Effects of physical exercise on rehabilitation of cancer patients undergoing radiotherapy.

Background: According to the World Health Organization and American Cancer Society, cancer survivors should involve in mild-to-moderate intensity exercises and consume vegetarian diet. These lifestyle alterations show improvement in cancer recurrence, risk reduction, and quality of life (QOL). Objective: The purpose of this study was to study the effect of physical activity on health/behavioural changes among adult cancer survivors. Materials and Methods: The study is randomized controlled trial which included 100 patients (Group A - Exercise group - 50 patients and Group B - Control group - 50 patients). Assessment of cardiopulmonary fitness, endurance, and QOL was done. Results: Significant improvement in pulse rate, SpO2 and endurance, mental health, and social dimension was found in exercising group with no significant improvement in spiritual dimension. Conclusion: Remodelling the lifestyle by diet adjustment, strength training, and exercises alters the incidence and prognosis of cancer.

Ovarian cancer with osteoblastic bone metastasis - A rare case report.

ABSTRACT: Ovarian cancer with bone involvement occurs rarely with an incidence of 0.1-0.12%. The common sites of bone metastasis are vertebrae, pelvic bones, and the skull. Patients present with severe localized bone pain, swelling, and difficulty in walking. We report a rare case of a 53-year-old female with metastatic epithelial serous adenocarcinoma of the ovary presented with multiple bony lesions in pelvic bones involving the sacrum, bilateral ilium, ischium and pubic bones and the right femur in the region of greater trochanter, smaller lesions in the left femur, and dorso lumbar vertebral metastasis while undergoing treatment as a part of distant spread. Radiologically, the osteolytic lesions are the most common, but in our case, the lesions are osteoblastic, which is rare.

Incidence of bone metastasis in head and neck malignancy: A retrospective study.

Aim: The retrospective analysis was done to describe the characteristics and frequency of bone metastases and prognosis of head and neck cancer patients with bone metastases. Materials and Methods: We investigated total 16209 patients of which 3620 were head and neck cancer patients entering our oncology outpatient department from January 2010 to December 2019. Of 3620 patients, 29 of them developed solitary or multiple bone metastases during the progression of the disease. Results: The overall incidence of bone metastases was found to be 0.8% (29 cases) in head and neck cancers. Bone metastasis was observed in solitary or multiple bones which includes vertebrae 12 (41.37%), hip 9 (31.03%), femur 3 (10.34%), and involve sternum, ribs, clavicle and orbits in few cases. All the patients had few months of survival after developing bone metastasis. Conclusions: With the recent advancement in technology, the survival rate and quality of life of patient suffering from head and neck carcinoma had increased. Distant metastasis to bones was rarely observed in these cancers. Bone dissemination is associated with poor outcome; thus it must always be taken into consideration when contemplating intervention in these patients. So, for early diagnose of this metastasis in complete responders' appropriate measures should be taken during follow-up.

Dosimetric effects of repeat computed tomography scan during radiotherapy planning in esophagus carcinoma.

Aim of Study: The aim was to assess the potential reduction in the doses to organs at risk (OARs) and target organ volume by doing replanning on repeat computed tomography (CT) scan during the 4th week of radiation therapy (RT). Materials and Methods: Twenty-four histologically proven patients of inoperable esophagus carcinoma were studied. All patients received induction chemotherapy followed by concurrent chemotherapy and radiotherapy. CT simulation with proper immobilization was done, and images were transferred to the treatment planning system. Delineation of target volumes and OARs was done, and two plans were generated for 60 Gy in 30 fractions and 40 Gy in 20 fractions with intensity-modulated RT keeping the doses to OARs within the tolerance limits. Replanning for 20 Gy in 10 fractions was done on repeat CT scan during the 4th week of radiotherapy treatment, and potential reduction in doses to OARs and target organ volume was assessed. Results: A total of 24 cases were analyzed for the adaptive plan with the coverage of the 95% prescription isodose for planning target volume. Statistical analysis was done by t-test. The difference in the doses received by the OARs was analyzed and was seen that due to re CT scan, the doses were reduced to the left lung V20 (mean 19.23 Gy vs. 17.35 Gy) and Dmean (mean 16.03 Gy vs. 14.25 Gy), right lung V20 (mean 18.38 Gy vs. 16.66 Gy) and Dmean (mean 15.70 Gy vs. 13.97 Gy), heart V25 (mean 38.72 Gy vs. 35.32 Gy) and Dmean (mean 26.40 Gy vs. 22.74 Gy), and spine 1% volume (mean 36.54 Gy vs. 33.39 Gy) and Dmax (mean 39.81 Gy vs. 34.34 Gy), gross tumor volume (GTV) (mean 67.37 cm 3 vs. 24.58 cm 3) and were all significantly smaller for the adaptive plan. Conclusion: By doing adaptive radiotherapy in the 4th week of treatment using repeat CT scan, along with the response evaluation, there is a significant reduction in the volume of GTV, and replanning of treatment on repeat CT scan also helps us in reducing doses to the OARs resulting in reduced toxicity.

