Outcomes of Hypofractionated Radiation Therapy in Locally Advanced Non-small cell Carcinoma Lung : A Single Institutional Experience

Introduction: Radical treatment in locally advanced non small cell carcinoma lung presents a management dilemma in patients with compromised performance status. Hypofractionated EBRT resolves this by confering high efficacy while avoiding excessive early toxicity. Objectives: To evaluate the efficacy and tolerance of hypofractionated radiotherapy in locally advanced lung cancer patients with compromised performance status. Methods: From January 2019 to January 2020,62 patients were enrolled to receive hypofractionated radiotherapy with 40Gy in 16 fractions with 5 fractions per week (2.5Gy per fraction) because of compromised performance status. Follow-up was conducted at 6 weeks and 3 months for symptomatic and radiological response (RECIST Criteria 1.1) .All results were evaluated statistically. Results: Mean age was 72.7years (+ 6.66) with 66.12% (n=41) above 70 years and 85% in ECOG PS 3. Out of 61 patients, 20% had complete response, 75% had partial response and 3% had stable disease at 6 weeks which progressed to 33% with complete and 62% with partial response at 3 months. 85% achieved symptom palliation. Radiation pneumonitis of grade 2 and above war observed in 60.65% and 62.29% and esophagitis of grade 2 and above was observed in 40.98% and 13.11% at 6 week and 3 months respectively. Conclusions: Hypofractionated RT confers the benefit of avoiding excessive early toxicity while maintaining high efficacy and be a finer alternative in patients with compromised performance status and/or advanced age

Definitive chemoradiation in non metastatic squamous cell carcinoma anal canal: a single institution experience

Background: To analyze the oncological outcomes in anal canal squamous cell carcinoma treated with concurrent chemoradiotherapy. Materials and Methods: A single centre retrospective hospital based study with sample size of 51 patients of anal canal Squamous cell carcinoma treated with concurrent chemoradiotherapy with mitomycin @10mg/m2 and 5FU based. Disease free survival (DFS), Colostomy free survival (CFS) and Overall survival (OS) rates were calculated by Kaplan-Meier method. Results: Among 51 eligible patients, after a median follow up of 46 months (range 10-68 months). The 3year Disease free survival (DFS) was 73.9%. 3patients developed locoregional recurrence while 1patient developed distant metastasis. At 3 years Overall survival (OS) rate was 77%. Out of 44 patients 6 patients lost to follow up while 2 patients died due to progressive disease and 2 due to non cancer causes. 3year Colostomy free survival (CFS) rate was 59%. Total 18 out of 44 patients underwent colostomy. No grade 3 or 4 late toxicities occurred after completion of treatment. Conclusion: This study concluded that definitive chemoradiotherapy achieves good local control, overall survival and colostomy free survival with acceptable toxicity and can be recommended as standard treatment in patients with carcinoma anal canal

A survival analysis of high-grade gliomas in sub-himalayan population including the times of lockdown during COVID 19 pandemic: A single institutional experience

Background and Objectives: High Grade Gliomas are categorised as Grade III and IV and have high mortality rate with poor prognosis. How we should adopt clinical practice in neuro-oncology during Covid 19 Pandemic is another area of scientific exploration . Hypofractionated radiotherapy protocols can be easily utilised in high grade gliomas during Covid 19 pandemic . Materials and Methods: Retrospective analysis of 147 patients with diagnosis of high-grade gliomas between January 2009 till December 2020 including Covid-19 pandemic lockdown time was done. Age , gender , KPS , symptoms , extent of surgery and use of concurrent temozolamide , were evaluated using univariate and multivariate analysis .Overall Survival was determined using the Kaplan Meir method . Results: Glioblastoma multiforme being the most common brain tumor (82.3%) in all high-grade gliomas .Near total or total excision was done in 83.7% of cases The median dose of EBRT delivered was 60Gy .75.5% patients were treated with concurrent and adjuvant chemotherapy . 29.2% patients were treated during Covid 19 pandemic lockdown time . The median overall survival was 15.9 months . The 1 year Overall survival was 67.8% , and 3 year OS was 6.4% . Out of 43 patients treated during covid pandemic time ,62.7% are alive and on follow up . Conclusion: The results of survival analysis demonstrated the benefit of adding radiation with concurrent and adjuvant temzolamide in high grade gliomas including covid 19 during lockdown time . Hypofractionated radiotherapy with concurrent temozolamide is safe during the Covid 19 pandemic

