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OBJECTIVEWe report the long term follow-up, toxicity, and outcomes of patients with localized squamous cell carcinoma of the esophagus (ESCC) who underwent definitive chemoradiotherapy (dCRT) at our institute.MATERIALS AND METHODSPatients diagnosed with carcinoma post cricoid, upper cervical and thoracic oesophagus and treated with dCRT treated between January 2000 and March 2012 were retrospectively analysed. Data was extracted from the hospital medical records and patient files. Patients deemed inoperable received upfront RT with or without concurrent chemotherapy and patients with borderline resectable and/or bulky disease received neoadjuvant chemotherapy followed by CRT or RT alone. Radiotherapy was delivered in two phases to a maximum dose of 63 Gy in daily fractions of 1.8 Gy using conventional or conformal techniques. Overall survival and progression free survival were defined from date of registration and were calculated by Kaplan-Meier method with comparisons between different subgroup performed using log rank test. All data were analyzed using SPSS Version 22.RESULTSThree hundred and fourteen patients with ESCC treated with dCRT were included in this analysis. Median age at presentation was 56 years and median Karnofsky Performance Status (KPS) at presentation was 70. Two-third of patients were treated with conformal technique alone or a combination of conventional and conformal technique. Median dose of radiation delivered was 60 Gy (range 30.6 Gy – 70 Gy). Neoadjuvant chemotherapy was administered in about 35% patients and 57% patients received concurrent chemotherapy. About 82% patients (77%) completed their planned treatment course; 10% patients required hospitalization during treatment due to complications and 7 patients did not complete treatment. Grade 1/2 dermatitis and mucositis was seen in 77% and 71% patients respectively. Grade 3 non-hematological and hematological toxicities were seen infrequently. Complete response at first follow up was observed in 56% of patients. At a median follow up of 56 months, 77 patients were alive with controlled disease. The 1-, 2- and 3-yr OS were 80%, 67% and 62% respectively. Median PFS was 28 months; 1-, 2- and 3-yr PFS were 66%, 52% and 46% respectively. A higher RT dose was found to be a significant predictor for OS and PFS on both uni- and multivariate analysis.CONCLUSIONOur study highlights that delivery of higher RT doses (≥63□Gy) is feasible in this patient group and that a higher RT dose was associated with significantly better PFS and OS.

Context Tumors of parapharyngeal space (PPS) are rare and histologically diverse. The management of these tumors requires diligent assessment and planning with due consideration of various anatomical and pathological aspects of the lesion. Aims This retrospective study aims to present our experiences in the clinical and pathological aspects of PPS tumors with a critical evaluation of management. Settings and Design Retrospective analytical study. Methods and Material The electronic medical records of 60 cases of PPS tumors, managed surgically from 2007 to 2017, were reviewed and analyzed using SPSS 22 software. The mean follow-up duration was 44 months. Results The mean age was 45 years with a male-to-female ratio of 1.7 (38:22). The majority of the tumors were benign (71.7%) and the most common presentation being upper neck mass or oropharyngeal mass. Histologically, neurogenic tumors were most common (43.3%) PPS tumors, followed by tumors of salivary gland origin. Magnetic resonance imaging was used as a diagnostic modality in 70% of cases, and computed tomography scan and positron emission tomography/CT were used in 26.7 and 3.3% of cases, respectively. In our study, the diagnostic accuracy of fine-needle aspiration cytology was 71% for benign and 47% for malignant lesions. The most common approach for surgery used was transcervical (72%). Conclusion The study reveals that cranial nerve palsy is the most common complication associated with PPS tumors. Completely resected, malignant tumors originating within PPS have a good prognosis, as compared with tumors extending or metastasized to PPS.

Loco-regional recurrences following surgery or radical radiation therapy for esophageal cancers represent a significant clinical problem. We performed a retrospective study to assess the safety and efficacy of salvage radiation for oligo-recurrence after primary curative therapy for esophageal cancer. Esophageal cancer patients treated with salvage radiotherapy between January 2011 and March 2020 at our institution were screened. Patients were included if they had undergone prior treatment for esophageal carcinoma with curative intent using either surgery or radiotherapy and had developed local/locoregional/isolated distant recurrences. Recurrences were diagnosed based on CT scan or/and FDG PET-CT scan. Treatment plan was discussed in a multi-disciplinary tumour board and patients were followed up as per institution policy. Survival rates were estimated using the Kaplan–Meier method and data was analyzed using IBM SPSS Statistics for Windows (Version 26.0. Armonk, NY: IBM Corp.) Oligo-recurrence was diagnosed in 33 patients; thirty patients had loco-regional-recurrence (LRR), 3 had distant metastasis); 28 patients underwent surgery as initial treatment; 5 received definitive RT. Recurrence was detected at a median of 21 months. Of the 30 patients with LRR, 25 patients received chemo-radiation and 5 received RT alone. At a median follow-up of 18 months, 20 patients were alive and 61% had controlled disease. Overall survival at 1- & 2- year were 83% and 65% respectively. Concurrent chemotherapy administration and RT dose of >56Gy were independent predictors for OS. No grade 3/4 acute or chronic toxicity were observed. Salvage RT with or without concomitant chemotherapy for loco-regional recurrences after surgery for esophageal cancer is safe and effective. Advanced, modern RT techniques may reduce treatment related morbidity and improve outcomes.

