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Pancreatic cancer is a disease of the elderly; patients65 years are 60% of the cases. Due to multiple comorbidities, treating these patients is challenging. We report the efficacy and safety of carbon ion radiotherapy (C-ion RT) in octogenarians.We retrospectively analyzed the cases of 46 pancreatic cancer patients aged ≥80 years (median 83, range 80-97) treated with definitive C-ion RT in 2007-2018 at our institute.Twenty-five patients (54%) had resectable or borderline-resectable disease; none underwent surgery (because of medical reasons, e.g., age, multiple comorbidities). C-ion RT was delivered with a median dose of 55.2 Gy (RBE) in 12 fractions. The survivors' median follow-up period was 43 (range 19-76) months. The entire cohort's median overall survival (OS) was 15 (95%CI: 14-22) months with a 3-year OS of 20% (95%CI: 11%-35%). On both univariate and multivariate analyses, baseline CA19-9 remained the significant independent OS prognostic factor (p = 0.032). The 3-year local control rate for all patients was 34% (95%CI: 19%-53%). Local failure (n = 25, 54%) was as common as distant relapse (n = 26, 57%); 33% of the patients experienced both local and systemic failure. About 15% underwent re-C-ion RT for infield recurrence; they achieved a median 22-month OS. No patients exhibited grade ≥3 severe acute or late toxicities (including those who received re-C-ion RT).C-ion RT in octogenarians with pancreatic cancer showed promising outcomes with acceptable acute and late toxicities and can be considered a reasonable alternative to radical surgery.

PURPOSE A COVID-19 lockdown in India posed significant challenges to the continuation of radiotherapy (RT) and systemic therapy services. Although several COVID-19 service guidelines have been promulgated, implementation data are yet unavailable. We performed a comprehensive audit of the implementation of services in a clinical oncology department. METHODS A departmental protocol of priority-based treatment guidance was developed, and a departmental staff rotation policy was implemented. Data were collected for the period of lockdown on outpatient visits, starting, and delivery of RT and systemic therapy. Adherence to protocol was audited, and factors affecting change from pre-COVID standards analyzed by multivariate logistic regression. RESULTS Outpatient consults dropped by 58%. Planned RT starts were implemented in 90%, 100%, 92%, 90%, and 75% of priority level 1-5 patients. Although 17% had a deferred start, the median time to start of adjuvant RT and overall treatment times were maintained. Concurrent chemotherapy was administered in 89% of those eligible. Systemic therapy was administered to 84.5% of planned patients. However, 33% and 57% of curative and palliative patients had modifications in cycle duration or deferrals. The patient’s inability to come was the most common reason for RT or ST deviation. Factors independently associated with a change from pre-COVID practice was priority-level allocation for RT and age and palliative intent for systemic therapy. CONCLUSION Despite significant access limitations, a planned priority-based system of delivery of treatment could be implemented.

IntroductionPeer review of target volume is recommended as an important step for ensuring high quality radiotherapy. The Royal College of Radiologists considers gynecological cancers as one of the sites where peer review of individual target volumes is required. We report results of an on-demand peer review system for gynecological cancers in our institute. MethodsPeer review was planned for gynecological cancer cases planned for curative intent radiotherapy. On demand peer review was conducted by two senior clinical oncologists specializing in gynecological cancers after segmentation was completed by junior clinical oncologists. Peer review discussions were recorded prospectively in an electronic database. In the present study, data of patients planned from radiotherapy between 15th September 2021 - September 2022 is audited. The compliance to the audit process, proportion of patients requiring major and minor modifications in target volumes, direction of changes noted as well as factors influencing the changes have been reported.ResultsIn the study period, 230 patients underwent planning for curative intent radiotherapy and 204 (88.3%) patients had at least one peer review. Major target volume changes were required in 108 patients, with the majority of changes reported in the nodal CTV. Analysis of P-charts showed a rapid change in proportion of patients requiring major modifications with stabilization at the end of 3 months to 38.2% and 28% for nodal and primary CTV respectively. Modifications were primarily required in the para-aortic and common iliac region for nodal CTV. Multivariable analysis showed that major modifications were associated with the use of extended field radiotherapy and use of radical radiation in non-cervical primaries. ConclusionAn on-demand peer review system was feasible and resulted in clinically meaningful changes in 53% of patients.

