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Patients with autosomal dominant polycystic kidney disease (ADPKD), especially those with renal failure, carry a higher risk of developing renal cell carcinoma (RCC) compared to the general population. Genetic mutations associated with ADPKD are known but a direct link associated with RCC is still controversial. We discuss the clinical course of two such patients. The first patient was diagnosed with ADPKD at the age of 10 years with an unreported tubulocystic RCC focus on his renal biopsy that was picked up on review 16 years later when he presented with vertebral metastases determined to have originated from the RCC. He was doing well on multikinase inhibitors till 4 years of diagnosis with metastatic disease when he succumbed to progressive disease after 3 lines of systemic therapy. The second patient was diagnosed with ADPKD in middle age and papillary RCC 3 years later. Within 3 months of cancer diagnosis, there was progression to metastatic disease and rapid decline despite systemic therapies. We surmise that the diagnosis of RCC may be missed in ADPKD till the advanced stages. Patients with ADPKD should be monitored regularly with imaging and biopsy if needed. Histology may be varied but once diagnosed, systemic therapies may help disease control.

Abiraterone acetate in combination with prednisone is approved for locally advanced as well as metastatic (hormone-sensitive and castrate-resistant) prostate cancer, with overall or disease-free survival gains in suitable patients. Long-term use poses a significant financial strain on the self-paying patients as well as the national health insurance schemes. Abiraterone is known to be a drug with a high “food effect” with increased bioavailability following high fat diet. Some retrospective series and phase 1 and 2 clinical studies have explored the use of low-dose abiraterone (at 25% of standard dose) with high fat meal with similar bioavailability and biochemical response to the standard drug dose. We review and report the available literature for this approach and discuss the financial and scientific implications of the same.

Introduction: Renal cell carcinoma metastasizes commonly to visceral organs such as adrenals, liver, lungs, or to bones. Metastases to body cavities such as pleura, pericardium and peritoneum are rare, and almost never in isolation. Case discussion: We discuss here a patient who was diagnosed with renal cell carcinoma following an episode of hematuria and underwent radical nephrectomy for the same. Within a month of surgery, he was evaluated for sudden onset breathlessness and detected to have massive left-sided pleural effusion, which returned malignant on pleural biopsy. The patient was treated with oral multikinase inhibitor following symptomatic therapy, with a favorable response. The imaging findings and relevant literature exploring the incidence of such presentations are discussed. Conclusion: Malignant effusions usually portend a poor prognosis but owing to the rarity of this condition and availability of newer therapies, long-term durable control may be expected.

Orbital metastasis, as the initial clinical presentation in hepatocellular carcinoma (HCC), is a rare manifestation. A 66-year-old male patient presented with a history of protrusion of the eyeballs, double vision, and swelling over the left side of the head for 8 months. Magnetic resonance imaging of the brain with orbit revealed a heterogeneous lesion in the left frontal lobe causing its destruction with intraorbital and intracranial extension. Triphasic contrast-enhanced computed tomography was suggestive of multiple hypodense areas in both lobes of the liver. Tissue diagnosis from the liver was suggestive of HCC. A diagnosis of multifocal HCC with orbital metastasis was made. The patient was treated with palliative radiotherapy and sorafenib. Orbital metastasis in HCC is rare. Prognosis is somber in such cases. The treatment should focus on providing palliation from symptoms.

Highlights • The patient-reported outcomes are as vital as the physician documented toxicities. • The QOL scores return back to normal in most scales similar to baseline value by 3 months. • VMAT based SIB is a feasible and safe strategy in terms of toxicity profile., Objective To assess the change in the quality of life (QOL) in head and neck cancer patients treated with Simultaneous Integrated Boost (SIB) by Volumetric Modulated Arc Therapy (VMAT) technique. Methods Thirty patients with localised head and neck cancers (Stage II- IVa) were treated with VMAT and SIB technique. The three-dose levels prescribed were 68.2 Gy at 2.2 Gy/fraction, 62 Gy at 2 Gy/fraction and 55.8 Gy at 1.8 Gy/fraction to the high, intermediate and low-risk volumes respectively. Concurrent chemotherapy with cisplatin 100 mg/m2 was administered once in three weeks. Acute toxicities were evaluated and scored according to the RTOG grading system. Quality of life (QOL) was assessed using European Organization of Research and Treatment of Cancer (EORTC) QLQC30 and HN35 questionnaires at baseline and in three instances (immediately, one month and three months after the radiotherapy). Results Out of the total 30, 80% patients had a complete response (CR) at the median follow up of 12 months, while three patients died because of progression, and the remaining 3 had stable disease. All planning objectives were achieved for organs at risk and planning target volume(PTV). There was a statiscally significant(p value

