Is it too early to recommend local treatment in oligometastatic non-small cell lung cancer: a plea for equipoise

Oligometastatic non-small cell lung cancer (OMD NSCLC) has been proposed to bridge the spectrum between non-metastatic and widely metastatic states and is perceived as an opportunity for potential cure if removed. Twelve clinical trials on local treatment have been reported, yet none are conclusive. These trials informed the development of a joint clinical practice guideline by the American & European Societies for Radiation Oncology, which endorses local treatment for OMD NSCLC. However, the heterogeneity between prognostic factors within these trials likely influenced outcomes and can only support guidance at this time. Caution against an uncritical acceptance of the guideline is discussed, as strong recommendations are offered based on expert opinion and inconclusive evidence. The guideline is also examined by a patient's caregiver, who emphasizes that uncertain evidence impedes shared decision making.

Cardiac markers in left-sided breast cancer patients receiving adjuvant radiotherapy: a prospective study

OBJECTIVES

To investigate the association between radiotherapy (RT) and cardiac biomarkers in women with left-sided breast cancer.

METHODS

This prospective observational study recruited patients with stage I-III left-sided breast cancer without coronary heart disease who required adjuvant RT. High-sensitivity troponin I(hsTnI), N-terminal pro-brain natriuretic peptide(NT-proBNP), and high-sensitivity C-reactive protein(hsCRP) levels were measured pre-RT, immediately after RT, and 3 months post-RT. Cardiac-sparing RT techniques were utilized (Field-in-Field IMRT/VMAT ± voluntary deep inspiration breath-hold). Statistical analyses were performed using non-parametric tests and multivariable quantile regression (QR).

RESULTS

One hundred five patients completed the study, with 63 evaluable at three months post-RT. Pre- and post-RT biomarkers showed no significant differences. Median pre-RT and post-RT values were: hsTnI (0.012ng/mL; 0.012ng/mL), hsCRP (3.1 mg/L; 2.8 mg/L), and NT-proBNP (59pg/mL; 45pg/mL). Three months post-RT, hsTnI, hsCRP and NT-proBNP levels also showed no significant differences. Multivariable QR revealed no association between heart Dmean [median(IQR): 2.87 Gy (2.05-3.94)] and post-RT biomarkers. Age and BMI were associated with hsCRP and NT-proBNP, respectively.

CONCLUSIONS

hsTnI, NT-proBNP, and hsCRP are not correlated with contemporary low cardiac exposure in left-sided breast cancer patients treated with contemporary RT techniques.

Primary Oropharyngeal SMARCA4-Deficient Carcinoma: Expanding the Diagnostic Spectrum in Head and Neck Cancer

With the advent of molecular immunohistochemistry and next generation sequencing, Switch/sucrose non-fermentable (SWI/SNF) chromatin remodeling complex altered tumors have gained recognition recently. SWI/SNF related, matrix associated, actin dependent regulator of chromatin subfamily B member 1 (SMARCB1) and SMARCA4 are the primary SWI/SNF components altered in several recently described undifferentiated malignancies in head and neck region with predilection for paranasal sinuses in SMARCB1-deficient tumors and nasal cavity in SMARCA4-deficient tumors. However, to the best of our knowledge, SMARCA4-deficient tumors of the oropharynx have not been described. We present an unusual case of SMARCA4-deficient carcinoma of the oropharynx (palatine tonsil) which is the first case in the literature, expanding the topographic distribution of SMARCA4-deficient tumors in the head and neck region and emphasizing the importance of BRG1 as an essential immunohistochemical marker for the diagnosis of this distinct entity.

Myxofibrosarcoma of Head and Neck Region - A Rare Case Report

Myxofibrosarcoma (MFS) is a rare subtype of soft tissue sarcoma that usually occurs in the extremities of the body. Its location in the head and neck region is unique. Surgery is the primary treatment for all non-metastatic MFS. It has high rates of local recurrence and metastasis. Like other soft tissue sarcomas, the aim of adjuvant treatment is to decrease the chances of local recurrence or metastasis in MFS. Due to its rarity, there is a lack of data showing the benefit of adjuvant treatment in MFS of the head and neck region. We are presenting a case report and literature review on MFS in the head and neck.