To analyze the outcome of locally advanced unresectable adenoid cystic carcinoma (ACC) of head and neck treated with radical concurrent chemoradiotherapy (CRT) at a single tertiary care centre. Between 2011 and 2018, 23 patients with locally advanced unresectable ACC of head and neck treated with non-surgical radical treatment with concurrent chemoradiotherapy were evaluated for outcome and toxicity. All but one patient received cisplatin-based concurrent chemotherapy and 74% of patients were treated with intensity-modulated radiotherapy. Median follow-up was 53 months (range 3–115 months). Following treatment, 11 patients achieved complete response (47.8%) and of the 12 patients with residual disease, 7 patients additionally had disease stabilization without local progression. Overall 15 patients had disease progression. Median time to progression was 28 months (range 6–67 months). The 3-year and 5-year overall survival, local progression-free survival (LPFS) and distant progression-free survival (DPFS) were 78%, 79.7%, 67.4% and 63%, 50.9%, 48.6%, respectively. Acute grade 3 mucositis was observed in three patients, and one patient additionally developed grade 4 neutropenia with subsequent complete recovery. No grade 3 or higher late toxicity was observed. Radical concurrent chemoradiotherapy is a promising treatment option in locally advanced unresectable ACC with acceptable toxicity.

Background To identify clinicoradiological factors that determine functional outcomes in laryngopharyngeal cancers treated with chemoradiotherapy. Methods One hundred patients of locally advanced laryngopharyngeal cancers who were treated with chemoradiotherapy were accrued in this prospective study. The coprimary endpoint of the study was local control (LC) and functional larynx preservation survival (FLPS). Results The median follow-up was 39 months. Thirty-nine patients had a local failure of which 17 underwent a salvage laryngectomy. A dysfunctional larynx with clinic-radiologically disease was seen in only 1 patient. Factors significant for LC were thyroid cartilage erosion/lysis and cricoarytenoid joint involvement. Within the T4a subset, patients with exolaryngeal disease through the soft tissue framework had significantly better LC and FLPS than those with cartilage erosion/lysis. Conclusions Patients with limited exolaryngeal disease through the soft-tissue framework can be considered for functional organ preservation, while those with thyroid cartilage involvement and cricoarytenoid joint involvement are not suitable.

Response assessment after chemo-radiotherapy (CTRT) in locally advanced esophageal cancer is usually performed using a PET-CT scan, an upper GI endoscopy (UGIE) and histological correlation with biopsy or cytology. We aim to study the incremental value of brush cytology in addition to PET-CT for response assessment. In this retrospective analysis, 40 patients with Stage II- IV carcinoma esophagus treated with radical intent between June 2015 and August 2019 were included. Patients were treated with either upfront concurrent CTRT or neo-adjuvant chemotherapy followed by CTRT. All patients underwent PET-CT and UGIE for initial staging and response assessment on follow-up. Patients with esophageal stricture (disease related or treatment induced) had brush cytology done during UGIE. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of brush cytology were calculated considering serial clinical follow-up as gold standard. Twenty-three male (57.5%) and 17 (42.5%) female patients with median age of 57 years (range: 27 – 79 years) were analyzed. Concurrent CTRT was delivered in 52.5%; 75% patients were treated with intensity-modulated radiotherapy (IMRT); median RT dose was 63 Gy (range- 41.4 to 64 Gy). At a median follow-up of 16 months (range 6- 54 months), 20 patients (55.5%) were clinically controlled, 9 (25%) had local recurrence, 5 (13.8%) had loco-regional recurrence and 2 had distant metastasis. Considering clinical follow-up as the gold standard, sensitivity, PPV and NPV of PET-CT combined with brush cytology improved compared to PET-CT alone and was found to be 75%, 90%, 85.7% and 81.8% respectively. We found that brush cytology on endoscopy is a simple tool with high specificity which adds value to the findings of response assessment PET-CT scan and thereby can increase the confidence of the treating oncologist in making clinical decisions.