Synchronous splenic metastases from oesophageal squamous cell carcinomas are extremely rare. Most of the cases of splenic metastases reported in the literature are mainly metachronous and occur usually from adenocarcinoma primary. The treatment options range from splenectomy to palliative chemotherapy with standard doses in fit individuals. However, in cases with poor performance status, the management is often the best supportive care only due to the fear of tolerance and toxicities with standard dose chemotherapy. Herein, we report a case of squamous cell carcinoma of the distal thoracic oesophagus in a poorly fit elderly male diagnosed with synchronous splenic metastases and successfully treated with palliative chemotherapy with reduced flat doses and radiotherapy with no significant toxicities.

Angiosarcomas are rare but highly aggressive malignancies originating from lymphatic or vascular endothelial cells and may arise from any site in the body. Angiosarcomas of the genitourinary tract, especially of seminal vesicle origin, are extremely rare with only five reported cases. Surgery forms the mainstay of therapy in localised disease while adjuvant therapies are still being refined. We present the case of a 40-year old gentleman who presented with lower urinary tract symptoms and, on evaluation, was found to have a localised angiosarcoma originating in right seminal vesicle and offered laparoscopic resection, adjuvant paclitaxel (12 weekly cycles) and adjuvant radiation therapy (66 grey in 30 fractions). He developed a peritoneal nodular recurrence after 6 months of radiotherapy that was successfully salvaged with excision and metronomic chemotherapy, which he is currently receiving. Localised angiosarcomas need multimodality management despite small size. Attempts should be made for surgical salvage of limited recurrences with encouraging outcomes.

Background The impact of radiation-related lymphopenia on clinical outcomes has been reported in various solid malignancies such as high grade gliomas, head and neck cancers, thoracic malignancies and gastro-intestinal malignancies but its impact is not clearly known in the context of common genito-urinary (GU) malignancies. Methodology To better understand the effect of radiation-associated lymphopenia in prostate and bladder cancer, we undertook this systematic review of clinical studies that have studied radiation-related lymphopenia in GU malignancies. A systematic methodology search of PubMed, Embase, and Cochrane library resulted in 2125 abstracts. Ten studies fulfilled the inclusion criteria which included any prospective, retrospective study or cohort study of prostate, urinary bladder, kidney, ureter, urethra, penile cancer in humans, and radiation should be part of treatment and intent has to be in definitive or adjuvant settings. Finally the study should have data on radiation-related lymphopenia. Results Four studies reported on the cancer-specific outcomes related to the lymphopenia. The incidence of low lymphocyte counts were documented in all the studies. Three studies analyzed the factors associated with the Lymphocyte depletion. Pooled incidence of severe lymphopenia was 29.25% and mild to moderate lymphopenia was 60.75%. Bone marrow volume receiving 40 Gy was associated with the incidence of lymphopenia. Conclusion One-third of the patients suffer from severe lymphopenia after radiation in prostate and bladder cancer. There are no clear data to support the correlation between severe lymphopenia and disease outcomes. Bone marrow dosimetry can affect the incidence and severity of lymphopenia. There is need of prospective datasets to identify the impact of radiation-related lymphopenia in GU malignancies focusing on long-term side effects, recurrence rates, and overall survival.

Background: Primary adenoid cystic carcinomas (ACCs) of central trachea-bronchi system are rare and heterogeneous tumors. Definitive radiotherapy (RT) is the recommended treatment in surgically unresectable or incomplete resection or in the presence of severe comorbidities. Objective: To evaluate the clinical features and outcomes of patients with ACC of trachea-bronchi treated with radiotherapy. Methods: Retrospective medical records review was done in all patients with histologically confirmed ACC of trachea-bronchi between January 2010 and December 2019. Patient disease and treatment characteristics and toxicity data were analyzed. Overall survival (OS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were computed using Kaplan-Meier method (log-rank test). Results: Nineteen patients (10 women and 9 men) were included in this analysis with median age of 40 years (range, 14–70). Of these patients, 63.2% (n = 12) presented in stage IV disease. Twelve and three patients received definitive (median dose 67.8 Gy) and adjuvant (median dose 50 Gy) RT, respectively. The median follow-up was 42.5 months (range, 4–120); 15 patients were alive and 4 were dead at that time. Local recurrence or progression was observed in 52.6% and distant metastasis found in 47.3% of patients. The 5-year OS, LRFS, and DMFS for all patients were 81.2%, 52.8%, and 39.6%, respectively. Baseline lymph node involvement showed significant impact on OS (56.3% vs 100%, p = 0.011). Among patients receiving definitive RT, patients with higher RT dose (⩾66 Gy) had significantly better survival outcomes (5-year LRFS: 75% vs 16.7%, p = 0.013). Conclusion: Definitive RT is an exemplary treatment for unresectable disease. Higher dose is recommended to improve long-term outcomes.