IntroductionThe COVID-19 pandemic has affected cancer care worldwide. We audited adherence to 19 predefined quality indicators (QI) of treatment in patients with carcinoma cervix in our institute. MethodsPatients with carcinoma cervix treated with curative intent radical radiotherapy were eligible for this study. Patients who started treatment between 24 March 2019 and 24 March 2021 were evaluated. We divided participants into two groups, the pre pandemic period between 24 March 2019 and 23 March 2020, and the period of pandemic from 24 March 2020 - 24 March 2021. Adherence to 19 predefined QI was evaluated for each patient’s treatment course. Multivariable analysis of adherence to QI was performed using proportional odds regression. Results154 patients underwent treatment, of whom 83 (53.9%) received treatment during the pandemic. 17 patients had COVID-19 infection before or during treatment. Adherence to QI decreased during the pandemic, primarily driven by delays in the start and delivery of treatment. The median number of QI adhered to in the pre pandemic period was 17 (IQR: 16 - 17.5) versus 17 during the pandemic (IQR: 16 - 17). Multivariable analysis showed that treatment during the pandemic period was associated with a lower adherence to QI (Odds ratio 3.30, 95% confidence intervals 1.70 - 6.50). ConclusionsThe COVID-19 pandemic was associated with reduced adherence to QI. Treatment delivery was affected not only by COVID-19 infection, but also logistic challenges due to restrictions related to the pandemic.

Highlights • Carbon-ion re-irradiation for pancreatic cancer; feasibility and efficacy. • Adjuvant chemotherapy improve local control of re-irradiation using carbon ions. • Carbon-ion radiotherapy for recurrent pancreatic cancer; reasonable option., Background and purpose Patients who receive carbon-ion radiotherapy (C-ion RT) for primary pancreatic cancer may experience locoregional recurrence; however, the treatment options for such patients are limited. We aimed to investigate the feasibility and efficacy of carbon-ion re-irradiation for patients with pancreatic cancer who experienced recurrence after initial C-ion RT. Materials and methods Twenty-one patients with recurrent pancreatic cancer who underwent repeat C-ion RT between December 2010 and November 2016 at our institute were retrospectively evaluated. The sites of post-initial C-ion RT failure were in-field central in 16 patients (76.2%) and marginal in 5 (23.8%). The median doses of initial and repeat C-ion RT were both 52.8 Gy (relative biological effectiveness [RBE]). Thirteen patients (61.9%) received concurrent chemotherapy with re-irradiation, while 11 (52.4%) received adjuvant chemotherapy. Results The median follow-up period after re-irradiation was 11 months. The 1-year local control, progression-free survival, and overall survival rates were 53.5%, 24.5%, and 48.7%, respectively. Toxicity data was obtained from the patients’ charts. Only 1 patient (4.8%) developed grade 3 acute toxicities and none developed grade ≥3 late toxicities. Univariate analysis indicated that patients who received adjuvant chemotherapy had significantly improved local control rates compared with those who did not; the 1-year local control rates were 80.0% and 0.0%, respectively (P = 0.0469). Conclusion Repeating C-ion RT may be a reasonable option with tolerable toxicity for patients with recurrent pancreatic cancers. Adjuvant chemotherapy appears to improve the local control rate. This is the first study to examine re-irradiation using C-ion for recurrent pancreatic cancer after initial C-ion RT.

We compared the dose distributions of carbon-ion pencil beam scanning (C-PBS), proton pencil beam scanning (P-PBS) and Volumetric Modulated Arc Therapy (VMAT) for locally recurrent rectal cancer. The C-PBS treatment planning computed tomography (CT) data sets of 10 locally recurrent rectal cancer cases were randomly selected. Three treatment plans were created using identical prescribed doses. The beam angles for C-PBS and P-PBS were identical. Dosimetry, including the dose received by 95% of the planning target volume (PTV) (D95%), dose to the 2 cc receiving the maximum dose (D2cc), organ at risk (OAR) volume receiving > 15Gy (V15) and > 30Gy (V30), was evaluated. Statistical significance was assessed using the Wilcoxon signed-rank test. Mean PTV-D95% values were > 95% of the volume for P-PBS and C-PBS, whereas that for VMAT was 94.3%. However, PTV-D95% values in P-PBS and VMAT were