Background Patients with cancer who develop COVID-19 are at higher risk for severe disease and death. We aimed to study the outcomes of patients with cancer who were infected with SARS CoV2, and identify risk factors for adverse outcomes after COVID-19. Methods We included patients with cancer, who were diagnosed with SARS CoV2 between 11th April 2020 and February 2021 at a tertiary referral cancer centre in India. We collected data on age, sex, coexisting medical conditions, type of cancer, intent of cancer management, cancer treatment details, and severity and outcome of COVID-19. The primary outcome was a composite of severe COVID (defined as grade 6 or more on the WHO ordinal scale) or death within 30 days. We performed multivariable logistic regression analysis to identify risk factors for severe COVID or death. Results We obtained data on 1253 patients with cancer and SARS CoV2 infection, of whom 293 (23.6%) had hematological malignancies. The severity of COVID was mild (grade 1 to 3 on WHO ordinal scale) in 1014 (81%) patients, moderate (WHO grade 4 or 5) in 167 (13%) patients and severe (WHO grade 6 or 7) in 72 (6%) patients. The primary outcome was seen in 160 patients (12.8%) and the all-cause 30-day mortality was 10.9% (138 deaths). Advanced age [adjusted OR 1.84 (0.86; 3.94)], history of smoking [aOR 1.78 (1.10; 2.91)], palliative intent of treatment [aOR 3.57 (2.48 to 5.12)] and presence of more than 2 comorbidities [aOR 1.66 (1.03 to 2.67)] were significant risk factors for severe COVID or death. Advanced age and palliative intent of treatment remained significant risk factors for 30-day mortality. Recent systemic anti-cancer therapy, sex or cancer type did not influence outcomes. Conclusion Most patients with cancer who developed COVID-19 in our setting had mild disease; the elderly and those treated with palliative intent were at higher risk of severe COVID-19 or death. Recent cancer therapy did not impact COVID-19 severity or outcomes suggesting that in most patients with cancer, the management of cancer should continue uninterrupted during the pandemic.

Patients with cancer are at higher risk for adverse coronavirus disease 2019 (COVID-19) outcomes. Here, we studied 1,253 patients with cancer, who were diagnosed with severe acute respiratory syndrome coronavirus 2 at a tertiary referral cancer center in India. Most patients had mild disease; in our settings, recent cancer therapies did not impact COVID-19 outcomes. Advancing age, smoking history, concurrent comorbidities and palliative intent of treatment were independently associated with severe COVID-19 or death. Thus, our study provides useful insights into cancer management during the COVID-19 pandemic.

Background Metastatic epidural spinal cord compression (MESCC) secondary to lung cancer (LC) is a debilitating complication associated with poor prognosis and is commonly treated with radiotherapy (RT). There is no consensus for RT dose fractionation in spinal cord compression. Methods Forty consecutive patients of LC with radiological evidence of MESCC treated with palliative RT were evaluated for functional outcomes (pain, ambulation, and sphincter function) at 2-, 4-, and 24-week post RT completion. Pain assessment was done using visual analogue scale (VAS) and response was categorized according to international consensus criteria, ambulation status (AS) using Tomita’s scale, and sphincter function by the presence or absence of a catheter. Overall survival (OS) was assessed using Kaplan-Meier method and compared using log-rank test. Impact of potential prognostic factors on survival was also analyzed and p-value ≤0.05 was considered significant. Results Sixteen, 22, and two patients received 8 Gy single fraction (SF), 20 Gy in five fractions (20/5), and 30 Gy in 10 fractions (30/10), respectively. At 2 weeks, overall response (OR) rates of pain, ambulation, and sphincter control were 73, 81, and 81%, respectively. At 4 and 24 weeks, 93.7, 84.3, 87.5% and 88, 94, 76.5% had OR, respectively. Median OS was 4 months. Six- and 12-months OS was 50 and 37.5%. Nonsignificant difference in OS was seen between SF and 20/5 fractions (median 2.2 vs. 7.1 months, p = 0.39). Age ≤50 years was the only significant factor (p Conclusion Radiotherapy provided equivalent pain control, ambulation, and sphincter function compared with reported literature in MESCC. Nonsignificant difference in OS exists between SF and multifraction RT regimens.

