Real-World Experience of Patient's Compliance and Clinical Outcomes for Trimodality Treatment for Esophageal Cancer: a Study from a Cancer Center in North-East India.

Preoperative chemoradiotherapy is a standard treatment for patients with locally advanced, resectable esophageal cancer. The treatment completion rates impact the survival outcomes (Eyck et al J Clin Oncol 39(18):1995-2004, 2021). Thus, we aimed to estimate the effect of neoadjuvant chemoradiotherapy (NACRT) in terms of treatment completion rates and survival in this subset of patients and bring out the clinical outcomes in that context. This was a retrospective study done at a tertiary cancer center in North-East India. The study period was from 1 January 2018 to 31 December 2021. We included patients diagnosed with locally advanced and resectable esophageal cancer (cT2-3NanyM0) involving the middle and/or lower thoracic esophagus and who were planned for trimodality treatment in the Joint Tumor Board. Out of the 82 patients who were planned for trimodality treatment, all were squamous cell carcinomas. We found that 54.9% of patients completed the entire trimodality treatment. The median age was 56 years (range 34 to 73 years). The male to female ratio was 59:23. Adverse events, of any grade, were seen in 76% of patients who received NACRT. Fatigue (66%) was the most common toxicity. The common hematologic toxicities were neutropenia and anemia (7.3% each). A total of 45 patients (54.9%) were able to complete all the three modalities of treatment. Transthoracic esophagectomy was the preferred approach (84.4%). The site of anastomosis was in the neck of all the patients. Anastomotic leak was seen in 17.7% of patients. Postoperative pulmonary and cardiac complications occurred in 31.1% and 8.9% of patients respectively. The 30-day mortality was 6.7% (three deaths). A pathological complete response was seen in 35.6% among patients who underwent an esophagectomy. R0 resection was achieved in 93.3% of patients. The median overall survival and disease-free survival were 19 months and 17 months respectively. The completion rate of trimodality treatment in the real-world scenario was found to be low in our study, the reasons for which need to be identified and effectively resolved. Oncological outcomes were similar to the published literature.

ChatGPT in Head and Neck Oncology-Opportunities and Challenges.

Head and neck oncology represents a complex and challenging field, encompassing the diagnosis, treatment and management of various malignancies affecting the intricate anatomical structures of the head and neck region. With advancements in artificial intelligence (AI), chatbot applications have emerged as a promising tool to revolutionize the field of Head and Neck oncology. ChatGPT is a cutting-edge language model developed by OpenAI that can help the oncologist in the clinic in scheduling appointments, establishing a clinical diagnosis, making a treatment plan and follow-up. ChatGPT also plays an essential role in telemedicine consultations, medical documentation, scientific writing and research. ChatGPT carries its inherent drawbacks too. ChatGPT raises significant ethical concerns related to authorship, accountability, transparency, bias, and the potential for misinformation. ChatGPT's training data is limited to September 2021; thus, regular updates are required to keep pace with the rapidly evolving medical research and advancements. Therefore, a judicial approach to using ChatGPT is of utmost importance. Head and Neck Oncologists can reap the maximum benefit of this technology in terms of patient care, education and research to improve clinical outcomes.

Definitive Radiotherapy in Locally Advanced Head and Neck Squamous Cell Cancer with Clinical Extranodal Extension.

Purpose: The extranodal extension (ENE) in head and neck squamous cell carcinoma (HNSCC) is a potential poor prognostic factor. Clinical ENE (cENE) was incorporated in the HNSCC staging system in the 8th edition of AJCC. There is not much evidence to support the treatment of HNSCC with cN3b with radiotherapy in radical intent. This study aims to assess the treatment outcome in patients of HNSCC with cN3b disease treated with definitive radiotherapy. Method: Forty-five HNSCC patients with cN3b disease treated with definitive radiotherapy with or without concurrent chemotherapy between January 2018 to December 2018 were retrospectively evaluated. Results: The median age of the study patients was 60 years (40-75years). Only 35 patients (77.8%) could complete the prescribed course of treatment, and the leading common cause of non-completion was treatment-related toxicities. After a median follow-up period of 9.3 months (range 2-33), the median OS and PFS were 22.6 months and 7.2 months, respectively. Fourteen patients (31.1%) in our study developed grade III/IV mucositis, and 11 (24.4%) developed severe grade III/IV dermatitis. The locoregional failure constituted 24 patients (53.3%). Conclusion: The treatment outcome of HNSCC with cN3b disease is inferior. A personalized and subjective approach should be undertaken before choosing radiotherapy with a radical intent in this group of patients.

