Personalized medicine in radiation oncology and radiation sensitivity index: Pathbreaking genomic way to define the role of radiation in cancer management.

ABSTRACTS: The technological developments associated with the branch of Radiation Oncology have been directed towards precise delivery of the dose, leading to improved survival in various solid malignancies. Radiation therapy as a treatment modality, is an integral component of more than half of the diagnosed malignancies. In spite of the role of adaptive radiation therapy evolving over the last decade, the fundamental question remains as to the difference in radiation response between individuals. Recently, the role of the radiosensitivity index has emerged, which has shown immense potential in the development of biologically driven tumor radiation therapy. The role of these novel methods of genome-based molecular assays needs to be explored to help in decision-making between radical treatment options for various malignancies and reduce the associated toxicity burden. In this article, we explore the current evidence available for various malignancy sites and provide a comprehensive review of the predictive values of various molecular markers available and their impact on the radiosensitivity index.

Effect of COVID-19 Pandemic on Oncology Residency Training in India and a Novel Online Academic Solution: Results of an Online Survey.

PURPOSE: Coronavirus disease 2019 (COVID-19) has had a global effect on the training of residents of medicine because of what has been required in the pandemic. The field of oncology has not been spared, as prepandemic training schedules have not been available for residents. We conducted an online survey to understand the effect of the pandemic and the effect of online teaching schedules as a measure to help residents of oncology in their training. METHODS AND MATERIALS: An online survey consisting of 31 questions was sent through various social media platforms based on the training pattern before the onset of COVID-19, effect of the pandemic on educational activities, and the effect of online academic activities on residency training and learning. The survey addressed the need for online academics as an alternate mode of teaching. The survey was left open for a period of 4 weeks with participation requests from the various branches of oncology, including radiation, surgical and medical oncology, onco-anesthesia, palliative oncology, neuro-oncology, and so forth. The frequencies obtained in the survey were analyzed using descriptive statistical analyses. RESULTS: After a 4-week period, there were 255 responses received from students of oncology from various specialties. Around 69.8.1% of respondents (n = 178) were junior residents, followed by senior residents (n = 72; 28.2%). The majority of the respondents were radiation oncologists (n = 204; 80%). Around 70.9% had an ongoing structured teaching program related to oncology training, with the majority (40.3%) of them having more than 3 hours every week of oncology-based training. Another 31.3% reported having 1 to 2 hours of such training every week, and 60.8% of participants agreed their training was affected by pandemic and related safety regulations. Most students (90.9%) found the online teaching sessions helped maintain training qualities as they were in the pre-COVID times. About 69.1% of the students felt that the quality of these online sessions was better compared with the institute-based onsite classroom teaching. However, as is expected, 77.6% of them agreed that their hands-on training was affected in the pandemic. When asked if online teaching can replace every aspect of classroom teaching, 66.7% of respondents did not agree. The majority (83.9%) felt that students should be given the opportunity to present a given topic under the supervision of a senior faculty member experienced and expert in that topic. The students pointed out the lack of practical exposure as the most common deficiency, followed by the lack of direct interaction with the teaching faculty. CONCLUSIONS: The pandemic has limited the access to essential training in the branches of oncology, and though online sessions cannot replace the hands-on training and clinical exposure needed for the students, online academics and webinars have proven to be an effective tool to minimize that effect and can lead to a positive outcome, as shown by the survey. A combination of online and onsite training modules may be the future of teaching and training in our country.

Proton versus Photon Breath-Hold Radiation for Left-Sided Breast Cancer after Breast-Conserving Surgery: A Dosimetric Comparison.

