) were newly diagnosed cases with initial presentation as metastatic disease. Commonest site of primary was on the left (21, 67.6%) followed by right side and transverse colon in 5 patients each. Liver was the most common site of metastasis (n = 18, 58.06%). In metastatic setting, the most common chemotherapy regimen used in the first line was CAPOX (n = 11, 35.48%). Only three patients could undergo metastatectomy. Monoclonal antibodies could be used only in 14 patients. Median overall survival (OS) of this cohort is 81.6 months (95% confidence interval [CI], 69.73–117.9). Conclusion A small but significant proportion of mCRC patients may achieve and maintain durable responses and long term survival with use of combination of chemotherapy with or without biologics.

PURPOSE Aim of this article is to describe a new knowledge-based planning (KBP) methodology using volumetric modulated arc therapy (VMAT) for stereotactic radiosurgery (SRS) and radiotherapy (SRT) assisted by an ensemble mapping technique for use in a Monte Carlo planning system. METHODS Libraries of 121 stereotactic patients were assembled on the basis of eight different parameters (a) tumor laterality, (b) whether planning target volume (PTV) dose coverage challenged by the presence of the organ at risk (OAR), (c) prescription dose and number of fractions, (d) number of PTVs, (e) tumor volume, (f) shortest distance between OAR and PTV (edge to edge distance, or EED), (g) center to center distance between OARs and PTV (CCD), and (h) lateral dimension of external contour (brain). For new patients, the most appropriate library plan was selected on the basis of the above categorization. A KBP plan was created based on this selected library plan with all parameters unchanged keeping the isocenter at the center of PTV. Using the same beam configuration, another independent treatment plan (IP) was generated by an experienced dosimetrist for comparison. IP and KBP were compared for 76 new patients. RESULTS Of 197 patients (121 library and 76 new), 103 (52.3%) were placed in the OAR-challenged category and 94 were placed in the OAR unchallenged category. The ensemble mapping technique shows that, for an OAR-challenged patient, picking up the library plan is appropriate. IP was marginally better than KBP in PTV coverage and dose conformity (PCI). Library plans, IP, and KBP offer a mean PCI of 0.77 ± 0.2, 0.79 ± 0.2, and 0.78 ± 0.4, mean PTV-V99% of 97.3 ± 22.0%, 98.9 ± 14.1%, and 98.2 ± 13.2%, and mean MU of 2403.8 ± 2403.8, 2344.0 ± 2423.6, and 2473.6 ± 2296.8, respectively. Statistically significant differences were observed in the planning time between the IP and KBP plans for both OAR-challenged (P

Background. Tumours of the eyelid are a rare subgroup of neoplasms with varied histology and inherent differences in clinical behaviour. Surgery is the standard of care, and adjuvant radiation therapy (RT) is given in the presence of features suggesting a high risk of local recurrence. The treatment of lymph nodes in the neck is debatable. We reviewed the utility of RT for lymph nodes in the neck in patients with malignant tumours of the eyelid. Methods. We reviewed medical records of all patients with tumours of the eyelid treated at our centre from July 2006 to December 2014 for their demographic, clinical profile, treatment details and outcome. Results. The records of 37 patients were included for analysis, of these 34 underwent surgery and 21 received adjuvant RT. Their median age was 60 (range 30–85) years. Sebaceous cell carcinoma was the most common (50.4%). The median disease-free survival (DFS) was 35 months (95% CI 17.9–52.0). The 1- and 3-year DFS were 82.7% and 45%, respectively. Univariate analysis showed a superior outcome with early stage (T1) tumours (p=0.01), RT dose of ≥60 Gy and those underwent lymph node dissection (p=0.03). The presence of high-risk factors including close or positive margin had an inferior outcome with a trend towards statistical significance (p=0.06). Conclusion. We found a favourable outcome with early T stage, RT dose of ≥60 Gy and lymph node dissection. High-risk histopathological features including close margins and positive lymph nodes merit adjuvant RT including regional lymph nodes.