Highlights • High LET and high RBE of carbon ion made it a promising tool for treating pancreatic cancers. • Dose averaged LET minimum within the GTV is significantly associated with local control. • Outcome of CIRT in pancreatic cancers can be improved by modulating dose averaged LET within the GTV., Background and purpose High linear energy transfer (LET) radiation carbon-ion radiotherapy (C-ion RT) is one of the most promising modalities for treating unresectable primary pancreatic cancers. However, how LET contributes to a therapeutic effect is not clear. To assess whether there is an enhanced effect of high LET radiation on tumour control, we aimed to determine the impact of dose-averaged LET on local control (LC) of primary pancreatic tumours. Materials and methods A retrospective analysis of 18 patients with primary pancreatic carcinomas treated with definitive C-ion RT with concurrent chemotherapy in 2013 was conducted. The dose of irradiation was 55.2 Gy (RBE). The relationship between dose-averaged LET and LC of primary tumours was evaluated. Results All patients had histologically confirmed adenocarcinoma. The median follow-up duration was 22 months. The actuarial LC and overall survival (OS) at 18 months were 62.5% and 70.1%, respectively. There were no cases of grade ≥3 late toxicities observed. Local recurrences developed in four patients (22%), all of which were infield central recurrences. Although there were no significant differences in gross tumour volume (GTV) dose coverage, patients with higher minimum dose-averaged LET (LETmin) values within the GTV had better LC (dose-averaged LETmin ≥44 keV/microm; 18-months LC 100.0% vs 34.3%; p = 0.0366). Conclusion Dose-averaged LETmin within the GTV was significantly associated with LC of primary pancreatic cancers. Our data suggest that outcomes for patients with unresectable primary pancreatic cancers receiving C-ion RT can be improved by modulating the dose-averaged LET within the GTV.

Randomised controlled trials (RCT) are important for generating high-quality evidence about efficacy and adverse effects associated with various types of interventions. RCTs are expensive and time consuming to conduct. Therefore, a significant portion of the research funding available for clinical research would be utilised for funding randomised clinical trials. The objective of the current study is to report the extent of funding received by investigators of academic RCT in India and the areas where the funding is allocated to in the clinical trials.

Protocol for the survey

This technical report introduces the utility of iodine paste markers using endodontic materials for the accurate contouring of mucosal lesions of oral mucosal melanoma, which are difficult to delineate on imaging during the planning of carbon-ion radiation therapy (CIRT). The patient had a primary oral mucosal melanoma located in the palatal mucosa without palatal or maxillary bone invasion. A dental root canal filling material, which is a calcium hydroxide/iodoform nonhardenable paste, was used as a marker. We first performed treatment-planning computed tomography (CT) without an iodine paste marker for mucosal lesions. Subsequently, we placed an iodine paste marker on the palatal mucosal lesion to accurately delineate the mucosal lesions of the palate. Finally, we obtained a reference CT image with an iodine paste marker. Computed tomography without the marker was fused to the reference CT with markers during treatment planning, and the gross tumor volume was contoured. Thereafter, CIRT was delivered without markers. During CIRT, expected acute mucositis was observed in the area of the planning target volume, including melanosis, in accordance with the dose distribution. The use of iodine paste markers for localized mucosal lesions, which are difficult to delineate on CT and magnetic resonance imaging, may be useful for accurately contouring gross tumor volumes on treatment-planning CT.