PURPOSE: Radiation to breast, chest wall, and/or regional nodes is an integral component of breast cancer management in many situations. Irradiating left-sided breast and/or regional nodes may be technically challenging because of cardiac tolerance and subsequent risk of long-term cardiac complications. Deep inspiratory breath-hold (DIBH) technique physically separates cardiac structures away from radiation target volume, thus reducing cardiac dose with either photon (Ph) or proton beam therapy (PBT). The utility of combining PBT with DIBH is less well understood. METHODS AND MATERIALS: We compared photon-DIBH (Ph-DIBH) versus proton DIBH (Pr-DIBH) for different planning parameters, including target coverage and organ at risk (OAR) sparing. Necessary ethical permission was obtained from the institutional review board. Ten previous patients with irradiated, intact, left-sided breast and Ph-DIBH were replanned with PBT for dosimetric comparison. Clinically relevant normal OARs were contoured, and Ph plans were generated with parallel, opposed tangent beams and direct fields for supraclavicular and/or axillae whenever required. For proton planning, all targets were delineated individually and best possible coverage of planning target volume was achieved. Dose-volume histogram was analyzed to determine the difference in doses received by different OARs. Minimum and maximum dose (Dmin and Dmax ) as well as dose received by a specific volume of OAR were compared. Each patient's initial plan (Ph-DIBH) was used as a control for comparing newly devised PBT plan (Pr-DIBH). Matched, paired t tests were applied to determine any significant differences between the 2 plans. RESULTS: Both the plans were adequate in target coverage. Dose to cardiac structure subunits and ipsilateral lung were significantly reduced with the proton breath-hold technique. Significant dose reduction with Pr-DIBH was observed in comparison to Ph-DIBH for mean dose (D mean) to the heart (0.23 Gy versus 1.19 Gy; P < .001); D mean to the left ventricle (0.25 Gy versus 1.7 Gy; P < .001); D mean, D max, and the half-maximal dose to the left anterior descending artery (1.15 Gy versus 5.54 Gy; P < .003; 7.7 Gy versus 22.15 Gy; P < .007; 1.61 Gy versus 4.42 Gy, P < .049); D max of the left circumflex coronary artery (0.13 Gy versus 1.35 Gy; P < .001) and D mean, the volume to the ipsilateral lung receiving 20 Gy and 5 Gy (2.28 Gy versus 8.04 Gy; P < .001; 2.36 Gy versus 15.54 Gy, P < .001; 13.9 Gy versus 30.28 Gy; P = .002). However, skin dose and contralateral breast dose were not significantly improved with proton. CONCLUSION: This comparative dosimetric study showed significant benefit of Pr-DIBH technique compared with Ph-DIBH in terms of cardiopulmonary sparing and may be the area of future clinical research.

Dual partial arc volumetric-modulated arc therapy: The game changer for accelerated hypofractionated whole-breast radiotherapy with simultaneous integrated tumor cavity boost in early breast cancer - A comparative dosimetric study with single partial arc volumetric-modulated arc therapy.

INTRODUCTION: In a previous study, we demonstrated clinical and dosimetric feasibility of single partial arc volumetric modulated arc therapy (VMAT) for accelerated hypofractionated whole breast radiotherapy with simultaneous integrated boost (SIB) to lumpectomy cavity for early breast cancer. In this dosimetric study, we compared dual partial arcs versus single arc. PATIENTS AND METHODS: Fifteen consecutive patients for treatment with hypofractionated accelerated radiotherapy with SIB using VMAT were planned with single partial arc in an earlier study, initial result of which is published elsewhere. The comparative dosimetric plan was created using two partial arcs. Skewness and kurtosis test, Paired Student's t-test, and Wilcoxon signed-rank test were applied for statistical analysis. P < 0.05 was considered statistically significant. RESULTS: Most planning targets are better achieved with dual arc technique. Coverage of planning target volume (PTV) whole breast (PTVWB) and PTV lumpectomy cavity (PTVBOOST) was significantly improved with dual partial arc without significant difference in conformity index and homogeneity index. Dual arc improved dosimetric parameter significantly. Mean dose (Dmean) and maximum dose (Dmax) of whole breast PTV as well as Dmax of PTVBOOST; ipsilateral and contralateral lung Dmean, Dmax, 5 Gy volume (V5); contralateral lung Dmean, Dmax, V5; Heart V25 and V18; Dmean of 5 mm thickness skin; Dmean and Dmax of ribs; and Dmean and Dmax of contralateral breast were improved with dual arc. CONCLUSION: This is first of its kind study establishing the advantage of dual partial arcs in the current context. Dual partial arcs improved dosimetry over single partial arc. Significant dose reduction can be achieved for multiple crucial organs at risk.