Intensity Modulated Radiotherapy in Head and Neck Cancer: Initial Experience of the First Treated Cases from North-East India.

Head and neck cancer incidence is relatively higher in north-eastern states than in other parts of India. Intensity-modulated radiotherapy (IMRT) was first introduced in our institute in 2012 to cater the entire north-east. This study attempts to assess the treatment outcomes and prognostic factors of head and neck cancer patients who had been treated with definitive radiotherapy in our institute from 2012 to 2016 using IMRT. This is a single institutional retrospective study. Thirty-six patients of head and neck cancer other than nasopharynx primary treated with definitive radiotherapy using IMRT between 2012 to 2016 were evaluated. The survival was analyzed using the Kaplan-Meir method, and various clinicopathologic factors were compared. The median age of the study patients was 58 years (range 24-79 years). The majority of the patients (69.4%) were below the age of 50 years. Thirty-two patients (88.9%) were male, and only four (11.1%) were females. After a median follow-up time of 40 months (7-84 months), the 5-year overall survival (OS) was 42.1%. The stage at presentation and radiotherapy treatment time were found to be significant prognostic factors of the outcome. The treatment-related toxicities were within acceptable limits. This retrospective study has reported the outcome and treatment-related toxicities of initially treated HNC patients with IMRT from northeast India.

Factors Associated With Neurocognitive Impairment Following Chemoradiotherapy in Patients With High-Grade Glioma: Results of a Prospective Trial.

BACKGROUND: High-grade gliomas (HGG) are highly fatal tumors despite advanced multimodality management. They are also associated with neurocognitive impairment, both due to disease pathology and treatment. We aimed to assess various risk factors responsible for neurocognitive decline in HGG patients undergoing adjuvant chemoradiation. METHODS: Newly diagnosed HGG patients who underwent maximal safe resection were included. Patients received volumetric modulated arc therapy to a dose of 60 Gy in 30 fractions, along with concurrent temozolomide (TMZ) at a dose of 75 mg/m²/day orally; thereafter adjuvant TMZ (150-200 mg/m² for 5 days), given every 28 days for 6 to 8 cycles. The Mini-Mental State Examination questionnaire was used to measure cognitive impairment of each study patient at various time points. Cox regression model was used for univariate and multivariable analysis of data to establish possible risk factors. RESULTS: Fifty-three patients were enrolled and analyzed. At a median follow-up of 15 months, 30 patients (56.6%) developed cognitive impairment, and 23 patients (43.4%) did not. On univariate analysis, HGG with WHO grade 4, glioblastoma and diffuse midline glioma histology, IDH-wild type, recursive partitioning analysis class IV/V, and only biopsy of primary tumor were significantly associated with neurocognitive impairment, but none of them were independent risk factors on multivariable analysis. Planning target volume and dose received by ipsilateral hippocampus were also significantly correlated with cognitive decline in HGG patients. CONCLUSION: Decline in neurocognitive functions in HGG patients is multifactorial and can be attributed to an amalgam of various tumor, patient, and treatment-related factors.

Subjective Global Assessment of Nutritional Status in Head and Neck Cancer Patients Treated with Radiotherapy - A Prospective Observational Study from North East India.

Head and neck cancer (HNC) patients undergoing curative radiotherapy (RT) are at risk of malnutrition due to disease process as well as effects of therapy. Identifying the nutritional status of these patients at the earliest, helps to introduce adequate and timely interventions that can improve compliance and outcomes of treatment. Various tools for nutritional assessment in cancer patients have been proposed. In this prospective observational study we used the Subjective Global Assessment (SGA) questionnaire in a cohort of HNC patients receiving definitive RT at a regional cancer center of North East India. Recording of data was done at baseline, at two weekly intervals during treatment, at end of radiotherapy (EORT) and at follow-up upto 6 months. We observed that despite proper nutrition counseling, our patients suffered from malnutrition throughout their course of RT, which was at its peak by EORT but gradually improved over six months of follow-up. Pain on eating and swallowing were the most debilitating symptoms which caused significant decline of nutrient intake, body fat and muscle mass among patients together with deteriorating SGA ratings. Our results will hopefully help us design better strategies for nutrition management while delivering curative (chemo)radiotherapy for HNC patients of this region- which has one of the highest incidences of HNC in the world.