Dosimetric study for mastectomy carcinoma left breast cases with volumetric modulated arc therapy (VMAT)

Background: Radiation therapy for breast cancer has evolved from conventional to 3-dimentional radiation therapy (3-DCRT) and through more precise IMRT and VMAT. 3-DCRT is preferred for ca breast treatment as it reduces low dose area in contra lateral lung but with the advances in radiotherapy image guided techniques can deliver precise and lower doses to OARs with better coverage. This study is aimed to evaluate the doses of PTV, heart and ipsi-lateral lung with contra lateral lung doses delivered by VMAT technique. Method and material: Total 10 patients of carcinoma left breast with mastectomy were selected for VMAT planning with prescription of 45 Gy/20#. Eclipse 16.1 treatment planning system was used and treatment was delivered by True Beam with 6 MV photon energy with image guidance. The VMAT technique includes the non-continuous partial arc and continuous partial arc to deliver the dose. Dose volume histogram (DVH) was used to analyze for doses of planning target volume (PTV) and organs at risk (OARs). Results: PTV was covered with average 94.96% of prescribed dose. The average homogeneity index was found 0.02 and average conformity index was found 0.97 for VMAT plans. Mean doses for heart were measured 14.49±2.11Gy and for V25Gy 11.16±1.97Gy. Ipsilateral lung mean doses were observed 16.23±1.01 Gy, V20Gy doses were 28.73±1.52Gy, V30Gy doses were 14.78±2.5Gy and V40Gy doses were 5.59±1.98Gy. The contralateral lung mean doses were reported 7.69±1.79Gy and V10Gy 19.05±2.05Gy. Average planning target volume was 1710.98cc. The average homogeneity index was 0.02 and conformity index was 0.96. Conclusion: OARs doses with the use of VMAT with continuous and partial arcs are within limit and PTV coverage was also satisfactory. The contralateral lung doses were also within limit. For more precise treatment and low doses of heart and contra lateral lung VMAT technique can be preferred for carcinoma left breast treatment

Dosimetric and volumetric analysis in endobronchial brachytherapy treatment of carcinoma lung patients: A pilot study

Background: To analyze the radiation doses received by Organ at Risk (OAR) nearby the target volume and volumetric changes in the target volume in carcinoma lung patients irradiated in three treatment session of endobronchial brachytherapy (EBBT). Methods: Dosimetric analysis was conducted on patients of carcinoma Lung received three session of Endobronchial brachytherapy treatment in High Dose Rate brachytherapy unit with Ir-192 source. A flexible Lumencare catheter was inserted into the bronchus and positioned catheter tip at the tumor. Length of the implanted catheter was measured with the source position simulator device. Acquired three dimensional CT image data set with x-ray marker was sent to TPS to generate an optimized treatment plan. The OAR’s and target volume were delineated for the accurate assessment of doses in each brachytherapy treatment session. The prescribed dose was normalization at 1.0cm from the center of the catheter. Doses to OAR’s and target volume were noted down from the DVH and detailed dose volume table from TPS. The prescribed dose was 7Gy per fraction in three fractions. Doses to OAR’s and Target volumes were also evaluated for each treatment session of the patient. The change in the volume of the target irradiated was noted down from the dose volume table in TPS. Results: Thirty sessions were evaluated in this study as these were infrequent procedures to perform. Average mean dose to Esophagus was varied from 1.18Grey to 0.85Grey, average maximum dose to Heart was varied from 4.77Grey to 3.69Grey and average maximum dose to left coronary artery was varied from 0.44Grey to 0.91Grey. Average changes in the volume of a Target volume was found in varied from 20.45cc to 13.70cc in each treatment session and found there is signification volume reduction in the target volume irradiated. Conclusion: This study showed that the doses to OARs are significantly increased in second and third session of EBBT and the doses to OAR’s were in their tolerance limit. There is a significant volume reduction in volume of the target in second and third treatment EBBT session. It implies that the EBBT is much effective in the treatment of lung carcinoma patients having disease lesion in primary and secondary bronchus