Synchronous orbital and mandibular metastases from squamous cell carcinoma of lung as initial disease presentation in a young female: First report of a rare occurrence.

Metastatic tumor to orbit or mandible as initial presentation is rare. According to the available literature, majority of these described cases had its origin from lung and breast. Adenocarcinoma is the most commonly described histology. Concurrence of both of these metastases from a squamous cell carcinoma of the lung has not been reported in literature as initial presenting symptom. A young female patient with synchronous orbital and mandibular metastases as initial presentation of squamous cell carcinoma of the lung is being presented. The patient was treated with palliative radiation and chemotherapy but unfortunately died of progressive disease. To the best our knowledge, this is the first report describing such unusual presentation.

Accelerated hypofractionated adjuvant whole breast radiation with simultaneous integrated boost using volumetric modulated arc therapy for early breast cancer: A phase I/II dosimetric and clinical feasibility study from a tertiary cancer care centre of India.

BACKGROUND: Hypofractionation has become standard of care after Breast Conserving Therapy (BCT) in many European and few others western countries. Though still debatable, tumor cavity boost is routinely practised in our centre. Hypofractionation is not yet the current standard of practice in Asian countries. Employing hypofractionation and simultaneous integrated boost to lumpectomy cavity with conformal technique is not the current practice in this region. Hence the study was performed to see whether accelerated hypofractionation and simultaneous boost can be combined using volumetric modulated arc therapy (VMAT) in treating early breast cancer (EBC) patients. PATIENTS AND METHODS: Female patients with EBC treated by whole breast radiation and boost were treated simultaneously to a dose of 40.5Gy and 48Gy in fifteen fractions over three weeks to entire breast and tumor cavity respectively with VMAT. Dosimetry including target coverage, OAR (organ at risk) sparing and acute radiation toxicity were evaluated. RESULTS: Ten consecutive patients were treated. Planning target volume (PTV) coverage and OAR sparing were mostly satisfactory. Mean volume of PTVWB and PTVBoost were 786.18cm3 and 228.9cm3 respectively. Mean Dmean to PTVWB and PTVBOOST were 41.9Gy and 49.1Gy respectively. Dmax to PTVWB and PTVBOOST were 127.56% and 110.67% respectively. Ipsilateral lung mean dose and V20 were 13.92Gy and 21.53% respectively. V40 and V25 of heart were 0.17% and 2.25% respectively. All patients are disease free after a median follow up of two years. Most acute toxicities were Grade1. Only two patients out of ten developed Grade 2 skin reaction during radiation. Early cosmesis using Harvard cosmesis scale is good to excellent. CONCLUSIONS: Accelerated hypofractionated RT using SIB-VMAT is a clinically feasible technique with acceptable initial result. Initial results are encouraging. MINI ABSTRACT: Simultaneous integrated boost with accelerated hypofractionated whole breast radiotherapy using Volumetric Modulated Arc Therapy is a novel approach. Patient selection and technical considerations are of paramount importance. The present study describes successful implementation of this approach.

Solitary fibrous tumor of the sellar region treated with adjuvant radiation therapy.

The solitary fibrous tumor of central nervous system is rare. Herein, a case of solitary fibrous tumor arising from sellar region is described. A 60-year-old man underwent subtotal excision of the tumor because of extensive infiltration of optical and vascular structures. In view of the presence of residual tumor, he was treated with adjuvant radiation therapy. After a follow-up period of 1 year, there was no progression of the lesion evident on magnetic resonance imaging of the brain. Solitary fibrous tumor should be considered as one of the differential diagnosis of a mass lesion arising in sellar region. Immunohistochemistry with CD34 is valuable for discerning the diagnosis. Complete surgery should be the goal of treatment and adjuvant radiation therapy may be considered for residual or recurrent disease.