Use of misoprostol before tandem application for intracavitary brachytherapy in patients of carcinoma cervix: An institution study.

Aim: To investigate the ease of tandem application and external os identification by giving sublingual misoprostol before initiation of intracavitary brachytherapy in cancer cervix patients. Materials and Methods: 36 patients with cervical cancer stage IIIB which were supposed to undergo intracavitary brachytherapy(ICBT) were randomly divided into 2 subgroups, group A patients receiving misoprostol and group B not receiving misoprostol.Misoprostol 400 mcg was given sublingually 3 hrs prior to the procedure. The efficacy of the drug was measured as per the ease of identification of os and easier tandem application and amount of bleeding during procedure. Results: Application of tandem and identification of external os was easier and amount of bleeding was also less in patients that were administered sublingual misoprostol. Conclusion: Sublingual Misoprostol given before ICBT helps in cervical ripening and thus leads to easier os recognition and central tandem application and reduce overall anaesthesia time.

Quadruple metachronous primary cancer in a single patient: A rare case report.

Multiple primary cancer is a condition where multiple occurrences of different malignancies occur in the same individual. As there is a rise in the long-term survival of patients, multiple primary cancer is now not a rare entity. To see four different tumors in the same patient is very rare, and here, we report the case of a 60-year-old female patient with quadruple primary cancer of bilateral breast, esophagus, and sarcoma of the leg.

To evaluate volume changes on computerized tomography scan and magnetic resonance imaging-based delineation during radiotherapy treatment planning in prostate cancer.

AIM: The aim of the present study was to evaluate the impact of magnetic resonance imaging (MRI) on radiotherapy target volume changes in prostate cancer. MATERIALS AND METHODS: Ten patients with localized prostate cancer receiving radical radiotherapy were included in the study. Computerized tomography (CT) simulation was done with adequate immobilization, and pelvic MRI was also done at the same time. The two were then registered on eclipse planning system and fused. Target delineation (gross tumor volume [GTV] and clinical target volume [CTV]) was done on both the image sets separately and their volumes were compared. RESULTS: In the current study, it has been found that the CT image-based contouring overestimated the GTV and CTV with 35.4% and 21.7%, respectively, as compared to that by MRI images. The difference observed was statistically significant in the case of GTV, whereas it was not statistically significant for CTV. CONCLUSIONS: It can be concluded that MRI is found to be a better modality for GTV delineation, as it gives superior soft-tissue contrast.

Incidence of second primary malignant neoplasm in Malwa region of central India.

BACKGROUND: Advancement in diagnostic and therapeutic modalities lead to increased cancer survivors who have 20% higher risk of developing second primary malignancy (SPM). AIM: To look for the incidence, epidemiological factors, treatment-related factors, and common risk factors responsible for the development of the SPM in Malwa region. MATERIALS AND METHODS: Records of 7709 patients who visited the Department of Oncology between May 2008 and August 2015 were analyzed and looked for the presence of SPM based on Warren and Gates criteria for head and neck and International Agency for Research on Cancer definition for other sites. Data pertaining age at diagnosis of each tumor, gender, site, histology, the duration between primary and secondary tumors, treatment received for each malignancy, smoking and drinking habits, and metastasis sites were recorded. RESULTS: Of 7709 patients, 56 developed SPM (11 synchronous and 45 metachronous) with an overall incidence of 0.726%. For metachronous SPM, the interval of 10-312 months was observed, with a mean time of 103.32 months (standard deviation 65.9 months). About 71.42% patients with SPM belonged to fifth, sixth, and seventh age decade. The median age of diagnosis for the second primary neoplasm was 57 years (range: 34-85 years). Maximum SPM were observed among head and neck tumors (33.93%) followed by breast (26.78%). The most common sites for SPM are head and neck (32.14%) followed by digestive system (19.64%). Breast as the first or the second location was seen associated with almost all systems. For the treatment of first primary, six received surgery, three received chemotherapy (CT), one received radiotherapy (RT) alone, and rest 46 patients received combined modality. For the treatment of SPM, 37 patients received combined modality, ten received CT, three with RT, and two with surgery while four patients received no treatment. Thirty-two patients had habits of tobacco, smoking and alcohol intake with twenty patients continued these after treatment for the first primary neoplasm. CONCLUSIONS: Patients with breast and head and neck cancer have a higher risk of developing SPM. The possibility of SPM should be considered and excluded during pretreatment evaluation and during follow-up of treated cancer patients.