Background The Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial established a new benchmark in the management of oesophageal cancer with neoadjuvant chemoradiation followed by surgery with a marked benefit for squamous cell carcinomas (SCCs). We evaluate if the CROSS protocol can be safely implemented with a broader eligibility criteria in a real-world setting. Methods A retrospective analysis of 80 patients of SCC oesophagus was performed, who were treated with neoadjuvant chemoradiation with radiation therapy (RT) to 41.4 Gy/23 Fr/4.5 weeks and weekly paclitaxel and carboplatin, followed by surgery at our institute between 2012 and 2019. Eligibility for the use of this regimen was expanded beyond the limits of size and stage allowed in the CROSS trial. Results The median age of this cohort was 57 years (range: 39-78 years). Most of the patients (77/80; 96.3%) had T3 disease and 25% patients (20/80) had N2/N3 disease. Thirty-three patients (41.3%) had the disease beyond CROSS eligibility criteria. All patients completed planned course of RT and five cycles of weekly chemotherapy were received by 61 patients (76.2%). Overall pathological complete response (pCR) could be achieved in 33 patients (41.3%). Among 33 CROSS ineligible patients, 14 (42.4%) had pCR. Acute grade 3 dysphagia and grade ≥ 3 neutropenia were seen in seven cases (8.3%) and nine cases (10.7%), respectively. At a median follow-up of 16 months, 1-year and 2-year overall survival (OS) were 84.4% (95% confidence interval (CI): 73.5%-91.1%) and 76.3% (95% CI: 63.2%-85.2%), respectively, for the entire cohort. For CROSS ineligible patients, 1-year and 2-year OS were 82% (95% CI: 61.8%-92.2%) and 72.7% (95% CI: 50.4%-86.2%), respectively. On univariate analysis, patients who had pathologically N0 disease had significantly better 2-year OS (85.7% versus 48.4%; p = 0.03) as compared to pathologically N+ patients. On univariate and multivariate analysis, there was no significant difference in OS and progression free survival between CROSS eligible and CROSS ineligible patients. Conclusion CROSS protocol can be safely implemented for carefully selected patients of SCC oesophagus outside clinical trial settings with expanded eligibility criteria.

Background Definite concurrent chemoradiation is the standard of care for locally advanced unresectable oesophageal cancers. However, heterogeneity exists in the practice of concurrent chemoradiation approaches. Here we describe the efficacy and toxicities of the standard arm of SCOPE1 protocol implemented at our institute. Methods Treatment records of 36 patients with unresectable oesophageal cancers treated with concurrent chemoradiation between January 2015 and June 2019 were audited. Treatment was based on the standard arm of SCOPE1 protocol (neoadjuvant and concurrent platinum and capecitabine with external beam radiation to a dose of 50 Gy/25 fractions/5 weeks). The electronic hospital information system and oncology information system were queried to obtain information on patient characteristics and treatment delivery patterns. Results Out of 36 patients, 35 had squamous cell carcinomas. 25% of the patients (9/36) were 70 years or older. 66.7% of patients (24/36) had T4 disease, and 16 (44.4%) had N2-N3 nodal disease at presentation. A total of 30 patients (83.3%) could not undergo surgery because of the location and locoregional extent of the disease. The median follow-up of the entire cohort and the surviving patients was 10 months (range 3-51 months) and 13 months (range 4-51 months), respectively. The median overall survival (OS) of the entire cohort was 28 months. The 2-year local progression-free survival and OS were 71.2% (95% CI: 48.5%-85.3%) and 57.4% (95%CI: 29.6%-77.6%), respectively. Commonly observed acute Grade 3 toxicities were dysphagia (22.2%) and thrombocytopenia (19.4%). Conclusion The outcomes of the SCOPE1 protocol have been validated for the first time in a different geographical, racial and ethnic population. Implementation of the standard arm of SCOPE1 protocol is feasible in our setting with acceptable adverse effects and good treatment compliance. Results are comparable to the results of the published trial.

Introduction Electronic data capture (EDC) tools can improve data quality gathered in clinical trials and may be more cost-effective than paper forms. However, limited data is available on the adoption of EDC tools in randomized controlled trials (RCT) conducted in India. Methods We invited investigators of registered randomized controlled trials in India to an online survey. The questionnaire included questions on the use of EDC (or alternative data capture methods) and features available. An EDC sophistication level (ranging from 1–6) was computed from the responses obtained. Respondents were also asked about barriers to the implementation of EDC in their setting. The EDC adoption rate (EAR) was defined as the proportion of clinical trials where EDC with a sophistication level of 2 or more was used. Multivariable logistic regression was used to identify factors that predicted EDC adoption. Results Responses were received for 400 trials, with an EAR of 27.5% (95% confidence intervals : 23.4–32.1%, n = 110). The number of sites influenced EDC adoption (odds ratio : 1.26, 95% CI : 1.12–1.47, p = 0.001) on multivariable analysis. EAR did not increase over time. The key barriers identified for not using an EDC were lack of technical support (170, 63.0%) and software cost (132, 48.9%). Conclusion The survey shows a low EAR in randomized trials registered in India. The barriers identified in the survey would need systematic solutions to improve the EAR in the future.