PURPOSE The purpose of the study is to analyze the overall survival, relapse-free survival, and relapse patterns of adjuvant sequential chemoradiation for gallbladder cancers after curative resection in patients with poor performance status. MATERIALS AND METHODS We retrospectively reviewed clinical records of gallbladder patients with pathologic stage T2-4 or node positivity treated with sequential chemoradiation at our institute between January 2015 and January 2019. Sequential chemoradiotherapy protocol consisted of six cycles of gemcitabine 1,000 mg/m2 and oxaliplatin 100 mg/m2 administered every 2 weekly and postoperative radiation therapy (45 Gy in 25 fractions over 5 weeks) by three-dimensional conformal technique. RESULTS A total of 36 patients were included. The median overall survival and relapse-free survival was 26 months (95% confidence interval [CI], 21.4-30.5) and 21 months (95% CI, 11.8-30.1), respectively. The 2-year overall and relapse-free survival rates were 55.1% (95% CI, 37.9%-72.3%) and 44.7% (95% CI, 27.5%-61.9%), respectively. Locoregional, systemic, and combined recurrence were noted in 2 (5.5%), 14 (38.8%), and 3 (8.3%) patients, respectively. On univariate analysis, tumour grading significantly influenced relapse free survival; nodal stage and overall stage demonstrated a statistically significant influence on overall survival (p < 0.05) with a trend towards significance for lymphovascular invasion. On multivariate analysis, no significant factors were found. Grade 3 and 4 haematological adverse events were observed only in 2 (5.5%) with chemotherapy. No grade 3 and 4 adverse events were observed due to radiation therapy. CONCLUSION Sequential chemoradiation is feasible and tolerable with acceptable efficacy in the adjuvant setting in patients unfit for concurrent chemoradiotherapy.

Introduction Brachytherapy, with or without external beam radiation therapy (EBRT), can be an alternative to surgery for organ preservation in early and locally advanced oral cavity cancers. This study aims to evaluate the effect of high dose rate (HDR) interstitial brachytherapy on early and locally advanced squamous cell carcinoma (SCC) of the oral cavity when used alone or as a boost to EBRT. Methods A total of 125 patients with histologically proven stage T1-3/N0-1 SCC of the oral cavity were included in the study. A total of 15 patients with stage I disease received an interstitial implant dose of 3,850 cGy at 350 cGy per fraction, two fractions a day. Another 53 patients had stage II, and 57 patients had stage III disease; these patients received EBRT of 50 Gy in 25 fractions along with an HDR brachytherapy boost of 21 Gy in seven fractions of 3 Gy per fraction twice daily. The stage III patients also received concurrent chemotherapy with injections of cisplatin (70 mg/m2) given every three weeks for three days in divided doses. All node-positive patients received a boost to the node of up to 64 Gy by external beam radiation. Disease response rates, five-year disease-free survival rates, and toxicities were analyzed. Results The median follow-up was 60 months. Among the patients, 103 (82.4%) had a complete response, while 22 (17.6%) had residual disease and were referred for surgical salvage. The five-year disease-free survival was 100% in stage I, 83% in stage II, and 77.2% in stage III; 4% of patients developed grade 3 acute skin toxicity and 23.2% developed acute grade 3 mucositis. Eleven patients died during the follow-up period. Two patients died due to myocardial infarction but had achieved a complete tumor response. One patient had pulmonary tuberculosis and died due to fulminant infection after three years of disease-free survival period. One patient developed a second primary in the brain stem that presented with quadriplegia and expired. Seven patients died due to the progression of the initial disease. Conclusions Proper brachytherapy technique and meticulous planning can minimize the toxicity while providing better tumor control and achieve high local control rates. Brachytherapy, with or without EBRT, can be a surrogate to surgery in early oral cavity cancers as it can achieve organ preservation while providing good functional outcomes.