Definitive chemoradiotherapy (CTRT) is the standard of care for unresectable esophageal cancer. Long segment esophageal primary disease makes it challenging to deliver radiation doses needed to achieve good local control without exceeding normal tissue tolerance to the surrounding organs at risk (OAR). We report our experience and outcomes of such patients where the RT doses were reduced from our institutional standard of 63Gy to 50.4Gy. Methods Between Jan 2017 and Dec 2019, 30/232 consecutive esophageal cancer patients were identified with long segment disease that required dose reduction from 63 to 50.4Gy and were included in this analysis. For this study, we divided nodal regions by their location into cervical, mediastinal, and gastro-hepatic. We generated and compared dosimetric parameters of the standard dose (63Gy) plan with that of treated low-dose plan (50.4Gy) using paired t-test. We also evaluated the patterns of recurrence and have reported them as local relapse (LR), loco-regional relapse (LRR), and distant metastases (DM). Results The median age was 55.5 years; 16 (53.3%) were males and 28 (93.3%) had squamous carcinoma. Single nodal site was involved in 6(20%), 2 sites in 20(66.7%) and 3 sites in 4 (13.3%). Median GTV and PTV length were 7.9 cm (IQR:6.4–9.7 cm) and 18.8 cm (IQR:14.08–22.31 cm) respectively. Median OAR doses with standard Vs treated plan achieved were: Total lung V20 and V5:28 Vs 22.14% (p = 0.00), and 81 Vs 70.5% (p = 0.005) respectively, and heart V20:70.92% Vs 64.7% (p = 0.000). No patients experienced ≥grade2 lung toxicity. After a median follow up of 8.4 months, 3 patients experienced LRR and 1 developed DM. Conclusion Treatment of long segment esophageal cancers warrants dose reduction to avoid higher doses to OAR like lung and heart. Early loco-regional and distant failures suggest need for improved treatment strategies or dose escalation with more conformal techniques like proton therapy. Longer follow-up is necessary to assess the median LR, LRR rates and overall survival for this reduced dose group as compared to the standard dose group.

Radiotherapy is one of the most commonly used treatment modality for brain metastases from lung cancer. Its use has evolved from conventional whole brain radiation therapy (WBRT) to more sophisticated stereotactic radiosurgery (SRS) and hippocampal sparing radiotherapy. Indications of cranial radiotherapy are also evolving with the advent of targeted therapies directed against molecular markers like epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK). Prognostic criteria such as recursive partitioning analyses and graded prognostic score helps in prognostication of brain metastases patients. Majority of the prospective and randomized studies of brain metastases from lung cancer have come from the developed countries with adequate resources. Efforts have been made to replicate or validate the data in developing countries. In this overview, we intend to discuss the role of radiotherapy for brain metastases in limited resource settings of developing countries. The aim should be to generate a good quality data which is applicable for routine clinical practice in a resource friendly manner. SRS is indicated in guidelines for limited brain metastases, however, it requires a more sophisticated treatment delivery and quality assurance machines which are not available at many centres in majority of the developing countries. Similarly, clinical research should be undertaken considering the demographic, clinical and genetic differences among different populations. Currently, tyrosine kinase inhibitors have dramatically changed the outcomes of metastatic non-small cell lung cancer including brain metastases. The role of WBRT is being questioned in driver mutated patients in developed countries. However, the applicability of this approach should be examined in resource constrained settings as availability of these drugs is limited, its higher cost and frequent use of surveillance brain imaging are the practical challenges.

Summary Locoregional recurrences following surgery for esophageal cancers represent a significant clinical problem with no standard recommendations for management. We conducted this systematic review and meta-analysis with the objective of studying safety and efficacy of salvage radiotherapy in this setting. All prospective and retrospective cohort studies, which studied patients who developed locoregional recurrence following initial radical surgery for esophageal cancer and subsequently received salvage radiation therapy (RT)/chemoradiation with all relevant information regarding survival outcome and toxicity available, were included. The quality of eligible individual studies was assessed using the Newcastle-Ottawa Scale score for risk of bias. R package MetaSurv was used to obtain a summary survival curve from survival probabilities and numbers of at-risk patients collected at various time points and to test the overall heterogeneity using the I2 statistic. Thirty studies (27 retrospective, 3 prospective) published from 1995 to 2020 with 1553 patients were included. The median interval between surgery and disease recurrence was 12.5 months. The median radiation dose used was 60 Gy and 57% received concurrent chemotherapy. The overall incidence of acute grade 3/4 mucositis and dermatitis were 8 and 4%, respectively; grade 3/4 acute pneumonitis was reported in 5%. The overall median follow-up of all studies included was 27 months. The 1-, 2- and 3-year overall survival (OS) probabilities were 67.9, 35.9 and 30.6%, respectively. Factors which predicted better survival on multivariate analysis were good PS, lower group stage, node negativity at index surgery, longer disease-free interval, nodal recurrence (as compared to anastomotic site recurrence), smaller disease volume, single site of recurrence, RT dose >50 Gy, conformal RT, use of concomitant chemotherapy and good radiological response after radiotherapy. Salvage radiotherapy with or without concomitant chemotherapy for locoregional recurrences after surgery for esophageal cancer is safe and effective. Modern radiotherapy techniques may improve outcomes and reduce treatment-related morbidity.