Background Most of the primary sphenoid sinus tumors present with locally advanced stages with involvement of adjacent critical structures and are not amenable to radical resection. We sought to evaluate the safety and efficacy of carbon‐ion radiotherapy (C‐ion RT) for sphenoid sinus malignancies. Methods This is a retrospective analysis of 22 patients of primary sphenoid carcinomas treated with definitive C‐ion RT. Results Adenoid cystic carcinoma was the most common histology (15 patients, 68.2%). The median follow‐up of this cohort was 48.5 months. The actuarial local control and overall survival at 5 years were 51.0% and 62.7%, respectively. Grade 4 visual impairment and grade 4 brain necrosis were seen in six and one patient, respectively. Conclusion C‐ion RT can provide a reasonably good clinical outcome in locally advanced sphenoid sinus malignancies with a marginally higher late toxicity profile because of extremely close proximity of the target volume to critical structures.

Introduction The current study was aimed at quantifying the disparity in geographic access to cancer clinical trials in India. Methods We collated data of cancer clinical trials from the clinical trial registry of India (CTRI) and data on state-wise cancer incidence from the Global Burden of Disease Study. The total sample size for each clinical trial was divided by the trial duration to get the sample size per year. This was then divided by the number of states in which accrual was planned to get the sample size per year per state (SSY). For interventional trials investigating a therapy, the SSY was divided by the number of incident cancers in the state to get the SSY per 1,000 incident cancer cases. The SSY data was then mapped to visualise the geographical disparity.Results We identified 181 ongoing studies, of whom 132 were interventional studies. There was a substantial inter-state disparity - with a median SSY of 1.55 per 1000 incident cancer cases (range 0.00 - 296.81 per 1,000 incident cases) for therapeutic interventional studies. Disparities were starker when cancer site-wise SSY was considered. Even in the state with the highest SSY, only 29.7 % of the newly diagnosed cancer cases have an available slot in a therapeutic cancer clinical trial. Disparities in access were also apparent between academic (range: 0.21 - 226.60) and industry-sponsored trials (range: 0.17 - 70.21).Conclusion There are significant geographic disparities in access to cancer clinical trials in India. Future investigations should evaluate the reasons and mitigation approaches for such disparities.

Background: In charged-particle therapy treatment planning, CT numbers of a patient’s body are converted into stopping power ratios (SPRs) using a CT-number-to-SPR conversion table constructed for standard human tissues. Since artificial devices used in treatments of head and neck cancer, such as mouthpieces, do not fit into the CT-number-to-SPR conversion table, they may deteriorate treatment accuracy. In this study, the SPRs of five mouthpiece materials were measured, and the error in predicted SPRs based on the conversion table was investigated.Methods: SPRs of five mouthpiece materials were predicted from their CT numbers using a calibrated conversion table. Independently, the SPRs of the materials were measured by the Bragg-peak shift of a carbon-ion beam passing through the materials. The errors in SPR of the materials were determined as the difference between the predicted and measured SPRs.Results: The SPRs (error) of the ethylene-vinyl acetate copolymers (EVAs), Nipoflex 710TM and BioplastTM, were 0.997 (0.023) and 0.982 (0.007), respectively. The SPRs (error) of the vinyl silicon impression material (Exafine putty typeTM), the light curable resin (Clear Photoreactive Resin for Formlabs 3D printersTM), and the bis-acrylic resin (TempsmartTM) were 1.517 (0.134), 1.161 (0.068), and 1.26 (0.101), respectively. Conclusions: The EVA BioplastTM had the minimum SPR error among the five tested materials, indicating the highest human-tissue equivalency. If other artificial materials such as Exafine putty typeTM are used as mouthpieces, it is recommended that their SPRs be overwritten by the correct values in treatment planning processes.

We present a rare case of an aberrant right vertebral artery originating from the arch of aorta distal to the origin of the left subclavian artery. The incidence of this particular variant of aberrant origin of the right vertebral artery is extremely uncommon with only seventeen cases reported in literature to date. This case was incidentally detected on a staging positron emission tomography-computerized tomography (PET-CT) scan for lung cancer. We review the incidence, embryological mechanism, and clinical importance of this aberrant course of the right vertebral artery.