Definitive radiotherapy for inoperable adenoid cystic carcinoma of the trachea: A rare case report.

Adenoid cystic carcinoma (ACC) of the trachea is rare; it represents 1% of all respiratory tract cancers. It is generally considered as a slow-growing, with prolonged clinical course. Most patients present with dyspnea, and the symptoms often mimic those of asthma or chronic bronchitis. Surgical resection is the mainstay of treatment often combined to radiotherapy because of close surgical margins. When surgery is not possible, most tumors respond to radiotherapy alone which often results in long periods of remission. There is no consensus on the best treatment for locally advanced inoperable ACC of trachea. This case report describes a 51-year-old woman unresectable ACC of trachea due to comorbid conditions, successfully managed by intensity modulated radiotherapy. At 8 months follow-up, the patient is healthy and asymptomatic.

Dosimetric analysis of Co-60 source based high dose rate (HDR) brachytherapy: A case series of ten patients with carcinoma of the uterine cervix.

AIM: To analyse the dosimetric parameters of Co-60 based high dose rate (HDR) brachytherapy plans for patients of carcinoma uterine cervix. BACKGROUND: Co-60 high dose rate (HDR) brachytherapy unit has been introduced in past few years and is gaining importance owing to its long half life, economical benefits and comparable clinical outcome compared to Ir-192 HDR brachytherapy. MATERIALS AND METHODS: A study was conducted on ten patients with locally advanced carcinoma of the uterine cervix (Ca Cx). Computed tomography (CT) images were taken after three channel applicator insertions. The planning for 7 Gray per fraction (7 Gy/#) was done for Co-60 HDR brachytherapy unit following the American Brachytherapy Society (ABS) guidelines. All the patients were treated with 3# with one week interval between fractions. RESULTS: The mean dose to high risk clinical target volumes (HRCTV) for D90 (dose to 90% volume) was found to be 102.05% (Standard Deviation (SD): 3.07). The mean D2cc (dose to 2 cubic centimeter volume) of the bladder, rectum and sigmoid were found to be 15.9 Gy (SD: 0.58), 11.5 Gy (SD: 0.91) and 4.1 Gy (SD: 1.52), respectively. CONCLUSION: The target coverage and doses to organs at risk (OARs) were achieved as per the ABS guidelines. Hence, it can be concluded that the Co-60 HDR brachytherapy unit is a good choice especially for the centers with a small number of brachytherapy procedures as no frequent source replacement is required like in an Ir-192 HDR unit.

Unusual Metastasis from Carcinoma Cervix.

INTRODUCTION: Although the incidence of cancer cervix has reduced in India during the last two decades, still most of the patients presenting in tertiary care centers are in advanced stages. MATERIAL AND METHODS: At this center, we see 6% of cancer cervix cases every year, and most of these cases are in stage III and IVa. All these patients have squamous cell carcinoma and were treated with a combination of external and intracavitary radiotherapy along with concurrent cisplatin given once weekly. Eighty-nine point nine % patients had achieved a complete response. RESULTS: Local recurrence was seen in 17.9% at a median duration of 10.5 months, and 8.17% developed distant metastasis involving lung, liver, bone, and supraclavicular lymph nodes. Three patients developed metastasis at unusual sites involving breast, paraspinal muscles, and duodenum which are very rarely involved. These patients were treated with chemotherapy using carboplatin and Paclitaxel combination but succumbed within 8-10 months of development of metastasis. CONCLUSION: The cause of involvement of these unusual sites is not clear, but it may be hematological spread, and we want to share these reports such that these sites are seen during follow-up of patients of cancer cervix.

Incidence of bone metastasis in carcinoma buccal mucosa.

INTRODUCTION: Head and neck cancer is a leading health problem in India due to the habit of chewing tobacco and bad oral and dental hygiene. Carcinoma buccal mucosa is more common and is 2.5% of all malignancies at our center. Most of the patients present in stage III and IV and the survival in these cases is not very good. Bone metastasis in advanced cases of carcinoma buccal mucosa is rarely reported in the world literature. MATERIALS AND METHODS: We present here cases developing bone metastasis in carcinoma buccal mucosa in last 5 years. These patients were young with loco-regionally advanced disease where bone metastasis developed within 1-year of definitive treatment. RESULTS: The flat bones and vertebrae were mainly involved and the survival was also short after diagnosis of metastasis despite the treatment with local Radiotherapy and chemotherapy. CONCLUSION: The exact cause of metastasis cannot be proved, but the probability of subclinical seedling of malignant cells before the eradication of the primary tumor should be considered along with advanced local and nodal disease with high grade of tumor.