PURPOSE Globally, colorectal cancer (CRC) ranks third in terms of incidence and second in terms of mortality. A relatively low burden of CRC has been reported from low- and middle-income countries (LMIC), and there is a paucity of publications related to CRC from LMIC. PATIENTS AND METHODS A computerized comprehensive structured CRC clinical database was developed. All the patients with histopathologically proven CRC undergoing either curative and palliative multimodality management or surgical interventions between 2000 and 2019 were included in the study. A descriptive analysis of the demographic profile and clinical spectrum was performed. RESULTS A total of 970 patients of CRC were treated between 2000 and 2019. Of these, 401 patients (41.3%) had colon cancer and 569 (58.7%) had rectal cancer. The male-to-female ratio was 1.79:1. The mean age at presentation was 47.7 years. A total of 337 (34.7%) patients qualified as young CRC (≤ 40 years of age at diagnosis). The commonest symptom among patients with colon cancer was abdominal pain; 55.6% of patients had a right-sided primary tumor as compared with 42.2% with left-sided tumors. The commonest symptom among patients with rectal cancer was bleeding per rectum. The predominant location of the tumor was in the lower rectum (58%). Majority of patients with CRC presented with locally advanced stage II and III disease. The most common histologic subtype encountered for both colon and rectal cancers was adenocarcinoma (84.8% and 81.2%, respectively). CONCLUSION This study has revealed certain important findings related to CRC in LMIC including a higher burden of young colorectal cancer, a relatively higher proportion of rectal cancers in comparison with colon cancer, a high percentage of patients with low-rectal cancer, and advanced stage at presentation.

Background No data exist for the long-term outcome of metastatic colorectal cancer (mCRC) from the Southern part of Asia. The primary objective of the study is to evaluate the survival outcome of mCRC from an Indian tertiary care center. The study also aims to highlight the treatment pattern practiced and the unique clinico-pathologic characteristics. Methods This is a single-center retrospective observational study done at a large referral tertiary care center in North India. All patients with synchronous or metachronous mCRC who received at least one dose of chemotherapy for metastatic disease, registered between 2003 to 2017 were included. Primary outcome measures were overall survival and progression-free survival and prognostic factors of overall survival. Descriptive analysis was done for the clinicopathological characteristics and treatment patterns. Kaplan Meier method for overall survival and progression-free survival. Cox regression analysis was performed for the determination of the prognostic factors for overall survival. Result Out of 377 eligible patients, 256 patients (68%) had de novo metastatic disease and the remaining 121 (32%) progressed to metastatic disease after initial treatment. The cohort was young (median age, 46 years) with the most common primary site being the rectum. A higher proportion of signet (9%) and mucinous histology (24%). The three common sites of metastasis were the liver, peritoneum, and lung. In the first line, most patients received oxaliplatin-based chemotherapy (70%). Only 12.5% of patients received biologicals in the first-line setting. The median follow-up and median overall survival of study cohort were 17 months and 18.5 months. The factors associated with poor outcome for overall survival on multivariate analysis were ECOG performance status of > 1, high CEA, low albumin, and the number of lines of chemotherapy received ( Conclusion The outcome of mCRC is inferior to the published literature. We found a relatively higher proportion of patients with the following characteristics; younger, rectum as primary tumor location, the signet, and mucinous histology, higher incidence of peritoneum involvement. The routine use of targeted therapies is limited. Government schemes (inclusion of targeted therapies in the Ayushman scheme), NGO assistance, and availability of generic low-cost targeted drugs may increase the availability.

The early twentieth century India saw profound paucity in health care delivery and education, and the beliefs of people were ruled mainly by ignorance, superstitions and myths. Diseases like cancer and its treatment were totally unknown during that time in India. Dr Ida Belle Scudder, American woman, came to India to break all norms and sacrificed her entire life to work in a missionary hospital. Gradually she trained herself to treat cancer patients and established a fully equipped radiotherapy centre to treat such patients. Later, the field of radiation oncology was transformed and modernised by another influential woman, Dr Ketayun Ardeshir Dinshaw, who with her leadership attributes left no stone unturned to firmly establish the role of radiation in the management of cancer and bringing its benefits to the people of India.