Background To assess the efficacy of intensity-modulated radiation therapy (IMRT) for tumors of the nasal cavity and paranasal sinus (PNS) region. Materials and methods Two hundred fourteen patients with tumors of the nasal cavity and PNS region treated with curative intent IMRT between 2007 and 2019 were included in this retrospective analysis. Results Fifty-one (24.1%) received definitive RT/CTRT and 163 (75.9%) received adjuvant RT. Most common histology was squamous cell carcinoma (26.1%) followed by adenoid cystic carcinoma (21.5%). The median follow-up was 43.5 months. The 5-year local control (LC), event-free survival (EFS), and overall survival (OS) for the entire cohort was 66.9%, 59%, and 73.9%, respectively. On univariate analysis treatment with nonsurgical modality, T classification and undifferentiated/poorly differentiated histology were associated with inferior 5-year LC, EFS, and OS. Four patients had late Grade 3/Grade 4 ocular toxicity. Conclusions IMRT should be the standard of care for tumors of PNS region across all histologies and treatment setting.

IntroductionTyrosine kinase inhibitors (TKIs) have significantly improved the progression-free survival (PFS) of metastatic non-small cell lung cancer (NSCLC) with oncogene mutations of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) compared with systemic therapy alone. However, the majority eventually develop resistance with a median PFS of 8–12 months. The pattern of failure studies showed disease relapse at the original sites of the disease-harbouring resistant tumour cells.Methods and analysisThis study is designed as a phase II randomised controlled trial to evaluate the efficacy of local consolidative radiation therapy (LCRT) in addition to TKI in upfront oligometastatic NSCLC. Patients will be screened at presentation for oligometastases (≤5 sites) and will start on TKI after confirmation of EGFR or ALK mutation status. After initial TKI for 2–4 months, eligible patients will be randomised in a 1:1 ratio with stratification of oligometastatic sites (1–3 vs 4–5), performance status of 0–1 versus 2 and brain metastases. The standard arm will continue to receive TKI, and the intervention arm will receive TKI plus LCRT. Stereotactic body radiation therapy will be delivered to all the oligometastatic sites.The primary end point is PFS, and secondary end points are overall survival, local control of oligometastatic sites, toxicity and patient-reported outcomes. The sample size calculation took a median PFS of 10 months in the standard arm. To detect an absolute improvement of 7 months in the interventional arm, with a one-sided alpha of 5% and 80% power, a total of 106 patients will be accrued over a period of 48 months.Ethics and disseminationThe study is approved by the Institutional Ethics Committee II of Tata Memorial Centre, Mumbai, and registered with Clinical Trials Registry—India, CTRI/2019/11/021872, dated 5 November 2019. All eligible participants will be provided with a participant information sheet and will be required to provide written informed consent for participation in the study. The study results will be presented at a national/international conference and will be published in a peer-reviewed journal.

PurposeTo compare long-term disease-related outcomes and late radiation morbidity between intensity-modulated radiation therapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) in head and neck squamous cell carcinoma (HNSCC) in the setting of a prospective randomized controlled trial.MethodsPreviously untreated patients with early to moderately advanced non-metastatic squamous carcinoma of the oropharynx, larynx, or hypopharynx (T1-T3, N0-N2b, M0) planned for comprehensive irradiation of primary site and bilateral neck nodes were randomly assigned to either IMRT or 3D-CRT after written informed consent. Patients were treated with 6MV photons to a total dose of 70Gy/35 fractions over 7 weeks (3D-CRT) or 66Gy/30 fractions over 6 weeks (IMRT). A sample size of 60 patients was estimated to demonstrate 35% absolute difference in the incidence of ≥grade 2 acute xerostomia between the two arms. All time-to-event outcomes were calculated from date of randomization until the defined event using the Kaplan-Meier method.ResultsAt a median follow-up of 140 months for surviving patients, 10-year Kaplan-Meier estimates of loco-regional control (LRC); progression-free survival (PFS); and overall survival (OS) with 95% confidence interval (95%CI) were 73.6% (95%CI: 61.2–86%); 45.2% (95%CI: 32–58.4%); and 50.3% (95%CI: 37.1–63.5%) respectively. There were no significant differences in 10-year disease-related outcomes between 3D-CRT and IMRT for LRC [79.2% (95%CI: 62.2–96.2%) vs 68.7% (95%CI: 51.1–86.3%),p = 0.39]; PFS [41.3% (95%CI: 22.3–60.3%) vs 48.6% (95%CI: 30.6–66.6%),p = 0.59]; or OS [44.9% (95%CI: 25.7–64.1%) vs 55.0% (95%CI: 37–73%),p = 0.49]. Significantly lesser proportion of patients in the IMRT arm experienced ≥grade 2 late xerostomia and subcutaneous fibrosis at all time-points. However, at longer follow-up, fewer patients remained evaluable for late radiation toxicity reducing statistical power and precision.ConclusionsIMRT provides a clinically meaningful and sustained reduction in the incidence of moderate to severe xerostomia and subcutaneous fibrosis compared to 3D-CRT without compromising disease-related outcomes in long-term survivors of non-nasopharyngeal HNSCC.