Lymphoepithelial carcinoma of the larynx: A clinical report with pooled analysis and review of published cases.

ABSTRACTS: Lymphoepithelial carcinoma (LEC) of the larynx is a rare tumor comprising 0.2% of all laryngeal neoplasms. To our knowledge, less than 50 cases of LEC of the larynx are reported in the literature. The lack of specific guidelines leads to uncertainty on this rare entity's diagnosis, treatment, and follow-up. The association of Epstein-Barr virus as a predisposing factor of LEC has been proposed in a few reports. Although the occurrence of LEC in the larynx is infrequent, it is essential to differentiate it from squamous cell carcinoma. Immunohistochemistry should be performed to demonstrate cytokeratin expression. It is a very aggressive tumor with high metastatic potential; however, it is hard to comment on the disease outcome of LEC of the larynx because only case reports are available in the literature. Here, we report a case of LEC of the larynx (CK +ve, CD 45 -ve, and EBER-ISH -ve) in a 49-year-old male. Initially, the patient was planned for surgery but defaulted. He reported back after 4 months, and there was clinicoradiological disease progression. Because of the unresectable status and poor general condition, he received palliative radiotherapy only. Additionally, we have conducted a pooled analysis of the individual cases of LEC of larynx available in the literature to understand the clinical behavior to optimize the treatment of these patients.

Pineal gland germinoma with spinal drop metastases: A case report and review of literature.

ABSTRACT: Germ cell tumor of the central nervous system (CNS) is an infrequent entity consisting of only 0.2%-1.7% of all primary CNS tumors. The pineal gland is the commonest location of CNS germinoma. Traditionally, radiotherapy alone has been used to treat localized pineal germinoma, which has delivered a very high cure rate. Spinal drop metastases from pineal germinoma can develop after a long time from diagnosis and primary treatment. Currently, craniospinal irradiation is the standard of care in metastatic pineal germinoma with spinal drop metastases along with systemic chemotherapy. Very few cases of pineal germinoma with spinal drop metastases have been published in the literature. We report a pineal gland germinoma case with spinal drop metastases in an 18-year-old boy and reviewed the published literature.

Split X-jaw Planning Technique of Volumetric Modulated Arc Radiotherapy.

This brief communication article examines the constraints posed by the Varian linear accelerator machine's volumetric-modulated arc therapy (VMAT) due to the maximum extent of the multileaf collimator (MLC) in the x-jaw direction. The MLC leaves within this machine are capable of extending up to 15 cm in the x-jaw direction. However, when VMAT is employed with excessive extension, modulation level decreases, leading to compromised target dose distribution, and the protection of critical organs. The existing VMAT techniques involve open and limited x-jaw approaches, but these methods present avenues for enhancement. One innovative approach is the split x-jaw planning technique, which involves segmenting the open field into two distinct fields with some overlap. This strategy yields four treatment arcs that comprehensively cover the planning target volume (PTV). Enhancing modulation and conformity can be achieved by restricting each field's size to 15 cm. Consequently, this technique demonstrates improved target dose distributions, heightened plan conformity, and more effective sparing of organs at risk compared to the limited and open methodologies. Initial dosimetric studies suggest that the split X-jaw technique holds promise as a superior planning solution for larger PTVs that exceed the MLC's maximum x-jaw extent.

Clinical Outcomes and Prognostic Factors of Locally Advanced Nasopharyngeal Cancer Treated with Intensity Modulated Radiotherapy: First Experience Report from Northeast India.

The aim is to retrospectively evaluate the clinical outcomes and prognostic factors in patients of locally advanced nasopharyngeal cancer (NPC) treated with intensity-modulated radiotherapy (IMRT). The northeastern states report relatively more NPC cases in comparison to other states of India. This study is an attempt to assess the treatment outcomes and prognostic factors of locally advanced NPC who had been treated with definitive radiotherapy with or without chemotherapy in our institute from 2012 to 2016 using IMRT. This is a single institutional retrospective study. Thirty-one consecutive patients of locally advanced NPC treated with definitive chemoradiation using the IMRT technique between 2012 to 2016 were evaluated. The survival was analyzed using Kaplan-Meir method and their relations with various clinicopathologic parameters were compared. After a median follow-up time of 36 months, the 5-year overall survival (OS) and disease-free survival (DFS) was 47.3% and 26.1% respectively. The younger patients of < 50 years had improved OS (p = 0.05). Patients of stage IVA had inferior 5-year OS (p = 0.1) and 5-years DFS (0.02) than those of stage III. The patients who received neoadjuvant chemotherapy showed improved DFS at 5 years (p = 0.09). The treatment-related toxicities were within acceptable limit. This retrospective analysis has reported outcomes of locally advanced NPC patients treated with IMRT with concurrent chemotherapy when IMRT was first introduced in our institute. This is the first of its kind from the Northeastern region of India.