BackgroundThis study aims to analyze the dynamics of the published articles and preprints of Covid-19 related literature from different scientific databases and sharing platforms.MethodsThe PubMed, Elsevier, and Research Gate (RG) databases were under consideration in this study over a specific time. Analyses were carried out on the number of publications as (a) function of time (day), (b) journals and (c) authors. Doubling time of the number of publications was analyzed for PubMed “all articles” and Elsevier published articles. Analyzed databases were (1A) PubMed “all articles” (01/12/2019-12/06/2020) (1B) PubMed Review articles (01/12/2019-2/5/2020) and (1C) PubMed Clinical Trials (01/01/2020-30/06/2020) (2) Elsevier all publications (01/12/2019-25/05/2020) (3) RG (Article, Pre Print, Technical Report) (15/04/2020–30/4/2020).FindingsTotal publications in the observation period for PubMed, Elsevier, and RG were 23000, 5898 and 5393 respectively. The average number of publications/day for PubMed, Elsevier and RG were 70.0 ±128.6, 77.6±125.3 and 255.6±205.8 respectively. PubMed shows an avalanche in the number of publication around May 10, number of publications jumped from 6.0±8.4/day to 282.5±110.3/day. The average doubling time for PubMed, Elsevier, and RG was 10.3±4 days, 20.6 days, and 2.3±2.0 days respectively. In PubMed average articles/journal was 5.2±10.3 and top 20 authors representing 935 articles are of Chinese descent. The average number of publications per author for PubMed, Elsevier, and RG was 1.2±1.4, 1.3±0.9, and 1.1±0.4 respectively. Subgroup analysis, PubMed review articles mean and median review time for each article were and 13.9 days respectively; and reducing at a rate of-0.21 days (count)/day.InterpretationAlthough the disease has been known for around 6 months, the number of publications related to the Covid-19 until now is huge and growing very fast with time. It is essential to rationalize the publications scientifically by the researchers, authors, reviewers, and publishing houses.FundingNone

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.

Volumetric modulated arc therapy (VMAT) is modern rotational intensity modulated therapy used for treatment of several sites. The study aimed to analyze partial tangential arc VMAT treatment planning and delivery, including analyzing the cardiac and contralateral breast doses resulting from this technique. A total of 153 consecutively treated breast cancer (conservation as well as mastectomy) patients were taken for this dosimetric study. All patients were planned using partial arc VMAT in the Monaco treatment planning system using two partial arc beams. All patients were divided into seven different categories: (1) all the patients in the study, (2) left sided whole breast and chest wall patients, (3) left Chest wall patients, (4) left whole breast patients, (5) right sided whole breast and chest wall patients, (6) right chest wall patients, and (7) right whole breast patients. We evaluated each treatment plan for PTV coverage and doses to OARs. SPSS version 16.0 software was used for statistical analysis. There were 91 left sided and 62 right sided breast cancer patients in the overall analysis. The percentage of PTV volume receiving 95% of the prescription dose (PTV V95%, mean ± SD) varied in the range of 91.2 ± 5.2-94.8 ± 2.1% with mean dose of 92.4 ± 5.2% for all cases. The (mean ± SD) cardiac dose for all the patients was 289 ± 23 cGy. The (mean ± SD) cardiac doses were higher for left sided patients (424 ± 33.8 cGy) as compared to right sided patients (123.9 ± 80 cGy) (p 0.001). Cardiac mean doses were higher with arc angles30° versus 30° (324.5 ± 247.1 vs. 234.4 ± 188.4 cGy) (p = 0.001). Similarly contralateral breast mean dose was higher with arc angles30° versus 30° (126 ± 115 vs. 88.6 ± 76.1 cGy) (p = 0.001). However cardiac V20, V30 and V40 Gy did not exhibit any statistical difference between the two groups (p = 0.26, 0.057 and 0.054 respectively). This is the first large study of its kind that assesses the dosimetric outcome of tangential partial arc VMAT treatments in a large group of mastectomy and breast conservation patients. Our study demonstrates the efficacy of this technique in dose coverage of PTV as well as in minimizing dose to OARs. Further, based on our results, we conclude that the arc length for the bi-tangential arcs should be 30° since it helps to achieve the most optimal balance between target coverage and acceptable OAR doses.