Lobectomy is considered the standard of care for early stage non-small-cell lung cancer. However, for those patients who remain unfit to undergo surgery due to advanced age, poor performance status, comorbidities, poor pulmonary reserve or a combination of these are now treated with stereotactic body radiation therapy (SBRT). Due to its noninvasive nature, lower cost, lower toxicity, reduced recovery time and equivalent efficacy, even medically operable patients are attracted to the option of SBRT despite the lack of level I evidence. Thus, studying the incidence and patterns of recurrence after SBRT help in understanding the magnitude of the problem, risk factors associated with the different patterns of recurrence, and aid in devising strategies to prevent them in future. Nodal recurrences are not uncommon after SBRT and can potentially lead to further seeding for distant metastases and ultimately poor survival. This review is aimed at reviewing the published data on the incidence of nodal recurrences after SBRT and compare it to surgery, identify potential risk factors for recurrence, salvage treatment options and prevention strategies.

Given the enormous strain the COVID-19 pandemic has put on healthcare worldwide, appropriate allocation of resources according to priority is of immense importance. As brain metastases are a common presentation in lung cancer, during the pandemic, it potentially can pose a major management challenge to clinicians. In this article, we outline a pragmatic approach that oncologists should consider while managing these patients. The overarching principle is to deliver best, evidence-based treatment without compromising patient care while ensuring the safety of healthcare workers.

BACKGROUND: Malignant Pleural Mesothelioma is an uncommon and aggressive disease associated with asbestos exposure. Management of MPM is complex and controversial as there is paucity of good quality evidence. Multimodality treatment with surgery, systemic therapy and radiation therapy is an option in non-metastatic MPM. We intend to analyze toxicity and outcomes in patients who received trimodality treatment for non-metastatic MPM at our institution. METHODS and MATERIALS: We reviewed the electronic medical records of surgically managed MPM patients at our institution in the last decade. Patient details, disease characteristics and treatment information were retrieved from the institutional electronic medical record and radiation oncology information system. Dosimetric parameters of target volume and organs at risk were documented from Eclipse workstation (v13.6, Varian medical systems). SPSS was used for statistical analysis. RESULTS: Between January 2008 and October 2018, 21 patients (17 male and 4 female) underwent surgery for MPM, all but 2 patients underwent extra-pleural pneumonectomy (EPP). Primary was located in the right and left in 11 and 10 patients respectively. Epithelioid MPM was the commonest histology (17 patients: 81%). Resection was R0 in 18 patients and R2 in 2 patients. Four patients had minor complications like wound erythema, wound seroma with cellulitis and hypotension and 8 Patients had major complications like pneumonia, rib fracture, pulmonary hypertension and pulmonary stump thrombus. All patients received neoadjuvant Pemetrexed/platinum doublet chemotherapy, except for 2. Fourteen patients received adjuvant hemithoracic RT; of these, 2 underwent treatment elsewhere and 2 were treated with conventional technique. Ten patients treated with conformal technique at our institute and dosimetric data was available for analysis. Average time to start RT after surgery was 51 days (range 32 to 82 days). All patients were treated with conformal technique using IMRT/VMAT to a dose of 45Gy in 25 fractions; one patient received a further boost of 5.4Gy. Mean overall RT duration was 35 days (range 30 to 42 days). Acute toxicity was uncommon; Grade I/II Pneumonitis was seen in 4 patients. One patient developed grade III acute lung toxicity unrelated to RT. At a median follow up of 25 months, 8 patients developed progressive disease. Eight patients had died, of whom six died due to disease and two died in immediate post op period. Two-year DFS and OS were 58% and 73% respectively. CONCLUSION: In spite of the extensive surgery and complex hemithoracic RT, we demonstrated excellent dosimetric, toxicity profile and favorable outcomes in non-metastatic MPM.