There are various efforts in de-identifying patient's radiation oncology data for their uses in the advancement of research in medicine. Though the task of de-identification needs to be defined in the context of research goals and objectives, existing systems lack the flexibility of modeling data and normalization of names of attributes for accomplishing them. In this work, we describe a de-identification process of radiation and clinical oncology data, which is guided by a data model and a schema of dynamically capturing domain ontology and normalization of terminologies, defined in tune with the research goals in this area. The radiological images are obtained in DICOM format. It consists of diagnostic, radiation therapy (RT) treatment planning, RT verification, and RT response images. During the DICOM de-identification, a few crucial pieces of information are taken about the dataset. The proposed model is generic in organizing information modeling in sync with the de-identification of a patient's clinical information. The treatment and clinical data are provided in the comma-separated values (CSV) format, which follows a predefined data structure. The de-identified data is harmonized throughout the entire process. We have presented four specific case studies on four different types of cancers, namely glioblastoma multiforme, head-neck, breast, and lung. We also present experimental validation on a few patients' data in these four areas. A few aspects are taken care of during de-identification, such as preservation of longitudinal date changes (LDC), incremental de-identification, referential data integrity between the clinical and image data, de-identified data harmonization, and transformation of the data to an underlined database schema.

INTRODUCTION: A COVID19 lockdown in India posed significant challenges to the continuation of radiotherapy (RT) and systemic therapy services. While several COVID19 service guidelines have been promulgated, implementation data is yet unavailable. We performed a comprehensive audit of the implementation of services in a clinical oncology department.METHODS AND MATERIALS: A departmental protocol of priority-based treatment guidance was developed and a departmental staff rotation policy was implemented. Data was collected for the period of lockdown on outpatient visits, starting, and delivery of RT and systemic therapy. Adherence to protocol was audited, and factors affecting change from pre-COVID standards analyzed by multivariate logistic regression.RESULTS: Outpatient consults dropped by 58%. Planned RT starts were implemented in 90%, 100%, 92%, 90% and 75% of priority level 1-5 patients. While 17% had a deferred start, the median time to start of adjuvant RT and overall treatment times were maintained. Concurrent chemotherapy was administered in 89% of those eligible. Systemic therapy was administered to 84.5% of planned patients with 33% and 57% of curative and palliative patients receiving modified or deferred cycles. The patient’s inability to come was the commonest reason for RT or ST deviation. Factors independently associated with a change from pre-COVID practice was priority level allocation for RT and age and palliative intent for systemic therapy.CONCLUSIONS: Despite significant access limitations a planned priority-based system of delivery of treatment could be implemented.

Carbon ion beams constitute the primary delivery method of heavy ion radiotherapy. It offers improved dose distribution, and enables concentration of dose within target volumes with minimal extraneous exposure of normal tissue, while delivering superior biological effect in comparison with photon and proton technologies. Here, we review the application of this technology to various gastrointestinal cancers.

Introduction Use of deep inspiration breath hold (DIBH) radiation therapy may reduce long-term cardiac mortality. The resource and time commitments associated with DIBH are impediments to its widespread adoption. We report the dosimetric benefits, workforce requirements, and potential reduction in cardiac mortality when DIBH is used for left-sided breast cancers. Methods and materials Data regarding the time consumed for planning and treating 50 patients with left-sided breast cancer with DIBH and 20 patients treated with free breathing (FB) radiation therapy were compiled prospectively for all personnel (regarding person-hours [PH]). A second plan was generated for all DIBH patients in the FB planning scan, which was then compared with the DIBH plan. Mortality reduction from use of DIBH was calculated using the years of life lost resulting from ischemic heart disease for Indians and the postulated reduction in risk of major cardiac events resulting from reduced cardiac dose. Results The median reduction in mean heart dose between the DIBH and FB plans was 166.7 cGy (interquartile range, 62.7-257.4). An extra 6.76 PH were required when implementing DIBH as compared with FB treatments. Approximately 3.57 PH were necessary per Gy of reduction in mean heart dose. The excess years of life lost from ischemic heart disease if DIBH was not done in was 0.95 per 100 patients, which translates into a saving of 12.8 hours of life saved per PH of work required for implementing DIBH. DIBH was cost effective with cost for implementation of DIBH for all left-sided breast cancers at 2.3 times the annual per capita gross domestic product. Conclusion Although routine implementation of DIBH requires significant resource commitments, it seems to be worthwhile regarding the projected reductions in cardiac mortality.