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.

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.

Psychological distress is often an under-diagnosed problem in cancer care. Addressing psychosocial issues would enhance treatment compliance, physician-patient relationship, treatment efficacy and quality of life. This article emphasizes the importance of integrating psycho-oncology services in cancer care and attempts to define the various roles that a psycho-oncologist can play across the entire trajectory. It also highlights the indispensable role played by the oncologists' referrals in maximizing the benefits of psycho-oncology services received by patients and their caregivers.

ObjectiveThis study was conducted for comparison of techniques between volumetric modulated arc therapy (VMAT), forward-planning intensity-modulated radiotherapy (FIMRT) and conventional technique for left-sided breast radiotherapy after conservative surgery.MethodsIn all, 20 postoperative left breast carcinoma patients were included in this study. In all plans the planning target volume (PTV) was the breast tissue with appropriate margin as per our institutional protocol. The contouring was done on a Monaco Sim (V5.00.02) contouring workstation. All patient were planned using partial arc VMAT in Monaco treatment planning system (TPS) (V5.00.02) and treated on Elekta Synergy linear accelerator. The 3D conformal radiotherapy (3DCRT) and FIMRT planning were done in CMS XIO (V5.00.01.1) TPS. The 3DCRT planning consisted of conventional medial and tangential wedge portals with multileaf collimator field shaping conforming to the target volume. For all the plans generated the following metrics were scored: V105%, V100%, V95%, mean dose (for PTV), V5%, V20%, D2cc and mean dose (for organs at risk).ResultsThe mean PTV volume for 20 patients was 1,074·6±405·1 cc. The highest PTV dose coverage was observed in the 3DCRT technique with 94·1±1·8% of the breast PTV receiving 95% of the prescription dose (V95%). However, it was also observed that this technique resulted in 21·3±10% of the PTV receiving more than 105% of the prescription dose (V105%), which was highest among the three techniques. In contrast, VMAT yielded lowest V95% of 93·0±1·8 and 3·3±5·5% of V105%.ConclusionThis study concluded equivalent result between FIMRT and VMAT. However, VMAT was found to be the choice of radiotherapy technique as it produces lesser dose distribution to heart compared with any other technique.

Context: This research describe the characteristic volume expansion of a moving target as a function of differential margins. Aim: We aimed to ascertain the volume change after giving margin for clinical and set up uncertainties including generating internal target volume (ITV) for moving target. Materials and Methods: Settings and Design – Spheres of diameter (0.5–10 cm) with differential expansion of 1–15 mm were generated using a mathematical formula. Moving targets of radius 1–5 cm were generated, and the resultant volume envelopes with incremental motion from 1 to 20 mm were obtained. All relative volume change results were fitted with mathematical functions to obtain a generalized mathematical formula. Statistical Analysis Used: None. Results: The percentage increase in volume (%ΔVp) was much more pronounced for smaller radius target. For moving target with relatively smaller radius, %ΔVp is predominant over the absolute volume change and vice versa in case of larger radius. Mathematical formulae were obtained for %ΔVp as a function of radius and expansion and for %ΔVp in ITV volume as a function of radius and tumor movement. Conclusions: This study provides an idea of volume change for various expansions for various size targets and/or moving target for different range of movements. It establishes a correlation of these volume changes with the changing target size and range of movements. Finally, a clinically useful mathematical formulation on volume expansion has been developed for rapid understanding of the consequence of volume expansion.

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.