BACKGROUNDWhole brain radiation therapy (WBRT) is an effective palliative measure and provides durable symptom relief in lung cancer patients with multiple brain metastases (BM). Clinico-radiological progression of BM after WBRT is a common and challenging scenario; treatment is tailored, with various factors like driver mutation status, age, performance status, progression free interval and time since last irradiation influencing the treatment decision. Surgery or focal RT with stereotactic techniques may be an option for patients with oligo-metastases. However, they might not be a feasible option for patients with multiple BM. We aim to study the impact and outcome of patients with BM from lung cancer receiving re-WBRT for clinico-radiological progression.MATERIALS AND METHODSWe retrospectively analyzed patients with BM from lung cancer who were registered at Tata Memorial Hospital, Mumbai, India between January 2016 to January 2019 and had undergone two courses of WBRT. Data of patients were retrieved from electronic medical records. Patients were treated using conventional or conformal technique with either tele-cobalt or Linear accelerator.RESULTSOut of 446 patients with lung cancer, diagnosed and treated with WBRT for BM, 6% patients (n=28) received re-WBRT. There were 16 men and 12 women with a median age of 53 years (range 30 to 70 years). Primary histology was adenocarcinoma in all except two patients who had small cell histology. Eighteen patients had driver mutation positive disease (11 with EGFR and 7 with ALK mutation) and a majority of patients (54%) had BM at presentation. Clinico-radiological progression was the commonest indication of re-WBRT. A majority of these patients had developed new symptoms while about 25% had recurrence of previous symptoms. Mean Karnofsky performance score (KPS) prior to re-WBRT was more than 70 in 13 patients (57%). Mean time interval between the two courses of WBRT were 16 months (range 5-37 months). Most patients received WBRT using a conventional technique (91%) and were treated in a tele-cobalt unit (83%). Re-WBRT fractionation schedule was 25 Gy/10 fractions (n=17, 61%) or 20 Gy/5 fractions (n=10, 36%). Mean biological effective dose (BED2Gy) for the first and second courses of WBRT were 63Gy and 56Gy respectively. The average cumulative BED2Gy was 118.91Gy (range 116.25 – 120Gy). Almost all patients received short acting steroids during the course of re-WBRT. All patients except for one completed the course of treatment. At a median follow up of 2.5 years, median survival of patients after re-WBRT was 5 months. Median survival since re-WBRT was 8 months if pre first course of WBRT ds-GPA was 3.5-4 vs 1 month if it was 0-1 (p= 0.025).CONCLUSIONIn lung cancer patients with symptomatic progression of multiple BM and good prognostic features (driver mutation positive, good performance status and long time interval since last WBRT), re-WBRT is safe and associated with better outcomes.

Objective:To study if pre-treatment CT texture features in locally advanced squamous cell carcinoma of laryngo-pharynx can predict long-term local control and laryngectomy free survival (LFS).Methods:Image texture features of 60 patients treated with chemoradiation (CTRT) within an ethically approved study were studied on contrast-enhanced images using a texture analysis research software (TexRad, UK). A filtration-histogram technique was used where the filtration step extracted and enhanced features of different sizes and intensity variations corresponding to a particular spatial scale filter (SSF): SSF = 0 (without filtration), SSF = 2 mm (fine texture), SSF = 3–5 mm (medium texture) and SSF = 6 mm (coarse texture). Quantification by statistical and histogram technique comprised mean intensity, standard-deviation, entropy, mean positive pixels, skewness and kurtosis. The ability of texture analysis to predict LFS or local control was determined using Kaplan–Meier analysis and multivariate cox model.Results:Median follow-up of patients was 24 months (95% CI:20–28). 39 (65%) patients were locally controlled at last follow-up. 10 (16%) had undergone salvage laryngectomy after CTRT. For both local control & LFS, threshold optimal cut-off values of texture features were analyzed. Medium filtered-texture feature that were associated with poorer laryngectomy free survival were entropy ≥4.54, (p = 0.006), kurtosis ≥4.18; p = 0.019, skewness ≤−0.59, p = 0.001, and standard deviation ≥43.18; p = 0.009). Inferior local control was associated with medium filtered features entropy ≥4.54; p 0.01 and skewness ≤ – 0.12; p = 0.02. Using fine filters, entropy ≥4.29 and kurtosis ≥−0.27 were also associated with inferior local control (p = 0.01 for both parameters). Multivariate analysis showed medium filter entropy as an independent predictor for LFS and local control (p < 0.001 & p = 0.001).Conclusion:Medium texture entropy is a predictor for inferior local control and laryngectomy free survival in locally advanced laryngo-pharyngeal cancer and this can complement clinico-radiological factors in predicting prognosticating these tumors.Advances in knowledge:Texture features play an important role as a surrogate imaging biomarker for predicting local control and laryngectomy free survival in locally advanced laryngo-pharyngeal tumors treated with definitive chemoradiation.

