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A 31-year-old man with no predisposing factors and no history of chronic disease presented with a small painless lump over his anterior chest wall. On evaluation, it was found to be undifferentiated pleomorphic sarcoma. He underwent wide local excision of the tumour with clear margins, followed by adjuvant radiotherapy. At 6-month follow-up, the patient is clinically and radiologically disease free.

Cancers arising from the hypopharynx are more commonly seen in developing countries including India, compared to the western countries. Out of all head and neck cancers (HNC), the reported incidence rates are 2–5% in the developed versus 15–30% in the developing countries [1]. In view of its anatomic location, the hypopharynx is a blind spot in the head and neck region of the human body. Unless the patient has serious compromise in the food swallowing activity, a gross change in voice or both, he/she does not report. Hence, more than 70% are diagnosed at an advanced stage, and the early stages I–II are reported in approximately 25% of all hypopharyngeal cancers [2]. Majority of these cancers arise from the pyriform sinus (PFS), whereas post-cricoid cancer is common in an anaemic female. Squamous cell carcinoma is the commonest histologic type. In India, hypopharyngeal cancers constitute more than 10% of all HNC [3].

The hypopharynx consists of three parts, pyriform sinus, posterior pharyngeal wall, and post-cricoid region covered by mucosal lining, which gives rise to carcinoma mainly of squamous cell type. Hypopharyngeal cancers (HPC), more so in advanced stages, are characterized by aggressive disease and dismal treatment outcomes. The main goal of treatment in carcinoma hypopharynx is not only to achieve cure but also to ensure adequate preservation of voice and eating capacity. In order to achieve the goal, there is a paradigm shift in the treatment approaches. The advancements and refinements in nonsurgical therapies have been brought in a lesser reliance on surgical management of hypopharyngeal cancers. In the past two decades, guidelines on larynx preservation have been published for advanced laryngopharyngeal cancers. However, given the entirely different natural history and poor prognosis for hypopharyngeal cancers as compared to laryngeal cancer, the issue of larynx preservation needs to be separately addressed for these rare and aggressive tumors. In the present chapter, we discuss pertinent aspects of larynx preservation by nonsurgical approaches for the locally advanced hypopharyngeal cancers. It is imperative that organ preservation outcomes should be correlated with morbidity and potential factors that can reduce chemoradiotherapy-related late morbidity and aid better organ functions.

This paper examines the extent of variation in the applicator geometry during multiple high dose rate (HDR) intracavitary brachytherapy (ICBT) applications and its impact on reporting as per ICRU report 38.Eighty orthogonal radiographs from 20 consecutive patients of carcinoma cervix (FIGO stages, IIA-IIIB) having four HDR ICBT applications of 6 Gy each at weekly intervals following teletherapy were evaluated. The applicator consisted of a flexible intrauterine tandem (IUT) independent of the ovoid assembly. The applicator geometry was evaluated in terms of: alpha angle, beta angle, intrauterine length (IUTL), interovoid (IOV), os to right ovoid (ORT) and os to left ovoid (OLT) distances along with vertical (VDL) and anteroposterior displacements (ADL) of the os with respect to the ovoids. The Cartesian co-ordinates (X, Y, and Z) of the IUT tip, centre of both ovoids and os were also measured. Doses to right point A (ARD), left point A (ALD), along with a reference volume of 6 Gy for ICRU height (IRH), width (IRW), thickness (IRT) and volume (IRV) were estimated for each application.Highly significant differences (P0.001) between four insertions in any given patient across 20 patients for alpha angle, beta angle, IUTL, IOV, ORT, VDL, co-ordinates of the IUT, ovoids and os were observed, except for ADL (P=0.041) and OLT (P=0.247). As a consequence, variations were observed in ARD (P=0.027), ALD (P=0.017); IRH, IRW, IRT and IRV (all P0.001). Applicator factors which influenced the various dose specification parameters were: beta angle and ORT for both ARD and ALD; UTLN, VDL and ORT for IRH; UTLN and IOV for IRW; UTLN for IRT and VDL for the 6 Gy IRV.A significant variation of the applicator geometry and its movement was observed in patients undergoing multiple HDR ICBT. This could have implications for reporting dose and volume specifications as required by ICRU report 38.

Carcinoma of the penis tends to have a predictable route of spread by direct invasion and by regional lymphatic involvement to the inguinal group of lymph nodes. Blood-borne distant spread is rare, last to occur, and is seen in 1–3% of cases. Metastasis to the spine is even rarer. We encountered one such case who presented with spinal metastasis, as documented by the whole body bone scan, and this was later followed by involvement of the inguinal nodes. This case is unique in its site of metastatic presentation as well as its pattern of presentation.