Dental Care in Head and Neck Cancer Patients Undergoing Radiotherapy.

External beam radiotherapy is an integral part of the management of head and neck cancer. Radiotherapy for head and neck cancer lead to many treatment-related toxicities, including a wide range of dental morbidities. These complications depend on the various patient and treatment-related factors. Patients with poor oral hygiene, pre-existing periodontal disease, and the conventional mode of radiotherapy delivery are major factors leading to acute and severe late dental problems. Most of the complications are preventable with proper oral and dental care before, during and after radiotherapy. Pre radiotherapy dental evaluation to diagnose patients with potential risk and timely intervention can reduce long-term morbidities like carries, osteoradionecrosis, etc., thereby improving patients' quality of life. This article highlights the various aspects of dental care and management in head neck cancer patients before, during and after radiation therapy.

Liposarcoma of Larynx-A Case Report and Updated Review of Literature.

Liposarcomas of the larynx is an extremely rare entity, and less than 50 cases have been published in English language literature. It is a malignant mesenchymal tumour arising from adipose tissue with a very high propensity for local recurrence. Well-differentiated liposarcomas are the most common variety but are challenging to diagnose because of their resemblance with benign tumors like lipoma and other malignant soft tissue sarcomas like myxoid chondrosarcoma. Therefore, immunohistochemistry (IHC) should be considered for confirmation. Wide local excision is the treatment of choice, and post-operative radiotherapy can be considered in cases of positive resection margins not amenable for revision surgery, high tumour grade, and myxoid variant. We are reporting a case of well-differentiated liposarcoma of the left aryepiglottic fold (AEF) in a 66-year-old man who was diagnosed to have a benign lipomatous lesion in the same location 3 years back. Based on the reports of the published cases, we are presenting a management algorithm for this entity.

Definitive radiotherapy in patients of synchronous esophageal and head and neck cancer-treatment outcome and toxicity.

AIM: The aim is to retrospectively evaluate the clinical outcomes and treatment related toxicities in patients of synchronous esophageal and head & neck cancer when treated with definitive radiotherapy with or without concurrent chemotherapy. BACKGROUND: Patients of esophageal cancer with a synchronous second primary in head and neck region can be treated with definitive radiotherapy but the clinical outcome has been reported to be poor. METHOD AND DESIGN: This is a single institutional retrospective study. Twenty-five patients fulfilling inclusion and exclusion criteria were evaluated. The survival was analysed using Kaplan-Meir method and their relations with various clinicopathologic parameters were compared. RESULTS: After a median follow-up time of 14 months, the 1 year and 2 year survival was 60% and 17% respectively. Significant improvement in overall survival was observed in patients with early staged esophageal cancer then locally advanced disease (P = 0.03). Patients with locally advanced head and neck cancer had poor survival than with early stage disease (P = 0.06). Those who received concurrent chemotherapy had better survival than those with radiotherapy alone. 40% patients developed grade III & IV dermatitis and 48% patients developed grade III oral mucositis. CONCLUSION: Chemoradiotherapy can safely be offered to patients with synchronous esophageal and head and neck cancer.

Facile synthesis of chitosan-modified ZnO/ZnFe2O4 nanocomposites for effective remediation of groundwater fluoride.