Trends in Weaning Practices among Infants and Toddlers in a Hilly Terrain of a Newly Formed State of India

Background: Weaning plays a major role in determining the nutritional status of a child. Poor weaning practices during infancy and early childhood, resulting in malnutrition, contribute to impairment of cognitive and social development, poor school performance and reduced productivity in later life. The objective of this study is to know weaning practices of mothers of difficult terrain. Methods: Cross-sectional study was conducted in all villages under Rural Health Training Center, the field practice area of Department of Community Medicine. A total of 500 mothers with children within 3 years of age were included in the study. Pre-tested pre-designed semi-structured questionnaire was used to collect information on weaning practices. Results: Majority of children (51.57%) were weaned at >6 months and were observed to be more under nourished (79.34%) as compared with those between 4 months and 6 months (61.50%). Majority of boys were weaned earlier than girls irrespective of the age of the weaning. Malnutrition was found in majority of those children who were weaned inadequately in terms of both frequency and amount. Conclusions: The present study revealed suboptimal weaning practices among the mothers of hilly region. Thus, appropriate educational strategies should be directed particularly on counteracting various myths related to infant feeding Moreover, promotion of appropriate feeding should target not only on maternal caregivers, but also on other family members, particularly husbands and grandmothers, taking into account the social and cultural situation of the area

Bladder Preservation with Neoadjuvant Chemotherapy Followed by Concurrent Chemoradiation for the Treatment of Muscle-invasive Carcinoma of the Bladder: A Single-Center Experience

Purpose The purpose of the study was to evaluate the short-term response and acute toxicities in muscle-invasive carcinoma urinary bladder treated with neoadjuvant chemotherapy followed by concurrent chemoradiation. Materials and Methods Thirty patients with muscle-invasive bladder cancer were treated with three cycles of neoadjuvant chemotherapy every 3 weeks. Response assessment was done after 4 weeks with repeat cystoscopy and imaging. Responders were treated with concurrent chemoradiation 60 Gy/30# at 2 Gy/# along with weekly injection cisplatin 35 mg/m2. Response assessment was done by new response evaluation criteria in solid tumors (version 1.1). Treatment-related acute toxicities were scored using common terminology criteria for adverse events version 4.0. Results Of the 30 patients, 25 patients responded to neoadjuvant chemotherapy with complete response in 17 patients (56.67%) and partial response in eight patients (26.66%). Five patients (16.66%) showed poor response and were advised radical cystectomy, of which four underwent radical cystectomy and one patient opted for concurrent chemoradiation. Of 26 patients who completed chemoradiation, complete response was seen in 21 patients (80.76%) and partial response was seen in four patients (15.38%). Only one patient developed progression of disease in the form of lung metastasis. All the patients with residual disease were advised to undergo salvage cystectomy. Among the patients receiving chemoradiation, grade 2 cystitis and diarrhea was seen in 10 patients (38.46%) and four patients (15.38%), respectively. Only one patient developed grade 3 diarrhea. Conclusion Bladder preservation treatment is an effective, safe, and convenient option for patients presenting with muscle-invasive carcinoma bladder. Neoadjuvant chemotherapy followed by chemoradiation was well-tolerated with an acceptable rate of complications

Evaluation of fatigue in head and neck cancer patients undergoing (intensity modulated radiation therapy) radiotherapy: A prospective study

Introduction: Fatigue is a common symptom in cancer patients and persists after the completion of cancer-directed treatment. We attempted to study temporal variation in fatigue levels in head and neck cancer (HNC) patients when they were treated by radiotherapy (RT) using intensity modulated radiation therapy techniques. Materials and Methods: Histologically proven HNC patients (AJCC stage II and III with Karnofsky performance status [KPS] ≥80) receiving RT between August 2009 and October 2011 were included. Fatigue was assessed before, during and at 3, 6, and 12 months following RT and compared with age-matched healthy controls by using EORTC QOLQ C30 (using question number 10, 12, and 18). Results: Twenty-six patients were evaluated, whose baseline average fatigue score was 22.4, which was significantly higher as compared to controls (average fatigue score = 12.8; P = 0.04). During RT, average fatigue score increased to 30 by 3 weeks (P = 0.02) and rising to 33.2 (P = 0.029) towards the end of RT. Three months following RT, average fatigue score decreased to 22.8 and remained between 23 and 20 at 6 and 12 months respectively. Significant higher fatigue scores were observed in patients with advanced stage (P = 0.000). Lower KPS score did not show significantly higher fatigue scores (P = 0.5). Conclusion: Our study shows that HNC patients suffer greater fatigue than age-matched healthy individuals which is further aggravated by RT. It gradually comes back to the pretreatment level by 3 months following treatment, but does not reach to a normal healthy level even at 12 months following treatment