PURPOSE The information about the outcome of primary CNS lymphoma (PCNSL) in India is scarce, because there is no population-based or large hospital-based data. MATERIALS AND METHODS This is a retrospective study that spanned 17 years (2001 to 2017) to study the outcome of PCNSL at the All India Institute of Medical Sciences (AIIMS), which is a tertiary care center in Northern India. RESULTS Only one of 99 patients was positive for HIV serology. Diffuse large B-cell lymphoma was the most common histology (97.7%). The median patient age was 50 years (range, 13 to 70 years), and the ratio of men to women was 1.9. The median duration of symptoms before diagnosis was 3.5 months (range, 0.5 to 48 months), and 58.5% had a performance status (PS) of 3 or more. Multiple intracranial lesions were present in 81.8% of patients. Surgical resection was performed in 45%, and approximately 22% of patients were ineligible for treatment. Most patients (n = 73) were treated with high-dose methotrexate (HDMTX)–based regimens (ie, methotrexate, vincristine, and procarbazine with or without rituximab). Pharmacokinetic monitoring of methotrexate was not available at our center. HDMTX-related mortality was 3.9%. The median follow-up duration, event-free survival (EFS), and overall survival (OS) were 34 months, 20.4 months, and 31.7 months, respectively. Addition of rituximab (n = 27) to MVP resulted in a higher objective response rate (88.9% v 73.9% without rituximab; P = .12), complete remission (81.5% v 56.5%; P = .03), 2-year EFS (57.3% v 40.4%; P = .02), and 2-year OS (61.6% v 53.4%; P = .056). CONCLUSION This is the largest study of PCNSL from India. The patients were immunocompetent and young but presented with a high-burden disease that precluded treatment in approximately 22%. The treatment with HDMTX appears safe without pharmacokinetic monitoring. The outcome is comparable to those observed in the West, and rituximab use showed additional benefit. There are notable barriers with respect to management of PCNSL in the real world, and efforts are required to improve the outcome more.

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.

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.

Volumetric modulated arc therapy (VMAT) has been implemented for left breast irradiation to reduce prescription dose to the heart and improve dose homogeneity across the targeted breast. Our in‐house method requires application of a bolus during the optimization process with a target outside of the body, then removing the bolus during the final calculation in order to incorporate skin flash in VMAT plans. To quantify the dosimetric trade‐offs between traditional 3D field‐in‐field tangents and VMAT with integrated skin flash for these patients, we compared nine consecutive patients who recently received radiation to their entire left breast but not their regional lymphatics. Tangent plans used non‐divergent tangents of mixed energies and VMAT plans utilized four 6 MV arcs of roughly 260°. Mean dose to the heart, contralateral lung, and contralateral breast and their volume receiving 5%, 10%, and 20% of the prescription dose were higher in all nine VMAT plans than in the static tangential beam plans. For all critical structures, the mean VMAT DVH was higher in the low‐dose region and crossed the 3D field‐in‐field DVH between 23.13% and 34.18% of the prescription dose (984.75‐1454.70 cGy). However, the volume of the contralateral breast and heart receiving the prescription dose was slightly lower in the VMAT plans, but not statistically significant. VMAT provided superior homogeneity, with a mean homogeneity index of 9.41 ± 1.64 compared to 11.05 ± 1.82 for 3D tangents. Results indicate that VMAT spares the heart, contralateral lung, and contralateral breast from prescription dose at the cost of increasing their mean and low‐dose volume and delivers a more homogenous dose distribution to the breast. For these reasons, VMAT is selectively applied at the request of the physician for left breast radiation without respiratory gating to spare the heart from prescription dose in cases of poor anatomical geometry.