This study explores the possibility of developing an eco-friendly adsorbent for effective remediation of groundwater fluoride, a well-known health hazard affecting more than 25 nations on the various continents. A facile and milder approach has been adopted to synthesize chitosan-modified ZnO/ZnFe2O4 nanocomposites. The synthesized materials have been characterized by different spectroscopic, microscopic, and diffractometric techniques. X-ray photoelectron spectroscopy and X-ray diffraction studies have confirmed the formation of pure and highly crystalline ZnO/ZnFe2O4 nanocomposites. The presence of surface-adsorbed chitosan in the modified ZnO/ZnFe2O4 has been confirmed by FT-IR and thermogravimetric analysis. The results from microscopic and BET surface area analysis of ZnO/ZnFe2O4 nanocomposites indicated that chitosan plays a crucial role in modulating the surface morphology and surface properties of the nanocomposites. The nanocomposites exhibit excellent adsorption performance in the remediation of groundwater fluoride. Experimental conditions have been systematically designed to evaluate the optimum adsorption condition for fluoride, and the results have been analyzed with various non-linear models to describe the kinetics and isotherms of adsorption. The adsorption primarily follows Lagergren pseudo-first-order kinetics, and the Langmuir adsorption capacity is varied from 10.54 to 13.03 mg g-1 over the temperature range 293-323 K. The thermodynamics study reveals that the adsorption process is endothermic and spontaneous. The mechanism of adsorption has been proposed based on the spectroscopic analysis of the fluoride-loaded adsorbent. The adsorption is non-specific in nature as co-existing anion can reduce its fluoride removal capacity. The effect of the co-existing anions on adsorption of fluoride follows the trend PO43- > CO32- > SO42- > Cl-. The adsorbent can be reused successfully for the 5th consecutive cycles of adsorption-desorption study. This study offers a very promising material for remediation of groundwater fluoride of affected areas.

Shape-tunable CuO-Nd(OH)3 nanocomposites with excellent adsorption capacity in organic dye removal and regeneration of spent adsorbent to reduce secondary waste.

Herein, we report for the first time, the synthesis of CuO-Nd(OH)3 nanocomposites via a co-precipitation method coupled with the hydrothermal aging process. Varying the pH of the reaction medium, the shape of the nanocomposites could be controlled which determines their surface areas. These CuO-Nd(OH)3 nanocomposites exhibit very high adsorption capacity with successful removal of ∼ 97% of brilliant blue G (BBG) from water in 180 min under ambient condition. The adsorption process primarily follows Lagergren pseudo-first-order kinetics. The Langmuir isotherm model fits well with a very high monolayer adsorption capacity of 394.1 mg g-1 at 30 °C. The mechanistic study supports chemisorption-type adsorption between the dye molecule and the adsorbent. Regeneration of the spent adsorbent makes the whole process cyclic and eco-friendly.

Nanomaterials as versatile adsorbents for heavy metal ions in water: a review.

Over the years, heavy metal pollution has become a very serious environmental problem worldwide. Even though anthropogenic sources are believed to be the major cause of heavy metal pollution, they can also be introduced into the environment from natural geogenic sources. Heavy metals, because of their toxicity and carcinogenicity, are considered to be the most harmful contaminants of groundwater as well as surface water, a serious threat to both human and aquatic life. Nanomaterials due to their size and higher surface area to volume ratio show some unique properties compared to their bulk counterpart and have drawn significant attention of the scientific community in the last few decades. This large surface area can make these materials as effective adsorbents in pollution remediation studies. In this review, an attempt has been made to focus on the applicability of different types of nanomaterials, such as clay-nanocomposites, metal oxide-based nanomaterials, carbon nanotubes, and various polymeric nanocomposites as adsorbents for removal of variety of heavy metals, such as As, Cd, Co, Cr, Cu, Hg, Mn, Ni, Pb, Sn, U, V, and Zn, from water as reported during the last few years. This work tries to analyze the metal-nanomaterial interactions, the mechanism of adsorption, the adsorption capacities of the nanomaterials, and the kinetics of adsorption under various experimental conditions. The review brings forward the relation between the physicochemical properties of the nanomaterials and heavy metal adsorption on them.

Collision energy dependence of state-to-state differential cross sections for rotationally inelastic scattering of H2O by He.

The inelastic scattering of H2O by He as a function of collision energy in the range 381 cm-1 to 763 cm-1 at an energy interval of approximately 100 cm-1 has been investigated in a crossed beam experiment using velocity map imaging. Change in collision energy was achieved by varying the collision angle between the H2O and He beam. We measured the state-to-state differential cross section (DCS) of scattered H2O products for the final rotational states JKaKc = 110, 111, 221 and 414. Rotational excitation of H2O is probed by (2 + 1) resonance enhanced multiphoton ionization (REMPI) spectroscopy. DCS measurements over a wide range of collision energies allowed us to probe the H2O-He potential energy surface (PES) with greater detail than in previous work. We found that a classical approximation of rotational rainbows can predict the collision energy dependence of the DCS. Close-coupling quantum mechanical calculations were used to produce DCS and partial cross sections. The forward-backward ratio (FBR), is introduced here to compare the experimental and theoretical DCS. Both theory and experiments suggest that an increase in the collision energy is accompanied with more forward scattering.