Background Breast cancers with Human Epidermal Growth Factor Receptor 2 (HER2) borderline outcomes are very puzzling for patient management. To whether HER2 borderlines are having different prognostic status in comparison to HER2 positive/negative. Methods This is a study among women diagnosed with invasive breast cancer from 1973 to 2014 who were identified in the Surveillance, Epidemiology, and End Results (SEER) of 9 registries database and having diagnosed with HER2 status (N=102167), i.e. HER2 positive (N=14678), HER2 negative (N=85354) and HER2 borderline (N=2135). Results This Surveillance, Epidemiology, and End Results (SEER) study represents the largest report of prospective invasive breast cancer with HER2 status till five years from the date of registration. The five years survival rate among HER2 borderline was found completely separate with HER2 positive and HER2 negative patients. In several subtypes of analysis, it has been found that status of survival among HER borderline patients is significantly poor than HER2 positive and HER2 negative. The likelihood of death in HER2 borderline is found high (15.06%) in comparison to HER2 positive (14.24%) and HER2 negative (6.49%) at the end of five years. Different types of metastasis like Bone, Brain, Liver, and Lung are also observed with the higher rate in HER2 borderline in comparison to HER2 negative.

Background Most of the patients of head and neck cancers are treated with concurrent chemo radiation or radiotherapy alone. Waiting time prior to radiotherapy is a major problem in many radiotherapy centres with reported delays of 70 days or even more especially in developing countries. Objective This study aims to determine the impact of waiting time for radiotherapy on survival of patients of head and neck cancer. Materials and methods Patients of squamous cell carcinomas of larynx, oropharynx, hypopharynx and nasopharynx treated with radiotherapy between January 2012 and December 2015 are considered in this study. A total of 287 patients' case files were analyzed to explore the effect of delay in starting radiotherapy on overall survival. Data was entered and analyzed using R software(R for Windows, version 3.1.1). Survival analysis was performed on different patient parameters to point-out the effect of waiting time for treatment initiation. Results It has been observed that waiting time for radiotherapy should not cross 45 days to get any survival benefit. However patients will get maximum survival advantage if treatment can be started within 20 days from the date of diagnosis. Conclusion This study revealed waiting time for radiotherapy has significant impact on survival of head and neck cancer patients. The optimum window period of waiting time for radiotherapy to provide maximal survival benefit to head and neck cancer patients is around 20–45 days.

Objective: We had developed compact rotating gantry for carbon ion using superconducting magnets in 2015 which became clinically operational in 2017. The objective of this study was to assess the clinical feasibility and safety of using compact rotating gantry with three-dimensional active scanning in delivery of carbon-ion radiotherapy (C-ion RT) for relatively stationary tumours. Methods: A prospective feasibility study was conducted with 10 patients who had been treated with C-ion RT using compact rotating gantry between April 2017 and April 2018 at Hospital of the National Institute of Radiological Sciences (NIRS) for head and neck and prostate cancers. The primary end point was evaluation of acute toxicities within 3 months of starting C-ion RT. Results: Out of 10 cases 8 were of head and neck cancers and 2 were of prostate cancers. All of those eight head and neck cases were of locally advanced stages. Both of the prostate cancer patients belong to intermediate risk categories. None of the patients developed even Grade 2 or more severe skin reactions. Six out of eight cases with head and neck cancers experienced Grade 2 mucosal reactions; however, nobody developed Grade 3 or more severe mucosal reactions. There was no gastrointestinal reaction observed in prostate cancer patients. One patient developed Grade 2 genitourinary reaction. Conclusion: C-ion RT using compact rotating gantry and three-dimensional active scanning is a safe and feasible treatment for relatively less mobile tumours. Advances in knowledge: This study will be the first step to establish the use of superconducting rotating gantry in C-ionRT in clinical setting paving the way for treating large number of patients and make it a standard of practice in the future.