Objective Carcinoma of external auditory canal (EAC) is a rare disease with variable management strategies and prognosis. We aimed to analyze treatment modalities, prognostic factors and survival outcomes in patients of squamous cell carcinoma of EAC treated at our institution. Methods Forty-three patients of squamous cell carcinoma of EAC were analyzed for clinical presentation, stage, surgical procedures and radiotherapy (RT) modalities employed. Stell and McCormick staging system was used for staging of the patients. Progression free survival (PFS) was estimated by the use of Kaplan–Meier product-limit method. Log rank test was used to assess the impact of prognostic variables on PFS. Multivariate analysis was performed using the Cox hazard regression model. p value of Results Median age was 56 years (range: 12–84 years). Male to female ratio was 31:12. Stage was T1, T2 and T3 in 2, 17 and 18 patients respectively. Sixteen patients underwent surgery. Thirty-six patients received RT (14 received definitive RT, 11 had post-operative RT and 11 had RT with palliative intent). Eight patients (16%) received chemotherapy (5 received concurrent with RT, 2 had adjuvant and 1 had neo-adjuvant chemotherapy). Nine patients (of 11 patients) achieved a complete response (CR) and 2 achieved a partial response (PR) after surgery plus post-operative RT. Nine patients and 5 patients respectively achieved CR and PR after definitive RT (with or without concurrent chemotherapy). Of the 11 patients who received palliative RT, 2 had very good objective response (>50%) and 7 patients had PR to palliative RT. After a median follow-up of 16 months, median PFS for the entire cohort was 14 months. Two-year PFS rates were 85.7%, 46.9% and 0% for patients treated with surgery and post-operative RT, definitive RT and palliative RT respectively. On univariate analysis, higher stage (p = 0.05) and facial nerve palsy at presentation (p = 0.0008) were significant predictors of inferior PFS. Conclusion Patients with carcinoma of EAC present mostly in advanced stage at our centre. Combined higher stage (T3) and facial nerve palsy at presentation portend poorer outcome. Combined modality treatment with surgery and radiotherapy should be advocated and palliative RT remains a reasonable treatment option in patients with advanced incurable disease.

Background: Extra nodal lymphoma (ENL) constitutes about 33 % of all non-Hodgkin`s lymphoma. 18-28% develops in the head and neck region. A multimodality treatment with multi-agent chemotherapy (CT) and radiotherapy (RT) is considered optimum. Materials and Methods: We retrieved the treatment charts of patients of HNENL treated in our institute from 2001-2012. The charts were reviewed and the demographic, treatment details and outcome of HNENL patients were retrieved using predesigned pro-forma. Results: We retrieved data of 75consecutive patients HNENL. Median age was 47years (Range: 8-76 years). Of the 75 patients 51 were male and 24 were female. 55patients were evaluable. The patient and tumor characteristics are summarized in Table 1. All patients were staged comprehensively with contrast enhanced computed tomography of head, neck, thorax, abdomen, pelvis and bone marrow aspiration and biopsy 66 patients received a combination multi-agent CT with CHOP being the commonest regimen. 42 patients received 4 or lesser number of cycles of chemotherapy whereas 24received more than 4 cycles chemotherapy. Post radiotherapy, 41 out of 42 patients had a complete response at 3 months. Only 21patients had a complete response after chemotherapy. All patients received radiation (mostly involved field radiation) as a part of the treatment. The median radiation dose was 45 Gray (Range: 36 Gray-50 Gray). The radiation was planned by 2D fluoro simulation based technique in 37cases and by 3 Dimensional conformal radiation therapy (3DCRT) in 36 cases. Two patients were planned by the intensity modulated radiation therapy (IMRT) technique. IMRT was planned for one thyroid and one nasal cavity primary. 5 patients experienced relapse after a median follow up of 19 months. The median survival was not reached. The estimated two and three year survival were 92.9% (95%CI- 68.6- 95.35) and 88% (95%CI- 60.82 - 92.66) respectively. Univariate analysis revealed higher stage and poorer baseline performance status to be significantly associated with worse progression free survival. 5 patients progressed (relapse or primary disease progression) after treatment. Of the 5 patients, two patients were primary orbital NHL, two patients had NHL nasal cavity and one was NHL thyroid. Conclusions: Combined modality treatment in HNENL confers excellent disease control with acceptable side effects.