Cutaneous angiosarcoma is a type of rare and locally aggressive malignancy requiring individualised treatment owing to paucity of randomised trials. We present the case of a middle-aged cancer survivor with locally advanced angiosarcoma of scalp managed with surgery, radiotherapy, chemotherapy and targeted therapy over a course of 6 years for two recurrences. The first recurrence was preceded by opsoclonus myoclonus syndrome, a type of paraneoplastic neurological syndrome (PNS), rarely reported in sarcomas. The second recurrence had a rapid clinical course, which led to a therapeutic dilemma of best supportive care versus active management. A trial of weekly paclitaxel was started that was continued for a total of 12 cycles with good objective clinical response. Presently, he is tolerating maintenance pazopanib well and is symptom free for 6 months. In cutaneous angiosarcoma patients, PNS may be a harbinger of recurrence and aggressive, multimodality treatment helps prolong survival.

Postirradiation osteosarcoma is an uncommon complication of radiation treatment for brain tumors. It is associated with a poor prognosis and survival is usually

Background: Primary gastric adenocarcinoma commonly occurs in the elderly in the sixth to seventh decade of life but is exceedingly rare in children and adolescents, accounting for only 0.05% of pediatric gastrointestinal malignancies. Because of the nonspecific clinical presentation, gastric adenocarcinomas in children and adolescents are often metastatic when they are discovered. Case Report: We describe a case of gastric adenocarcinoma in a 16-year-old female who was diagnosed early and successfully treated with surgery and chemoradiation by volumetric modulated arc technique. Conclusion: The possibility of gastric adenocarcinoma should be considered in children and adolescents with persistent nonspecific symptoms of vomiting and upper abdominal pain so that the diagnosis can be made at early stages and radical treatment can be offered.

Introduction This study aimed to measure cervical regression during external beam radiation therapy (EBRT) and optimize the scheduling of brachytherapy concurrently with EBRT. Methods Fifty consecutive patients with carcinoma of the cervix stage IIA to IIIB received concurrent chemoradiotherapy with weekly Cisplatin 40 mg/m2. Cervical regression was evaluated using serial CT scans obtained before and during concurrent chemoradiotherapy (on the third, fourth, and fifth weeks). High dose rate brachytherapy was introduced after 30Gy of EBRT. A total of 25.5Gy in three fractions were delivered during the third, fourth, and fifth weeks of EBRT. Cervical volumes were recorded from the CT scan for cervical regression. Results The mean cervical volume at baseline (i.e., before the start of treatment) was 85.53 cubic centimetres (cc). The mean cervical volumes at the end of the third, fourth, and fifth week were 28.95cc, 24.92cc, and 21.80cc, respectively. The mean cervical regression from baseline to the end of the third, fourth, and fifth week was 60%, 65%, and 69%, respectively. The time for 50% cervical regression was calculated to be 18 days and occurred around 27Gy of EBRT. Conclusion More than 50% of cervical regressions occur at the end of the third week (i.e., after delivery of 30Gy of EBRT), so it is optimal to introduce brachytherapy at the end of the third week. A conventional point-based plan can cover the high-risk clinical target volume (HRCTV) if the volume is 25cc may be well covered with optimization or a combination of intracavitary and interstitial brachytherapy.

The gastrointestinal tract (GIT) is a rare site of primary malignant melanoma. Most of the melanomas diagnosed in the GIT are secondary to cutaneous melanomas. Very few cases of primary melanoma of the stomach have been reported in the literature. We report a rare case of primary malignant melanoma of the stomach in a 60-year-old female patient who presented with nonspecific symptoms. Imaging revealed multiple liver metastases, and on subsequent evaluation, upper gastrointestinal endoscopy (UGIE) showed a lesion in the stomach. Biopsy from the lesion in the stomach was suggestive of melanoma. After excluding other sites of melanoma, a diagnosis of primary malignant melanoma of the stomach with liver metastasis was made. Primary malignant melanoma of the stomach is an exceedingly rare neoplasm. UGIE and biopsy remain the mainstay of diagnosis. Most of the patients present with advanced stage disease, and the prognosis remains dismal. The response to chemotherapy as well as targeted therapy is not well documented in the literature.

Acinic cell carcinoma (ACC) of the salivary glands is a low grade malignancy which can present with late recurrences and distant metastasis. Being relatively resistant to chemotherapy, managing metastatic ACC is a clinical challenge, especially considering the long duration of survival of these patients. A 33-year-old female presented with recurrent ACC of the left parotid, eighteen years after initial presentation; with incidentally detected asymptomatic lung metastases. She remained stable after six cycles of triple agent chemotherapy and continues to be clinically asymptomatic at nine months post chemotherapy. We hereby, report this case to highlight the late recurrence and metastatic pattern of ACC and the benefit of achieving stable disease with triple agent chemotherapy. Further clinical studies on other anticancer agents are required to achieve better treatment outcomes.