Effectiveness of Head-and-Neck Molecular Imaging Reporting and Data System Criterion in Head-and-Neck Squamous Cell Carcinoma PostConcurrent Chemoradiotherapy

Purpose

Postconcurrent chemoradiotherapy (CRT) response assessment has been challenging in locally advanced head-and-neck squamous cell carcinoma (LA-HNSCC) due to prevailing postradiation changes. Molecular response methods have been encouraging, although further clarifications and validations were needed. We tested the effectiveness of a proposed semi-quantitative molecular response criterion in these patients.

Materials and Methods

Two subspecialty-trained physicians evaluated 18F-fluorodeoxyglucose positron emission tomography/computed tomography of LA-HNSCC patients (n = 83) post 3 months CRT using a five points Head and Neck Molecular Imaging-Reporting and Data System (HAN-MI-RADS) criterion. Where available, histopathology examination with clinical and imaging interpretation was taken as a reference for the disease. A diagnostic accuracy comparison was done with the existing Hopkins score. Further effectiveness was analyzed with disease-free survival (DFI) and overall survival (OS).

Results

Metastasis was developed in 11/83 patients at 3 months of evaluation. Of 72 patients, 39, 2, and 31 patients had a complete response, equivocal response, and partial response as per HAN-MI-RADS. Per patient sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for predicting loco-regional disease up to 1 and 2 years was 93.3%, 92.5%, 90.3%, 94.9%, 92.9%, and 84.9%, 91.9%, 90.3%, 87.2%, and 88.6% respectively. One year and two years DFI for each HAN-MI-RADS score showed a statistically significant difference while it was not for OS. The receiver operating characteristic curve analysis showed significantly better outcome predictability of HAN-MI-RADS (area under the curve [AUC] 0.884) than Hopkins (AUC 0.699).

Conclusions

A five points HAN-MI-RADS criterion was found promising for response assessment with less equivocal results and statistically significant higher AUC than Hopkins for loco-regional recurrence prediction.

Tri-modality therapy in advanced esophageal carcinoma: long-term results and insights from a developing world, institutional cohort

OBJECTIVE

To evaluate treatment outcomes in patients from a low-middle income country (LMIC) with esophageal carcinoma who underwent esophagectomy after neoadjuvant chemoradiation (NACRT/S).

METHODS

Between 2010 and 2020, 254 patients (median follow-up: 53 months) met our inclusion criteria. Out-of-field nodal regions were determined by reviewing individual radiotherapy plans. Cox regression modelling was performed to analyze overall survival (OS) and recurrence-free survival (RFS), while pathological complete response (pCR) prediction utilized Poisson regression.

RESULTS

The median OS was 71.4 months (interquartile range: 19.6-∞), RFS did not reach the median and pCR rate was 46%. On multivariable Cox regression, BMI [0.93 (0.89-0.98); 0.94 (0.89-0.99)] and absence of out-of-field node with extranodal extension (ENE)[0.22 (0.09-0.53); 0.30 (0.12-0.75)] influenced OS and RFS, respectively. Age [1.03 (1.01-1.06)], nodal stage [cN2-3 vs cN0: 2.67 (1.08-6.57)] and adventitial involvement [2.54 (1.36-4.72)] also influenced OS, while involved margins [3.12 (1.24-7.81)] influenced RFS. On multivariable Poisson regression, non-CROSS-chemotherapy regimens [0.65 (0.44-0.95)] and residual primary disease on pre-surgical imaging [0.73 (0.57-0.93)] were significantly associated with pCR. The most frequently involved in-field and out-of-field nodal regions were the periesophageal and perigastric (greater and lesser curvature) regions, respectively.

CONCLUSION

NACRT/S is feasible and effective in patients from LMIC. Out-of-field ENE merits further investigation as a prognostic factor since it significantly influenced both OS and RFS.

ADVANCES IN KNOWLEDGE

The results of clinical trials are replicable in LMICs. Out-of-field ENE is an independent prognostic factor for OS and RFS.

Impact of Radiation Treatment Delay Due to COVID-19 Pandemic

Purpose/Objective(s)

To study the effect of radiation treatment delay due to COVID-19 infection.