Radiation-induced Vulvar Angiokeratoma Along with Other Late Radiation Toxicities after Carcinoma Cervix: A Rare Case Report.

Angiokeratoma including vulvar angiokeratoma is a very rare complication of radiation. Exact incidence is still unknown, we report a case that developed radiation-induced angiokeratoma of skin in the vulvar region along with other late radiation sequelae in the form of bone fracture, new bone formation, bone marrow widening, muscle hypertrophy, and subcutaneous fibrosis, 18 years after radiotherapy to the pelvic region for the treatment of carcinoma cervix. All these late radiation sequel are rare to be seen in a single patient, and none of the case reports could be found in the world literature.

Carcinoma prostate with gastric metastasis: A rare case report.

Prostate carcinoma is the most common malignancy in males and it commonly manifests with bony metastasis in India, but occasionally visceral metastasis to lungs and liver may also be seen. Metastasis to the gastrointestinal tract is very rare. In literature, we could find six cases only. We present here 7 th patient of carcinoma prostate, which metastasized to stomach. He had epigastric pain, which was mistaken initially with analgesic induced acid peptic disease abut later, on endoscopy a gastric nodule was seen. Histopathology and immunohistochemistry of this confirmed it to be metastasis from prostate. This visceral metastasis to stomach usually spreads through lymphatic's rather than by hematogenous route. This case is being presented because of its rare occurrence.

Survival with concurrent temozolomide and radiotherapy in pediatric brainstem glioma with relation to the tumor volume.

BACKGROUND: Brainstem gliomas account for approximately 25% of all posterior fossa tumors. In pediatric age group, it constitutes about 10% of all brain tumors. Brainstem glioma is an aggressive and lethal type of malignancy with poor outcome despite all treatments. AIM: We studied the incidence and treatment outcome in pediatric patients with brainstem glioma depending on their tumor volume presenting in our institution in last 5 years. Brain tumors comprised 2.95% of all cancers and brainstem gliomas were 8% of all brain tumors. MATERIALS AND METHODS: Nine pediatric patients were included in this analysis, who were treated with localized external radiotherapy 54-59.4 Gy along with temozolomide 75 mg/m(2) during the whole course of radiotherapy. RESULTS: The median survival in all these patients was 20 months and the overall 2 years survival is 44.4% (4/9). The median survival of patients with primary disease volume <40cc is 26 months whereas when the volume is more than 40cc the median survival is 13.5 months as calculated by Chi-square test. CONCLUSION: As this study includes a small number of patients with unknown histology and treated on the basis of magnetic resonance imaging findings, no definite opinion can be given as some patients may have a low-grade tumor. More studies are required to establish the relation of size of the tumor with survival.

A study on the necessity of kV-CBCT imaging compared to kV-orthogonal portal imaging based on setup errors: considering other socioeconomical factors.

PURPOSE: Evaluation of setup accuracy in kV-orthogonal portal imaging (OPI)-based and kV-CBCT-based radiotherapy treatment and to find out the necessity of cone-beam computed tomography (CBCT) compared to OPI. MATERIALS AND METHODS: A retrospective study was carried out on 30 patients, who received radiotherapy to the Brain, Head and Neck, and Pelvis. In the OPI technique, anterior-posterior and right-lateral portal images were taken by the On Board Imaging (OBI) system and were superimposed on the reference images. Similarly, in the kV-CBCT technique, CBCT was performed by the OBI system and CBCT images were superimposed on the reference CT images. A total of 150 comparison sets of kV-OPI and kV-CBCT images were analyzed and evaluated. Shifts in the Lateral, Longitudinal, and Vertical directions were noted in both techniques. The iso displacement vector (IDV) was calculated for all imaging. RESULTS: The mean IDV (in cm) are found to be 0.3395 (SD: 0.1477) and 0.3088 (SD: 0.1593) in cases of the brain, 0.4266 (SD: 0.1511) and 0.3666 (SD: 0.1533) in cases of the head and neck, and 1.0339 (SD: 0.5893) and 0.9498 (SD: 0.6047) in cases of the pelvis for the CBCT and OPI techniques, respectively. The P values were 0.3201, 0.0515, and 0.4829 for the brain, head and neck, and pelvic cases, respectively. CONCLUSIONS: There is statistically no significant difference between both the imaging techniques. As the dose delivered by the CBCT technique is higher than that by the OPI technique, from the socioeconomical and radiation safety point of view, the OPI technique is possibly better than the CBCT technique. Hence, it can be concluded that CBCT is not a mandatory technique compared to the OPI technique in routine brain, head and neck, and pelvic cases, except in those cases where better information about interfraction movements of soft tissue is necessarily required for positioning of the target, as is the case in prostate carcinoma.

