Intramuscular injections of human placental extract versus conventional symptomatic approaches in radiation-induced oral mucositis, in patients with head and neck cancers, on definitive chemoradiotherapy - A ray of hope?

BACKGROUND: Despite the availability of a wide range of agents, no single treatment exists for the management of radiation-induced oral mucositis, in patients, with head and neck malignancies, on radical chemoradiation; a debilitating and limiting sequela. Human placental extract is one option that has been proposed. AIMS AND OBJECTIVES: This study aimed at evaluating the therapeutic benefits of human placental extract (Placentrex) in the management of radiation-induced oral mucositis in patients on curative intent treatment for head and neck cancers with concurrent chemoradiation, and to compare the observations with other conventional approaches. MATERIAL AND METHODS: Patients presenting to the Department of Radiation Oncology, of a tertiary cancer care center, with biopsy-proven carcinoma of the oral cavity, oropharynx, and hypopharynx, planned for definitive, curative intent chemoradiation, between January 2020 and June 2021, were recruited for this study. The interventional group received a deep intramuscular injection of 2 ml of Placentrex to the deltoid muscle, once-a-day from the 11th fraction of radiation till completion, on treatment and non-treatment days. The control group received supportive, symptomatic, conventional treatments for mucositis. The response was assessed every week during treatment and at the third and sixth months of follow-up and was compared. RESULTS: The study comprised 26 patients, 15 in the interventional group and 11 in the control group. On completion of treatment, 40% in the interventional arm and 81.82% in the control arm had progressed to grade 2 and 3 mucositis (P < 0.05). Treatment interruption was seen in 13% in the interventional arm and 55% in the control arm (P < 0.001). CONCLUSIONS: Results from this study show that human placental extract, injection Placentrex, had a significant effect in decreasing the severity of radiation-induced mucositis and thereby reducing any interruption or delay in treatment when compared to other conventional methods.

Diagnostic efficacy of dynamic contrast-enhanced magnetic resonance perfusion imaging in detecting local tumor recurrence in patients with head and neck malignancies after definitive treatment.

BACKGROUND AND AIM: Accurate interpretation of post-treatment imaging in head and neck malignancies poses a challenge due to treatment sequelae. Magnetic resonance (MR) perfusion helps in this scenario by evaluating the hemodynamic characteristics of lesions. This study aimed to elucidate the diagnostic efficacy of dynamic contrast-enhanced (DCE)-MR perfusion imaging in detecting recurrence in patients after they underwent definitive treatment for head and neck tumors. MATERIALS AND METHODS: Thirty patients who had received definitive curative-intent treatment for histopathology-proven malignant head and neck tumors and in whom recurrent tumor was detected on precontrast MR imaging (MRI) were accrued in the study. Patients underwent DCE-MR perfusion imaging. Time to peak (TTP), relative maximum enhancement (RME), and relative washout (RWO) ratio were calculated by using time-intensity curve (TIC). The diagnostic accuracy was compared with histopathology. RESULTS: A cut-off value of ≥125.3 for RME showed a sensitivity of 76.2% and specificity of 66.7% for differentiating post-radiation changes and recurrence. The optimal cut-off for RWO ratio was ≥-6.24 with a sensitivity of 76.2% and specificity of 55.6%. The optimal cut-off of TTP was ≤45.8 s with a sensitivity of 61.9% and specificity of 77.8%. Diagnostic accuracies of RME, RWO, and TTP were 73.3%, 70%, and 66.7%, respectively. CONCLUSIONS: DCE-MRI had significant diagnostic accuracy in detecting and differentiating recurrences. TIC analysis of high-temporal resolution DCE-MRI can provide information regarding microcirculation of tumors, and hence can be considered as an imaging modality of choice for assessment of early local tumor recurrence in head and neck tumors.

Depth of Invasion in Squamous Cell Carcinoma of Buccal Mucosa: Is Magnetic Resonance Imaging a Good Predictor of Pathological Findings?

INTRODUCTION OR BACKGROUND: This prospective analysis of patients with squamous cell carcinoma of the buccal mucosa, aimed to analyze the correlation between depth of invasion (DOI) observed in pre-operative imaging and the post-operative histopathological findings, and to assess the predictive value of magnetic resonance imaging. PATIENTS AND METHODS: All cases of squamous cell carcinoma of buccal mucosa, planned for primary surgery followed by adjuvant treatment, between June 2017 to December 2019 were included in the analysis. All patients were taken up for imaging using 3 Tesla MR imaging system and subsequently had undergone surgery. The imaging parameters and the histopathological data were analyzed statistically. RESULTS: Of the 45 patients analyzed, 86.7% were males. Mean age at presentation was 60.62 years. All had squamous histology, with 62.2% being moderately differentiated. 68.9% were T4, 46.7%, N0 and 31.3%, N3. Six node positive patients showed perinodal invasion on histopathology. The mean DOI observed in MRI was 16.54mm, while that in histopathological evaluation was 20.24mm. DISCUSSION: A significant correlation was observed between imaging and histopathology values in terms of the DOI, with Spearman's Rho correlation coefficient showing 0.693 (p-<0.001). Nodal positivity observed in the imaging and the histopathological findings showed only a moderate correlation of 0.409, with p values of 0.005 (Pearson, Spearman's rho) and 0.007 (Kendall's tau_b). A significant correlation was not observed between nodal involvement and DOI assessed by imaging nor with histopathological assessment. With a cut-off value of 5mm as imaging DOI, the positive predictive value (PPV) for nodal positivity was only 37.14%, while the negative predictive value (NPV) was 95%. The sensitivity was 96.3%, and specificity 30.16%. When the cutoff was raised to 10mm, the values for PPV, NPV, sensitivity and specificity were, 44.07%, 61.29%, 68.42% and 36.54%. CONCLUSION: Despite being a histopathological parameter, accurate or near accurate evaluation of DOI can be achieved using MR imaging. Our study convincingly shows that magnetic resonance imaging can be considered the imaging of choice for the evaluation of depth of invasion of the tumour in squamous cell carcinoma of the buccal mucosa, though it fails to show any predictive value for nodal involvement.