Materials/Methods

This study is a descriptive analysis. We studied all patients who were COVID-19 positive while undergoing radiation treatment. In addition, those COVID-19 positive patients before the start of radiation during their neoadjuvant treatment period or surgery were also analyzed. However, patients detected with COVID-19 infection after the radiation treatment course were excluded. The study period was from June 2020 to May 2021. A radiation treatment delay was defined as a delay in starting the treatment, a break in therapy during their scheduled radiation course, or treatment discontinuation. Patients who had a radiation treatment delay were followed-up till December 2021.

Results

Ninety-four patients who met the criteria were identified for the analysis. Seventy-seven of them had a mild infection, while 17 had a moderate or severe infection. Of the 94 patients identified, 83 patients had a treatment delay. The median treatment delay (MTD) was 18 (6 to 47) days and the median follow-up period was 13 months. In this cohort, 66 patients were treated with a curative intent, of which 51 are on follow-up {34 patients are disease-free (MTD – 18.5, 10 to 43), seven had either a residual disease or locoregional recurrence (MTD – 22, 10 to 32), seven had distant metastasis (MTD – 18, 15 to 47), and three patients died (MTD – 20, 8 to 27)}. Amongst the three patients who died, only one died of COVID-19 infection or sequel (Case Fatality Rate, CFR – 1.06%).

Conclusion

The CFR due to COVID-19 infection amongst those who underwent radiotherapy was low. At the same time, higher MTD might have been the reason for residual or locoregional recurrences. However, a longer follow-up is required to confirm this. Till then, it will remain debatable whether it was worth delaying radiotherapy for mild to moderate COVID-19 infection for a significant time to cause a potential cancer treatment failure.

To Study the Impact of Different Optimization Methods on Intensity-Modulated Radiotherapy and Volumetric-Modulated Arc Therapy Plans for Hip Prosthesis Patients

Purpose

To study the impact of different optimization methods in dealing with metallic hip implant using intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) techniques.

Materials and Methods

A cohort of 16 patients having metallic implants was selected for the study. Three sets of IMRT and VMAT plans were generated. Set 1 IMRT (IM_Base), VMAT (VM_Base) without any restrictions on beam entry and exit, set 2 (IM_ENT and VM_ENT) optimizer restricts the beam entry and set 3 (IM_EXT+ENT), neither entry nor exit doses were allowed toward the metallic implant.

Results

There was no significant difference in target (D95%) and organ-at-risk doses between IM_Base and IM_ENT. There were significant (P = 0.002) improvements in planning target volume (PTV) V95% and homogeneity from IM_EXT+ENT to IM_ENT. There was no significant difference in plan quality between VM_Base and VM_ENT. There were significant (P = 0.005) improvements in PTV, V95%, homogeneity from VM_EXT+ENT to VM_ENT. V40Gy, V30Gy for bladder, rectum, bowel, and bowel maximum dose decreases significantly (P < 0.005) in IM_ENT compared to IM_EXT+ENT, but not significant for VMAT plans. Similarly, there was a significant decrease in dose spill outside target (P < 0.05) comparing 40%, 50%, 60%, and 70% dose spills for IM_ENT compared to IM_EXT+ENT, but variations among VMAT plans are insignificant. VMAT plans were always superior to IMRT plans for the same optimization methods.

Conclusion

The best approach is to plan hip prosthesis cases with blocked entry of radiation beam for IMRT and VMAT. The VMAT plans had more volumetric coverage, fewer hotspots, and lesser heterogeneity.

Treatment Delay during Radiotherapy of Cancer Patients due to COVID-19 Pandemic

PURPOSE

To analyze the impact of treatment delay caused by COVID-19 infection on patients scheduled for radiotherapy treatment.

METHODS AND MATERIALS

In this descriptive study, we analyzed all patients who were COVID-19 positive during the scheduled radiotherapy course, those who had an infection while on neoadjuvant treatment period, or during surgery before the start of radiation. The study period was from June 2020 to May 2021. A treatment delay was defined as a delay in starting the radiation treatment, a gap during their scheduled radiation treatment, or treatment discontinuation. All patients who had a treatment delay were followed-up till November 2021.