Available clinical, radiological and histopathologic risk factors are not adequate for accurate prognosis in uterine cervix carcinoma. Hence there is a need to identify indicators to select high risk cases. Most cancers occur and progress through step-wise somatic genetic mutations. Thus screening of whole genome for specific genomic alterations and its outcome following treatment may predict prognosis. The present study was carried out to investigate genomic alterations associated with cervical carcinoma and any association of genomic alterations with clinico-pathologic parameters.Cervical carcinoma cases (n = 4) were subjected to protocol based clinical evaluation, treatment and follow up as a double blind procedure. Tumour samples were collected before radiotherapy and 3 months after completion of radiotherapy. All the samples were stored at -80 degrees C. Comparative genomic hybridization (CGH) was carried out to screen genomic alterations in all tumour samples obtained before treatment. Conventional fluorescent in situ hybridization (FISH) was carried out to confirm the CGH findings and to follow up post-treatment samples. Patients were followed up for a minimum of one year or until death.The CGH analysis identified genomic losses and gains. The gains were observed mainly in chromosomes 1q 25.1, 3q 26.1, 6q 13-16, 9p 22 and X, and losses in chromosome 10 and 11q21-24. CGH and FISH results were complementary to each other. Of the four patients, two were alive and two were dead at the end of follow up.Initial results indicated that persistence of genomic alterations and appearance of giant nucleus was associated with poor prognosis and the same may be used to follow up patient. Similar studies on large sample with longer period of follow up are warranted to validate our result.

This study attempts to evaluate the advantage of individualized midline shield (IMLS) constructed on the basis of uterine geometry and applicator position in terms of the dosimetric consequences to points A-right (AR) and left (AL) as compared to standard midline shield (SMLS) in radiation therapy of carcinoma cervix. Twenty consecutive patients of carcinoma cervix (Stage I, II and III) were treated by external beam radiotherapy (EBRT) (50 Gy/5 weeks/25 fractions) and high-dose rate intracavitary brachytherapy (24 Gy/4 weeks/4 fractions) prescribed at point A. At the completion of 40 Gy by EBRT (phase I), IMLS (5 cm wide) at isocenter was fabricated on the basis of uterine geometry as ascertained by a dummy intracavitary application. The remaining 10 Gy of EBRT was delivered using IMLS (phase II) to effectively minimize and optimize the dose to point A. The dose profiles of IMLS were compared against the corresponding dose profile of a 5 cm SMLS and were found to be dependent on the positional variation of AR and AL with respect to the midline. With IMLS, the dose to AR and AL for the 10 Gy of phase II varied between 21.7-38.87% (30.01 +/- 4.87) and 22.42-35.72% (28.12 +/- 3.79) respectively. However with SMLS, the AR and AL doses would have ranged from 22.03% to 77.26% (34.55 +/- 15.94) for AR and from 20.59% to 96.2% (46.93 +/- 28.15) for AL leading to considerable inhomogeneity. Thus, in protocols incorporating midline shield for radiotherapy of carcinoma cervix, IMLS in place of SMLS could be preferred for achieving a definitive and homogeneous dose to the points AR and AL.

HIGH precision radiation therapy is based on the fact that the tumor and normal surrounding structures have to be delineated in all three dimensions before the radiation oncologist plans the treatment for the patient. The three dimensional computerized treatment planning system then generates a plan in which the tumor gets a high dose and the normal tissues around it get a very low dose of radiation. The radiation is then delivered using a linear accelerator with a multi leaf or micro multi leaf collimator. This methods results in higher cure rates and minimal normal tissue complications. Based on this premise the modern radiation therapy techniques viz. stereotactic radiotherapy, stereotactic radiosurgery, 3 dimensional conformal radiation therapy (3D CRT), and intensity modulated radiation therapy (IMRT) have been developed and have become standard of care in modern radiation therapy departments around the world, including India. Such treatments are planned using CT/ MRI imaging. Till a decade ago the planning techniques were different because the planning was done based on fluoroscopy and not on CT/MRI images. This resulted in two and not three dimensional delineation of tumor and normal tissues and therefore the radiation portals were large so that there was no geographical miss of the tumor. This, however, resulted in inclusion of a larger volume of normal surrounding tissues and the radiation oncologists had to keep the total dose to a lower level in order to keep the complication rates low, but the lower tumor doses were not sufficient enough to result in higher cure rates. When the intention is to spare the normal tissues and the delineation is in three dimensions, the radiation oncologist uses a very tight margin around the tumor which helps in escalating the total tumor dose. This philosophy is utilized in all the modern treatment techniques mentioned above. It has been observed and documented over the last few years that all the organs in the body move during the radiation treatment and also over a period of 4-6 weeks over which all the radiation therapy treatments are delivered. This observation has led us to think that if the