Palliative radiotherapy in locally advanced head and neck cancer after failure of induction chemotherapy: Comparison of two fractionation schemes

Context: Among patients with locally advanced head and neck squamous cell cancers (LAHNSCC), the prognosis after nonresponse or progression despite induction chemotherapy (IC) is dismal, and further treatment is often palliative in intent. Given that nonresponse to chemotherapy could indicate subsequent radioresistance, we intended to assess the outcomes with two different fractionation schemes. Aims: To compare the outcomes of two fractionation schemes- ′standard′ (consisting 3GyX5 daily fractions for 2 consecutive weeks) versus ′hybrid′ (6GyX3 fractions on alternate days during the 1 st week, followed by 2GyX5 daily fractions in the 2 nd week). Settings and Design: Prospective randomized controlled two-arm unblinded trial. Materials and Methods: Patients with locally advanced oropharyngeal, laryngeal, and hypopharyngeal cancers treated with a minimum of two cycles of taxane, platinum, and fluorouracil-based IC were eligible if residual disease volume amounted >30 cm 3 . Kaplan-Meier survival curves were compared by the log-rank test. Response rates were compared using the unpaired t-test. Quality of life (QOL) was measured via patient reported questionnaires. Results: Of the initially enrolled 51 patients, 45 patients (24 from standard arm, and 21 from the hybrid arm) were eligible for analysis. Despite being underpowered to attain statistical significance, there still seemed to be a trend towards improvement in progression-free (Hazard ratio (HR) for progression: 0.5966; 95% CI 0.3216-1.1066) and overall survival (HR for death: 0.6062; 95% CI 0.2676-1.3734) with the hybrid arm when compared to the standard arm. Benefits were also observed with regards to response rates and QOL. Rate of complications were similar in both arms. Conclusions: In comparison to the routinely used palliative fractionation scheme of 30 Gray (Gy) in 10 fractions (Fr), the use of hybrid fractionation which integrates hypofractionation in the 1 st week, followed by conventional fractionation in the 2 nd week, could possibly offer better response rates, QOL increments, and potential survival benefits among LAHNSCC patients even after failing to respond to IC

Assessment of quality of life in resectable gastric cancer patients undergoing chemoradiotherapy as adjuvant treatmentLetter to the Editor

Introduction: Quality of life (QOL) is increasingly recognized as an important endpoint in cancer therapies. However, few data are available on QOL in patients who have received radiotherapy as adjuvant treatment for cancer stomach. Methods: Thirty patients who underwent curative resection were enrolled and received chemoradiotherapy (45 Gy in 25 fractions using three-dimensional conformal radiotherapy technique), together with 5-fluorouracil and leucovorin. The European Organization for Research and Treatment of Cancer QOL questionnaire C30 and STO Q22 was assessed at four time points: pre- and postchemoradiotherapy and at 1-month and 6-month follow-up. Results: Mean age of the patients was 54 years. Male:female ratio was 4:1. Stage II and Stage III disease was present in 60% and 30% of patients, respectively. All patients were able to complete the chemoradiotherapy protocol. Our study found out significant impairment in QOL for emotional functioning, fatigue, nausea and vomiting and dyspnea. Results showed that QOL levels decrease postchemoradiotherapy; however, QOL levels returned to baseline at 1-month and 6-month follow-up period. Conclusion: Chemoradiotherapy as adjuvant treatment for cancer stomach patients who have undergone resection with curative intent is a safe and well-tolerated regimen with respect to QOL