RESULTS

The median follow-up time of the study was 13 months. Ninety-four patients were selected for the study who met the inclusion criteria. Seventy-seven patients had a mild COVID-19 infection, while 17 had a moderate to severe illness. Of the entire cohort, 83 patients had a treatment delay. The median treatment delay (MTD) in days was 18 (6 to 47). Amongst those who had a treatment delay, 66 patients were treated with curative intent, of which 51 patients are on follow-up - 34 patients are disease-free (MTD - 18.5, 10 to 43), seven had either a residual disease or locoregional recurrence (MTD - 22, 10 to 32), seven had distant metastasis (MTD - 18, 15 to 47), and three patients died (MTD - 20, 8 to 27). Of three patients who died, only one died of COVID-19-related causes.

CONCLUSIONS

Even though the mortality due to COVID-19 infection among those who underwent radiotherapy was low, a treatment delay might have caused adverse treatment outcomes. Longer follow-up of these patients is required to further establish this. It will remain debatable whether it was worth delaying radiotherapy for mild to moderate COVID-19 infection for a significant time to cause a potential cancer treatment failure.

Immunotherapy in advanced non-small-cell lung cancer (NSCLC) after progression on chemotherapy: real-world results from a prospective institutional cohort

Objective: To analyze the outcomes of patients receiving immunotherapy (IO) with advanced non-driver mutated non-small-cell lung cancer (NSCLC) after progression on systemic treatment. Methods: The overall survival (OS), progression-free survival (PFS) and best response to IO of 64 patients who met our inclusion criteria were analyzed. Results: Median follow-up, OS and PFS were 35.9, 7.1 and 3.2 months, respectively. On uni- and multi-variable analysis, better ECOG PS and fewer extra-thoracic metastases were associated with prolonged OS and PFS. Response to IO was associated with prolonged OS, while thoracic radiotherapy and isolated CNS involvement were associated with prolonged PFS. ECOG PS, thoracic radiotherapy and PDL1 status significantly influenced the likelihood of response to IO. Overall, 30% patients experienced any grade toxicity. Conclusion: Our results are concordant with reported trial outcomes and support the application of IO in Indian patients.

Combined Diagnostic Accuracy of Diffusion and Perfusion MR Imaging to Differentiate Radiation-Induced Necrosis from Recurrence in Glioblastoma

We aimed to use quantitative values derived from perfusion and diffusion-weighted MR imaging (PWI and DWI) to differentiate radiation-induced necrosis (RIN) from tumor recurrence in Glioblastoma (GBM) and investigate the best parameters for improved diagnostic accuracy and clinical decision-making. Methods: A retrospective analysis of follow-up MRI with new enhancing observations was performed in histopathologically confirmed subjects of post-treated GBM, who underwent re-surgical exploration. Quantitative estimation of rCBV (relative cerebral blood volume) from PWI and three methods of apparent diffusion coefficient (ADC) estimation were performed, namely ADC R1 (whole cross-sectional area of tumor), ADC R2 (only solid enhancing lesion), and ADC R3 (central necrosis). ROC curve and logistic regression analysis was completed. A confusion matrix table created using Excel provided the best combination parameters to ameliorate false-positive and false-negative results. Results: Forty-four subjects with a mean age of 46 years (range, 19−70 years) underwent re-surgical exploration with RIN in 28 (67%) and recurrent tumor in 16 (33%) on histopathology. rCBV threshold of >3.4 had the best diagnostic accuracy (AUC = 0.93, 81% sensitivity and 89% specificity). A multiple logistic regression model showed significant contributions from rCBV (p < 0.001) and ADC R3 (p = 0.001). After analysis of confusion matrix ADC R3 > 2032 × 10−6 mm2 achieved 100% specificity with gain in sensitivity (94% vs. 56%). Conclusions: A combination of parameters had better diagnostic performance, and a stepwise combination of rCBV and ADC R3 obviated unnecessary biopsies in 10% (3/28), leading to improved clinical decision-making.