Treatment in resectable non-metastatic adenocarcinoma of stomach: Changing paradigms.

Adjuvant treatment in gastric adenocarcinoma has been a challenge for the treating specialists, and despite several trials, a clear consensus is yet to be defined. The higher propensity for lymph nodal involvement and locoregional recurrences led to the hypothesis that locoregional and systemic treatments need to be equally aggressive to achieve better outcomes in the management of gastric adenocarcinoma. Regional, ethnic, and biological differences between the Eastern and Western population are also found to reflect in the tumor behavior and its response to treatment. The MAGIC (Medical Research Council Adjuvant Gastric Infusional Chemotherapy), Intergroup 0116, ACTS-GC (Adjuvant Chemotherapy Trial of S-1 for Gastric Cancer), CLASSIC (Capecitabine and Oxaliplatin Adjuvant Study in Stomach Cancer), ARTIST (Adjuvant Chemoradiation Therapy in Stomach Cancer), and the recently published CRITICS (Chemoradiotherapy after Induction Chemotherapy in Cancer of the Stomach) trials were a few of the randomized controlled trials that tried to give a clearer perspective of this tumor, though it still remains a dilemma. A study incorporating the tumor and demographic factors along with the availability of skilled talent and resources might generate an answer.

Single-fraction radiation: A promising adjuvant therapy to prevent keloid recurrence.

INTRODUCTION: Keloids are characterized by collection of atypical fibroblasts with excessive deposition of extracellular matrix components. Keloids are prone to high recurrence (50%-80%) with unimodality treatment. Radiation is a promising approach among the adjuvant modalities in vogue though consensus is lacking on dose-fractionation schedule. AIM: The present study aimed to analyze the efficacy of single-fraction high-dose adjuvant radiotherapy to prevent keloid recurrence. MATERIALS AND METHODS: Details of patients treated for keloids using external beam radiation therapy from January 2011 to December 2016 were retrieved from electronic medical records and radiation therapy charts and analyzed. RESULTS: Thirty-seven keloid lesions in thirty patients were analyzed. Keloids received radiation within 24-72 h postsurgery using 6 MeV electron beam. 45.9% of keloids were in the chest wall. Dose ranged between 5 Gy and 12 Gy in 1-3 fractions. Eight Gy was used in 78.4%. The single fraction was preferred in 91.9%. Good cosmesis was achieved in all except three who had wound dehiscence. Median follow-up was 32.67 months. 16.2% had recurrence. Median time to recur was 13.6 months, and median recurrence-free interval 21.23 months. Among those who received 8 Gy single fraction, 73.4% remained recurrence-free at 5 years. CONCLUSION: Albeit a retrospective analysis, ours is the only study in literature offering 8 Gy single dose, using electrons, as a postoperative adjuvant treatment to prevent recurrence in keloids. Our recurrence rates were similar to that quoted in published series. This hence can be validated in further studies as it is cosmetically acceptable, safe, painless, and cost-effective with good patient compliance.

A cross sectional review of patient information available in the World Wide Web on CyberKnife: fallacies and pitfalls.

PURPOSE: The purpose of this study is to assess the quality of videos available in YouTube on CyberKnife. METHODS: The term "CyberKnife" was input into the search window of www.youtube.com on a specific date and the first 50 videos were assessed for technical and content issues. The data was tabulated and analysed. RESULTS: The search yielded 32,300 videos in 0.33 s. Among the first 50 analysed, most were professional videos, mostly on CyberKnife in general and for brain tumours. Most of the videos did not mention anything about patient selection or lesion size. The other technical details were covered by most although they seemed muffled by the animations. Many patient videos were recordings of one entire treatment, thus giving future patients an insight on what to expect. Almost half the videos projected glorified views about the treatment technique. CONCLUSIONS: The company videos were reasonably accurate and well presented as were many institutional videos, although there was a tendency to gloss over a few points. The glorification of the treatment technique was a disturbing finding. The profound trust of the patients on the health care system is humbling.