Background Treatment of unresectable HNSCC is not well defined and has a poor outcome. This study has been designed to address the unmet needs of such groups of patients with primary end points of (a) proportion of patients eligible for radical treatment in each arm (b) loco-regional disease control at 6months between two arms. Materials and methods Locally advanced and unresectable HNSCC patients (except Nasopharynx and Larynx) unfit for radical treatment were randomized to arm A [short course RT alone (4Gy/#/day for 5days)] or arm B [RT as arm A+concurrent cisplatin at 6mg/m 2 /day IV bolus for 5days]. Those with at least PR were taken for further RT to complete biological equivalent dose of 70Gy, in both the arms. In arm B, concurrent CDDP at a dose of 40mg/m 2 /week was administered. Results 114 patients (57 in each arm) were randomized but 111 were analyzable. 15 (27.27%) patients in arm A and 28 (50%) patients in arm B had ⩾PR ( p =0.01) however patients taken for FRT were 14 (25.45%) and 26 (46.42%) in arms A and B respectively ( p =0.02). Locoregional control i.e. (CR+PR) at 6months was 16.36% in arm A versus 32.14% in arm B ( p =0.15). Median PFS (arm A – 3.2months, arm B – 6.2months; p =0.02) and OS (arm A – 5.9months, arm B – 10.1months; p =0.03) was significantly more in arm B. There was relative improvement in quality of life for most parameters in arm B. Conclusion Concurrent low dose CTRT can be an effective treatment modality in advanced and incurable HNSCC. However, a larger phase III trial is required.

Background The purpose of this study was for us to describe a case of recurrent sebaceous carcinoma treated with postoperative reirradiation. Methods A 38-year-old man was diagnosed with sebaceous carcinoma of the right lower eyelid. The patient developed local recurrence 4 times, with the first one at 30 months after the excision. The first local recurrence was treated with excision and postoperative radiotherapy with 60 Gy/30 fractions/6 weeks. He manifested preauricular nodal metastasis with the third local recurrence, which was confirmed with 18F-fluorodeoxyglucose positron emission tomography-CT (18F-FDG PET-CT). He received 2 courses of adjuvant reirradiation to the right orbit with 45 Gy/25 fractions/5 weeks and 30 Gy/15 fractions/3 weeks, respectively. Results The patient was successfully treated with no evidence of locoregional recurrence at 2 years after the cancer-directed therapy. The patient's follow-up from the date of diagnosis has been 9 years. Conclusion Adjuvant reirradiation with modest doses may be considered with a view to provide disease control and long-term survival. © 2015 Wiley Periodicals, Inc. Head Neck 38: E16–E19, 2016

Background:Aspiration pneumonia is an important cause of death in head and neck cancer patients. This study therefore aimed to evaluate the risk factors associated with aspiration pneumonia in head and neck cancer patients.Methods:Hospital death records from 12 years (2000–2012) were reviewed to obtain the number of deaths. Treatment details and cause of death were analysed. Statistical analysis was performed to identify the risk factors for aspiration pneumonia.Results:The records revealed that aspiration pneumonia was the cause of death in 51 out of 85 patients. Primary tumour site (oropharynx and hypopharynx, odds ratio 3.3; 95 per cent confidence interval 1.17–9.4, p = 0.02) and advanced tumour stage (odds ratio 4.2, 95 per cent confidence interval 1.16–15.61, p = 0.02) had significant negative impacts on aspiration pneumonia related mortality.Conclusion:Advanced pharyngeal cancer patients are at an increased risk of aspiration pneumonia related death. Investigations for the early detection of this condition are recommended in these high-risk patients.

Background: This pilot study looked into the physical, social, psychological and economic issues of Indian adult cancer survivors. Materials and Methods: Assumed cancer free patients, after cancer directed therapy (CDT), were assessed on the basis of a questionnaire developed by the investigators. The mental status of the survivors was elicited by modified MINI international neuro-psychiatric interview. This cross sectional assessment was conducted as a direct interaction with each patient for 30 to 45 minutes at a cancer hospital in 2012. Results: Thirty one adult cancer survivors participated in this study. Median age was 53 years with a median follow up duration of 21.8 months (Range 2.3-194.1 months). The majority (68%) did not receive financial support for treatment. Median interval after CDT to start of activity of daily living was 1.5 months (range: 0-24 months). Fatigue and loss of appetite were reported by 52% and 29% respectively. The cancer diagnosis and its treatment adversely impacted the financial condition in 42% of patients. Nineteen percent each showed social anxiety and post-traumatic stress disorder and another 13% patients reported depression. Conclusions: This prospective assessment highlights survivorship issues and the need to address those issues particularly in the context of developing countries where resources and manpower are limited.