Dosimetric influence of acuros XB dose-to-medium and dose-to-water reporting modes on carcinoma cervix using intensity-modulated radiation therapy and volumetric rapidarc technique

Aim:

We aimed to evaluate the dosimetric influence of Acuros XB (AXB) dose-to-medium (D_m) and dose-to-water (D_w) reporting mode on carcinoma cervix using intensity-modulated radiation therapy (IMRT) and RapidArc (RA) technique.

Materials and Methods:

A cohort of thirty patients cared for carcinoma cervix was retrospectively selected for the study. Plans were computed using analytical anisotropic algorithm (AAA), AXB-D_m, and AXB-D_w algorithms for dosimetric comparison. A paired t-test and Pitman–Morgan dispersion test were executed to appraise the difference in mean values and the inter-patient variability of the differences.

Results:

The dose–volume parameters were higher for AXB-D_w in contrast to AAA for IMRT and RA plans, excluding D_98%, minimum dose to planning target volume (PTV) and rectum mean dose (RA). There was no systematic trend observed in dose–volume parameters for PTV and organs at risk (OARs) between AXB-D_m and AXB-D_w for IMRT and RA plans. The dose–volume parameters for target were higher for AXB-D_m in comparison to AAA in IMRT and RA plans, except D_98% and minimum dose to PTV. Analysis envisaged less inter-patient variability while switching from AAA to AXB-D_m in comparison to those switching from AAA to AXB-D_w.

Conclusions:

The present study reveals the important difference between AAA, AXB-D_m, and AXB-D_w computations for cervix carcinoma using IMRT and RA techniques. The inter-patient variability and systematic difference in dose–volume parameters computed using AAA, AXB-D_m, and AXB-D_w algorithms present the possible impact on the dose prescription to PTV and their relative constraints to OARs for IMRT and RA techniques. This may help in the decision-making in clinic while switching from AAA to AXB (D_m or D_w) algorithm for cervix carcinoma using IMRT and RA techniques.

Effect of contrast medium on treatment modalities planned with different photon beam energies: a planning study

BACKGROUND

Routinely, patient's planning scans are acquired after administration of iodinized contrast media but they will be treated in the absence of that. Similarly, high energy photons have a better penetrating power, while low energy photons will result in tighter dose distribution and negligible neutron contamination. The aim of the study was to investigate a suitable photon beam energy in the presence of intravenous contrast medium.

MATERIALS AND METHODS

An indigenously made original-contrast (OC) phantom was mentioned as virtual-contrast (VC) and virtual-without-contrast (VWC) phantom were generated by assigning the Hounsfield Units (HU) to different structures. Intensity-modulated (IMRT) and volumetric-modulated-arc (VMAT) plans were generated as per criteria of the TG-119 protocol.

RESULTS

It was observed that the maximum dose to the spinal cord was better with 6 mega-voltage (MV) in IMRT. The coverage of Prostate PTV (PR PTV) was similar with all the photon energies and was comparable with TG-119, except for original-contrast (OC) phantom using the VMAT technique. Homogeneity-index (HI) was comparatively better for VMAT plans.

CONCLUSION

The contrast CT images lower the dose to targets. IMRT or VMAT plans, generated on such CT images will be delivered with higher doses than evaluated. However, the overdose remains non-significant.

Can the Choice of Radiotherapy Delivery Technique Influence Which Target Delineation Protocol to Use? A Plan-Quality-Based Analysis in Left Breast Cancer

Introduction This study investigates the optimal target delineation protocol stratified by treatment planning technique in patients undergoing whole breast radiotherapy after breast conservation surgery.

Materials and Methods Target delineation using Tangent (RTOG 0413 Whole Breast Irradiation Protocol), European SocieTy for Radiotherapy and Oncology (ESTRO), and Radiation Therapy & Oncology Group (RTOG) guidelines was performed on 10 randomly selected treatment planning computed tomography datasets of patients with left-sided breast cancer. An objective plan quality metric (PQM) scoring schema was defined and communicated to the medical physicist prior to commencement of treatment planning. Treatment planning was performed using field-in-field (FiF) intensity modulated radiotherapy technique (IMRT), inverse IMRT, and volumetric modulated arc therapy (VMAT), for each type of target. Two-way repeated measures, analysis of variance was utilized to compare the total PQM scores and dosimetric variables, stratified by treatment planning method.