Background Oronasal fistulae (ONF) are one of the rare but serious complications of conventional photon radiotherapy. This study aimed to identify the risk factors for the development of ONF after carbon-ion radiotherapy (C-ion RT). Materials and Methods The data of 62 cases of sinonasal and oral cavity cancers treated with C-ion RT and followed-up in excess of 5 years were retrospectively reviewed. The correlation between the clinical and dosimetric parameters and the development of ONF was analysed. Results A total of 80.6% cases had sinonasal malignancies, and most tumours had advanced T stages (96.8%). Maxillary invasion was observed in 16 cases (25.8%), and malignant melanoma was the most common histology (46.8 %). All the cases received a dose of between 57.6 Gy (RBE) and 64 Gy (RBE) in 16 fractions over 4 weeks. At a median follow up of 88.8 months, 23 cases (37.1%) developed small localised ONF; however, none were of grade III severity. On separate multivariate analyses of clinical parameters in the entire cohort and in cases without maxillary invasion, the number of teeth irradiated with more than 50 Gy (RBE) was found to be the common significant independent risk factor for development of ONF. Conclusion The number of teeth irradiated with more than 50 Gy (RBE) is a significant independent risk factor for the development of ONF, which is a late complication of C-ion RT delivered in 16 fractions.

e18659 Background: Surgery followed by chemoradiotherapy with temozolomide (TMZ) is the standard of care for glioblastoma. There are limited reports of quality metrics in glioblastoma. We present an audit of adherence to selected quality indicators proposed in the PRIME Quality Improvement study. Methods: Retrospective audit of quality indices for glioblastoma patients treated between 2017 - 2020. Patients were treated within a standard protocol of postsurgical integrated molecular diagnosis, radiotherapy with concurrent and adjuvant TMZ. Multiparametric MRI at predefined time-points of pre- and post radiation, interim and end of adjuvant TMZ guided management. Demographic, clinical, pathological, imaging, therapy and outcomes data was abstracted. Numbers with proportions for indices were calculated. Survival was estimated using the Kaplan Meier method. Results: Ninety-four glioblastoma patients were treated from 2017 to 2020. Quality metrics are reported (table). Patients in whom adjuvant TMZ could not be started or continued for 6 cycles had progressive disease and salvage chemotherapy was initiated. The 12 month overall and progression free survival was 74.6% (95% CI : 65.4% - 85.1%) and 43.6% (95% CI : 33.8% - 56.3%) respectively. Conclusions: Our patients met quality indices in most domains; outcomes are comparable with global results. These metrics will be periodically evaluated and updated to include newer standards to assess our continued service appropriateness.[Table: see text]

Nasopharyngeal carcinoma is highly radio- and chemosensitive tumor with its unique clinical and biological behavior. Treatment of stage I disease is radical radiotherapy alone. For stage II disease treatment is radiotherapy with or without chemotherapy. The standard of care for locally advanced nasopharyngeal cancer (stages III-IVB) is concurrent chemoradiation. Optimum timing and sequence of chemotherapy are not yet well-defined. The role of adjuvant and induction chemotherapy is debatable. Here we are going to highlight the role of chemotherapy in nasopharyngeal carcinoma, its benefit, and controversies regarding timing and sequences.

Background: Concurrent chemoradiation is currently considered to be the standard of care in the treatment of head and neck cancer. In developing countries like ours, a good number of patients cannot tolerate chemoradiation because of the poor general condition and financial constraints. Those patients are treated with radiation alone. The optimum radiotherapy (RT) schedule for best local control and acceptable toxicity is not yet clear. We aimed to find out whether shortening of treatment time using six instead of five RT fractions per week improves the locoregional control in squamous cell carcinoma of head and neck. Materials and Methods: We conducted a prospective randomized study for a period of 2 years from September 2007 to August 2009 in 109 untreated patients of squamous cell carcinoma of head and neck with histologically confirmed diagnosis and no evidence of distant metastasis. Study group (55 patients) received accelerated RT with 6 fractions per week (66 Gy/33#/51/2 weeks). Control group (54 patients) received conventional RT with 5 fractions per week (66 Gy/33#/61/2 weeks). Tumor control, survival, acute and late toxicities were assessed. Results: At a median follow-up of 43 months, 29 patients (52.7%) in the 6 fractions group and 24 patients (44.4%) in the 5 fractions group were disease-free (P = 0.852). The benefit of shortening was higher for advanced disease control though it was not statistically significant. Grade 3 and 4 skin toxicity was significantly higher in the accelerated RT (70.9%) arm as compared to conventional (35.1%) arm (P = 0.04). Grade 3 mucositis was significantly higher in the accelerated RT arm (32.7% vs. 16.6%; P = 0.041). Those acute toxicities were managed conservatively. There was no difference in late toxicities between the two arms. Conclusion: Use of 6 fractions per week instead of 5 fractions per week is feasible, tolerable, and results in a better outcome in the patients of head and neck cancers.