Background Management of MPM is complex and controversial as there is a paucity of good quality evidence. We report the toxicity and outcomes in patients who received trimodality treatment for non-metastatic MPM at our institution. Methods & materials We reviewed the electronic medical records of surgically managed MPM patients at our institution in the last decade. Dosimetric parameters of target volume and organs at risk were documented by the treatment planning workstation. SPSS was used for statistical analysis. Results Between January 2008 and October 2018, 21 patients underwent surgery for MPM – all but 2 patients underwent extra-pleural pneumonectomy (EPP); epithelioid MPM was the most common histology. All patients, except 2, received neoadjuvant Pemetrexed/platinum doublet chemotherapy. Fourteen patients received adjuvant hemithoracic RT; ten patients were treated with a conformal technique at our institute and dosimetric data was available for analysis. Average time to start RT after surgery was 51 days (range 32–82 days). All patients were treated with a conformal technique using IMRT/VMAT to a dose of 45Gy in 25 fractions. Mean overall RT duration was 35 days (range 30–42 days). Grade I/II Pneumonitis was seen in 4 patients. One patient developed grade III acute lung toxicity unrelated to RT. At a median follow up of 25 months, 8 patients had died, of whom six died due to the disease and two died in the immediate post op period. Two-year DFS and OS were 58% and 73%, respectively. Conclusion In spite of the extensive surgery and complex hemithoracic RT, we demonstrated excellent dosimetry, toxicity profile and favorable outcomes in non-metastatic MPM.

Oral cavity cancer (OCC) poses a global challenge that plagues both the Orient and the Occident, accounting for an estimated 350 000 new cases and 177 000 deaths in 2018. OCC is a major public health problem in the Indian subcontinent, where it ranks among the top three cancer types in both incidence and mortality. Major risk factors are the use of tobacco, betel quid and alcohol consumption. OCC is a heterogeneous group of multiple histologies that affects multiple subsites. The oral cavity includes the lips, buccal mucosa, teeth, gingiva, anterior two-thirds of the tongue, floor of the mouth and hard palate. OCC is defined as cancer of lips, mouth and tongue as defined by the International Classification of Diseases coding scheme. The epidemiology, aetio-pathogenesis and treatment philosophy are similar within this group. Although salivary gland malignancies, sarcomas, mucosal melanomas and lymphomas can also arise within the oral cavity, this review will focus on squamous cell cancer, which is the predominant histology in OCC. We review and contrast data from developing and developed countries. We also highlight the unique regional challenges that countries in the East face; citing India as an example, we elaborate on the opportunities and scope for improvement in the management of OCC.

IntroductionTwo-phase II randomised studies have shown a significant benefit of local consolidation therapy in oligometastatic non-small cell lung cancer (NSCLC). This phase III randomised controlled trial (RCT) will evaluate the efficacy of local consolidation radiation therapy (RT) in oligometastases (OM) NSCLC after completion of initial systemic therapy.Methods and analysisThis is a single-centre phase III RCT of OM NSCLC patients. One hundred and ninety patients will undergo 1:1 randomisation to either standard maintenance therapy (control arm) or local consolidation RT and standard maintenance therapy (experimental arm). Patients will be stratified into the number of OM sites (1–2 vs 3–5), nodal metastases (N0–N1 vs N2–N3) and presence or absence of brain metastases. Stereotactic body radiation therapy to all the oligometastatic sites and definitive RT to primary disease will be given in the experimental arm. The primary endpoint is overall survival and secondary endpoints include progression-free survival, local control of OM sites, new distant metastases free survival, objective response rate, toxicity and quality of life. Translation endpoint include circulating tumour cells and radiomics using texture analysis.Ethics and disseminationAll patients will be provided with a written informed consent form which needs to be signed before randomisation. The study is approved by the institutional ethics committee-II (project number 3445) and registered with Clinical Trials Registry—India, dated 21 April 2020.Trial registration numberCTRI/2020/04/024761; Pre-Results.