Results Total PQM score of plans for FiF, IMRT, and VMAT revealed that Tangent and ESTRO delineations were equivalent regardless of planning technique (Tangent vs. ESTRO for FiF, p = 0.099; Tangent vs. ESTRO for IMRT, p = 0.029; Tangent vs. ESTRO for VMAT, p = 0.438). Both delineation protocols were significantly superior to RTOG for all treatment planning techniques.

Conclusion For all treatment planning techniques, ESTRO and Tangent delineation were equivalent and both achieved significantly higher scores than RTOG delineation.

Practical consensus recommendations regarding the management of hormone receptor positive early breast cancer in elderly women

Breast cancer is a leading cause of death among women, and its incidence increases with age. Currently the treatment of breast cancer in older patients is almost identical to their younger counterparts. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists regarding the management of early breast cancer specifically in elderly women.

Plan quality assessment of modern radiotherapy delivery techniques in left-sided breast cancer: an analysis stratified by target delineation guidelines

OBJECTIVE

This study compares planning techniques stratified by consensus delineation guidelines in patients undergoing whole-breast radiotherapy based on an objective plan quality assessment scale.

METHODS

10 patients with left-sided breast cancer were randomly selected, and target delineation for intact breast was performed using Tangent (RTOG 0413), ESTRO, and RTOG guidelines. Consensus Plan Quality Metric (PQM) scoring was defined and communicated to the physicist before commencing treatment planning. Field-in-field IMRT (FiF), inverse IMRT (IMRT) and volumetric modulated arc therapy (VMAT) plans were created for each delineation. Statistical analyses utilised a two-way repeated measures analysis of variance, after applying a Bonferroni correction.

RESULTS

Total PQM score of plans for Tangent and ESTRO were comparable for FiF and IMRT techniques (FiF vs IMRT for Tangent, p = 0.637; FiF vs IMRT for ESTRO, p = 0.304), and were also significantly higher compared to VMAT. Total PQM score of plans for RTOG revealed that IMRT planning achieved a significantly higher score compared to both FiF and VMAT (IMRT vs FiF, p < 0.001; IMRT vs VMAT, p < 0.001).

CONCLUSIONS

Total PQM scores were equivalent for FiF and IMRT for both Tangent and ESTRO delineations, whereas IMRT was best suited for RTOG delineation.

ADVANCES IN KNOWLEDGE

FiF and IMRT planning techniques are best suited for ESTRO or Tangent delineations. IMRT also yields better results with RTOG delineation.

Indian clinical practice consensus guidelines for the management of squamous cell carcinoma of head and neck

Head and neck cancers (HNCs) are malignant tumors of the upper aerodigestive tract and are the sixth most common cancer worldwide. In India, around 30-40% of all cancers are HNCs. Even though there are global guidelines or recommendations for the management of HNCs, these may not be appropriate for Indian scenarios. In an effort to discuss current practices, latest developments and to come to a consensus to recommend management strategies for different anatomical subsites of HNCs for Indian patients, a group of experts (medical, surgical and radiation oncologists and dentists) was formed. A review of literature from medical databases was conducted to provide the best possible evidence base, which was reviewed by experts during a consensus group meeting (January, 2019) to provide recommendations.

Malignant esophagorespiratory fistulas: a comparative effectiveness survival analysis

OBJECTIVES

To analyse the survival of patients with malignant esophagorespiratory fistulas (ERF) and perform a comparative effectiveness analysis of ERF-directed interventions.

METHODS

Fifty-five patients met our inclusion criteria, and data on ERF-directed interventions (stent placement, surgical repair and best supportive care) and their outcomes, along with clinical and treatment details, were recorded. The primary endpoints were overall survival (OS) and survival after developing ERF (F-OS).