External beam radiation techniques for breast cancer in the new millennium: New challenging perspectives.

Radiation therapy in breast cancer has evolved dramatically over the past century. It has traveled a long path touching different milestones and taking unprecedented turns. At the end, a fine tune of clinical understanding, skill, technological advancement and translation of radiobiological understanding to clinical outcome has taken place. What all these have given is better survival with quality survivorship. It is thus prudent to understand breast irradiation in a new perspective suitable for the current millennium.

Primary sinonasal meningioma in a child.

Meningiomas are common intracranial extra-axial masses. They are rarely encountered in extracranial locations; when they are, the most common head and neck locations are the paranasal sinuses and the temporal bone. Meningiomas in children are very rare, especially in the neonatal period. The clinical presentation and clinical findings are often nonspecific. The diagnosis can be established by imaging and histopathologic examination with immunohistochemistry. We describe a case of primary sinonasal meningioma in a 2-year-old boy whose onset of symptoms had begun during the neonatal period. We discuss the clinical features, imaging results, and histopathologic and immunohistochemical findings in this case.

Langerhans cell histiocytosis of atlantoaxial joint in a middle-aged man presenting with deafness as first symptom and soft-tissue mass at neck showing excellent response to radiotherapy alone: Report of an extremely rare and unusual clinical condition and review of literature.

Langerhans cell histiocytosis (LCH) is a disorder of clonal proliferation of dendritic cell mainly occurring in children. Spine involvement is rare. This usually presents with pain and torticollis when neck is involved. Histopathology with immunohistochemistry is confirmatory. Local curative therapy with excision or curettage is used for localized disease. Radiotherapy is usually reserved for selected cases. Systemic chemotherapy is the treatment of choice for widespread systemic disease. In this article, we present an unusual presentation of atlantoaxial LCH with mastoid involvement resulting in hearing loss as the first symptom and quadruparesis in a middle aged male patient, which was also associated with soft-tissue mass at the nape of the neck and deafness. The patient was treated with radical radiotherapy, which provided excellent response to the disease. Involvement of atlantoaxial joint and temporal bone associated with soft-tissue mass neck and deafness in a middle-aged man is an extremely rare clinical situation.

Osteosarcoma of the mandible--second cancer in a case of Hodgkin's lymphoma post-chemotherapy.

Osteosarcoma as a second cancer occurring in an adolescent male previously treated with only chemotherapy for Hodgkin's lymphoma is rare. A 14 year old male presented with gradual swelling of right jaw and numbness of lip and chin for last three months. He was treated with only chemotherapy for Hodgkin's lymphoma four years back. Incisional biopsy was taken from mandibular swelling, histopathology suggesting osteosarcoma. Right hemimandibulectomy and reconstruction with metallic implant were done along with excision of right parotid lymph node. Chemotherapy was started with cisplatin and doxorubicin regimen. Absence of radiation as a risk factor and very young age of the patient presenting with a second cancer made this case a rarity and hence the case is being reported.

Carcinoma in situ of true vocal cord in a nonsmoker adolescent female.

Carcinoma in situ (precancerous lesion) of true vocal cord in a nonsmoker adolescent female without any history of prior neck irradiation is rare. A 16-year-old female patient without any of the known risk factors presented with history of gradual-onset hoarseness of voice unrelieved by symptomatic treatments for 1 year. Contrast-enhanced CT scan of neck and laryngoscopy and histopathology of the tissue from irregular lesions along the medial margin of the left vocal cord diagnosed it as a case of carcinoma in situ of vocal cord. Absence of known risk factors and very young age of the patient made this case a rarity and hence the case is being reported.