Impact of repeat computerized tomography replans in the radiation therapy of head and neck cancers.

Anatomical changes can occur during course of head-and-neck (H and N) radiotherapy like tumor shrinkage, decreased edema and/or weight loss. This can lead to discrepancies in planned and delivered dose increasing the dose to organs at risk. A study was conducted to determine the volumetric and dosimetric changes with the help of repeat computed tomography (CT) and replanning for selected H and N cancer patients treated with IMRT plans to see for these effects. In 15 patients with primary H and N cancer, a repeat CT scan after 3(rd) week of radiotherapy was done when it was clinically indicated and then two plans were generated on repeat CT scan, actual plan (AP) planned on repeat CT scan, and hybrid plan (HP), which was generated by applying the first intensity-modulated radiation therapy (IMRT) plan (including monitoring units) to the images of second CT scan. Both plans (AP and HP) on repeat CT scan were compared for volumetric and dosimetric parameter. The mean variation in volumes between CT and repeat CT were 44.32 cc, 82.2 cc, and 149.83 cc for gross tumor volume (GTV), clinical target volumes (CTV), and planning target volume (PTV), respectively. Mean conformity index and homogeneity index was 0.68 and 1.07, respectively for AP and 0.5 and 1.16, respectively for HP. Mean D95 and D99 of PTV was 97.92% (standard deviation, SD 2.32) and 93.4% (SD 3.75), respectively for AP and 92.8% (SD 3.83) and 82.8% (SD 8.0), respectively for HP. Increase in mean doses to right parotid, left parotid, spine, and brainstem were 5.56 Gy (Dmean), 3.28 Gy (Dmean), 1.25 Gy (Dmax), and 3.88 Gy (Dmax), respectively in HP compared to AP. Repeat CT and replanning reduces the chance of discrepancies in delivered dose due to volume changes and also improves coverage to target volume and further reduces dose to organ at risk.

Role of concurrent chemoradiation in inoperable carcinoma esophagus: a prospective study.

INTRODUCTION: The treatment of choice in cancer esophagus is controversial. Radiation therapy oncology group, Eastern cooperative oncology group and Cochrane studies have shown superiority of concurrent chemoradiation in inoperable carcinoma esophagus. In these studies full dose cisplatin was given every 3 weeks along with radiotherapy and hence had some toxicity. So, we started treating inoperable carcinoma esophagus patients with low dose weekly cisplatin given concurrently with radiotherapy aiming at low toxicity and similar results. MATERIALS AND METHODS: A total of 31 cases of inoperable cases of carcinoma esophagus were treated with once weekly cisplatin 30 mg/m 2 along with radiotherapy 60 Gy in 30 fractions in 6 weeks on Telecobalt/Linear accelerator. RESULTS: We could achieve lower toxicity with 80%, 35% and 19% with 1, 2, and 3 year's survival with a median survival of 18 months. So, we conclude that this regimen is better than 3 weekly chemotherapy regimen as is better tolerated with less toxicity and similar outcome.

Radiation dose verification using real tissue phantom in modern radiotherapy techniques.

In vitro dosimetric verification prior to patient treatment has a key role in accurate and precision radiotherapy treatment delivery. Most of commercially available dosimetric phantoms have almost homogeneous density throughout their volume, while real interior of patient body has variable and varying densities inside. In this study an attempt has been made to verify the physical dosimetry in actual human body scenario by using goat head as "head phantom" and goat meat as "tissue phantom". The mean percentage variation between planned and measured doses was found to be 2.48 (standard deviation (SD): 0.74), 2.36 (SD: 0.77), 3.62 (SD: 1.05), and 3.31 (SD: 0.78) for three-dimensional conformal radiotherapy (3DCRT) (head phantom), intensity modulated radiotherapy (IMRT; head phantom), 3DCRT (tissue phantom), and IMRT (tissue phantom), respectively. Although percentage variations in case of head phantom were within tolerance limit (< ± 3%), but still it is higher than the results obtained by using commercially available phantoms. And the percentage variations in most of cases of tissue phantom were out of tolerance limit. On the basis of these preliminary results it is logical and rational to develop radiation dosimetry methods based on real human body and also to develop an artificial phantom which should truly represent the interior of human body.