RESULTS

The median OS and F-OS for the entire cohort was 299 days (SE=23.2) and 123 days (SE=11.63), respectively. On univariable analysis, the American Joint Committee on Cancer (AJCC) stage (I-III vs IV) influenced both OS (403 vs 171 days; p=0.006) and F-OS (129 vs 67 days; p=0.034). Proximal location of ERF influenced OS favourably (494 vs 285 days; p=0.021), whereas patients developing ERF late in their disease course experienced inferior F-OS (96 vs 232 days; p=0.03). On multivariable analysis, the AJCC stage (IV vs I-III, HR=3.03 (1.41-6.50)), time to developing ERF from diagnosis (greater than vs within 3 months, HR=5.82 (1.84-18.36)) and location of ERF (distal vs proximal, HR=2.47 (1.14-5.34)) had a significant impact on F-OS. The comparative efficacy (OS and F-OS) of best supportive care was statistically equivalent to any intervention irrespective of AJCC stage and success/failure of initial or subsequent intervention(s).

CONCLUSIONS

The survival of patients with ERF is dismal, and our analysis suggests that best supportive care results in equivalent OS and F-OS when compared with any intervention.

Impact of acuros XB algorithm in deep-inspiration breath-hold (DIBH) respiratory techniques used for the treatment of left breast cancer

Aim

To investigate the impact of Acuros XB (AXB) algorithm in the deep-inspiration breath-hold (DIBH) technique used for treatment of left sided breast cancer.

Background

AXB may estimate better lung toxicities and treatment outcome in DIBH.

Materials and Methods

Treatment plans were computed using the field-in-field technique for a 6 MV beam in two respiratory phases - free breathing (FB) and DIBH. The AXB-calculations were performed under identical beam setup and the same numbers of monitor units as used for AAA-calculation.

Results

Mean Hounsfield units (HU), mass density (g/cc) and relative electron density were -782.1 ± 24.8 and -883.5 ± 24.9; 0.196 ± 0.025 and 0.083 ± 0.032; 0.218 ± 0.025 and 0.117 ± 0.025 for the lung in the FB and DIBH respiratory phase, respectively. For a similar target coverage (p > 0.05) in the DIBH respiratory phase between the AXB and AAA algorithm, there was a slight increase in organ at risk (OAR) dose for AXB in comparison to AAA, except for mean dose to the ipsilateral lung. AAA predicts higher mean dose to the ipsilateral lung and lesser V_20Gy for the ipsilateral and common lung in comparison to AXB. The differences in mean dose to the ipsilateral lung were 0.87 ± 2.66 % (p > 0.05) in FB, and 1.01 ± 1.07% (p < 0.05) in DIBH, in V_20Gy the differences were 1.76 ± 0.83% and 1.71 ± 0.82% in FB (p < 0.05), 3.34 ± 1.15 % and 3.24 ± 1.17 % in DIBH (p < 0.05), for the ipsilateral and common lung, respectively.

Conclusion

For a similar target volume coverage, there were important differences between the AXB and AAA algorithm for low-density inhomogeneity medium present in the DIBH respiratory phase for left sided breast cancer patients. DIBH treatment in conjunction with AXB may result in better estimation of lung toxicities and treatment outcome.

Health-related quality of life assessment for head-and-neck cancer patients during and at 3 months after radiotherapy - A prospective, analytical questionnaire-based study

Introduction

Health-related quality of life (HRQoL) is a more specific area of QoL that deals with the evaluation and assessment of the impact of the disease and its treatment-related morbidities on a patient's physical, psychological, and social aspects. The aim of the present study was to assess the HRQoL of patients with head-and-neck cancer (HNCs) during and at 3 months after completion of radiotherapy (RT) by intensity-modulated RT.

Materials and Methods

This study was a prospective, longitudinal, observational, and self-completed questionnaire-based study that included 120 patients with HNC who underwent intensity-modulated RT. The questionnaire had adequate internal consistency. The questionnaires were given to each patient at the beginning of treatment (pretreatment), weekly visits during the course of RT (at the end of 1^st, 2^nd, 3^rd, 4^th, 5^th, and 6^th week), on the day of completion of RT, and then finally at 3 months after completion of RT. Thus, a total of successive nine time points were assessed.

Results and Conclusions

One hundred and eleven patients completed the questionnaires at all nine time points. HRQoL usually decreases during treatment and then increases to pretreatment levels by 3 months after treatment. The Quality of Life Questionnaire, Core Module and Quality of Life Questionnaire, Head and Neck Module were found to be both valid and reliable. There was a significant QoL reduction for the patients throughout treatment in relation to functions and symptoms in the treatment of HNC. However, all the functions and most of the symptoms returned to baseline at the 3-month follow-up.

Validation of the RapidArc Delivery System Using a Volumetric Phantom as Per Task Group Report 119 of the American Association of Physicists in Medicine

Aim

This study validated the RapidArc (RA) delivery using a volumetric ArcCHECK phantom as per the guidelines proposed in Task Group Report 119 from the American Association of Physicists in Medicine Task group 119 (AAPM TG 119). This study also investigated the impact of the Acuros XB (AXB) algorithm in comparison to analytical anisotropic algorithm (AAA) on the RA dose calculations in the homogeneous medium of the ArcCHECK phantom.

Materials and Methods

A volumetric ArcCHECK phantom along with AAPM TG 119 tests was used to evaluate the RA plans and verify the dose delivery for photon beam of 6 MV energy.

Results

The RA planning results were comparable and satisfied the planning criteria stated in the TG 119 report for all test cases. The average percentage gamma passing rates for the AAA-calculated plans were 98.5 (standard deviation [SD]: 0.6), 98.5 (SD: 1.3), and 98.1 (SD: 2.0) and for the AXB-calculated plans were 95.1 (SD: 1.8), 96.1 (SD: 1.3), and 94.0 (SD: 0.9) for the Clinac-iX (6 MV) and TrueBeam (TB)-STx (6 MV_filtered beam [FB] and 6 MV_flattening filter-free beam [FFFB]), respectively. For ion chamber measurements, the average percentage dose differences for the AAA-calculated plans were 1.5 (SD: 2.5), 2.7 (SD: 1.4), and 1.4(SD: 2.7) and for AXB-calculated plans were 2.3 (SD: 1.6), 3.2 (SD: 1.5), and 2.3 (SD: 2.0) for Clinac-iX (6 MV) and TB-STx (6 MV_FB and 6 MV_FFFB), respectively.

Conclusion

Thus, the ArcCHECK can successfully be utilized for the validation of the RA delivery. The AXB has potential to perform dose calculations comparable to those of the AAA for RA plans in the homogeneous medium of the ArcCHECK phantom.

Effect of Photon Energy on Conventional Intensity-Modulated Radiotherapy and Rapid Arc Radiotherapy Planning for Deep-Seated Targets in Carcinoma Cervix

Introduction To evaluate the dosimetric effect of photon energies on fixed field intensity-modulated radiotherapy (IMRT) and dual arc (DA) planning and to compare the dosimetric differences between conventional IMRT and DA radiotherapy planning.

Materials and Methods IMRT and DA plans were generated for 15 patients having cervical cancer using different photon energies. IMRT and DA plans were generated using seven fields and double arcs, respectively. Dosimetric comparison was done in terms of planning target volume (PTV) coverage, sparing of organ at risk (OAR), homogeneity index (HI), conformity index (CI), and monitor units (MUs). Photo-neutron (energy ≤10MV) contribution was not considered for this study. Near region (NR) and far region (FR) were contoured to evaluate the dose deposited in nontarget area.

Results No significant difference was observed (p > 0.05) in PTV coverage for conventional IMRT and DA; however, 6 MV yielded significantly better coverage over 15 MV (p < 0.05) for both the treatment modalities. Mean bladder dose was significantly more for conventional IMRT compared with DA. For rectal mean dose, p-value was nonsignificant for IMRT in comparison to DA, while significant difference was observed for change in photon energies for both treatment modalities respectively, except for 10 MV versus 15 MV DA plans. Significant improvements in HI (except 6 MV vs. 10 MV DA), CI (except 6 MV vs. 10 MV IMRT and DA), MUs, NR, and FR were noted.

Conclusion DA generates more conformal, homogenous plans, requires less numbers of MUs, and deposits fewer doses to NR and FR regions of nontarget tissues in comparison to conventional IMRT. Although increase in photon energy for IMRT and DA plans reduces numbers of MUs and dose deposited to NR and FR regions, yet the choice for treatment of carcinoma cervix remains 6 MV due to production of photo-neutrons at higher energies.