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   Table of Contents - Current issue
January-March 2023
Volume 14 | Issue 1
Page Nos. 1-51

Online since Wednesday, March 1, 2023

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Radiotherapy target volumes in esophageal cancer: The twisting kaleidoscope p. 1
Gautam Sarma, Jyotiman Nath, Biswajit Sarma
Incidence of carcinoma esophagus accounts for approximately 6% of all gastrointestinal malignancies. According to GLOBOCAN 2020 data, 604,100 cases of carcinoma esophagus were detected (3.1% of total cases), and it was the 8th most common cancer in the world. The first choice of treatment for resectable esophageal cancer is surgery. Neoadjuvant radio-chemotherapy improved the overall survival (OS) of patients with advanced carcinomas of the esophagus by about 10% in 5 years, as shown by different studies. In unresectable cases, carcinoma esophagus definitive chemoradiation is the treatment of choice. Determination of the target volume of the esophagus has changed with time due to the advancement of technology. Determining the target volumes accurately is essential to achieve precise dose delivery to the targets. Controversies still exist between different regions and societies regarding target volume determination. However, the choice of the treatment volumes, techniques, and dose for optimal use must be individualized. Patients' disease status, preference, and comorbidities should also be considered while making decisions. This article will review the different target volumes, techniques, and doses used in various large trials used in definitive, neoadjuvant, and adjuvant studies.
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Role of addition of chemotherapy to palliative radiotherapy protocol: A review of literature and experience from a tertiary cancer center of India p. 8
Pavan Deepak Mandigala Venkata Ramana, Gulafshan Jabi, Mohsin Khan
Unresectable head-and-neck cancers (HNCs) pose a significant challenge to clinical oncologists. Radiotherapy (RT) has a pivotal role in palliation of symptoms in advanced unresectable stage. Palliative RT protocols generally employ hypofractionated regimes in an attempt to reduce the overall treatment time and acute toxicities. Concurrent chemoradiotherapy (CCRT) may improve local control facilitating faster palliation of symptoms. Yet the role of chemotherapy with hypofractionated schedules is unclear in palliative settings due to the fear of increased toxicities. The literature review was hence conducted to validate the tolerability and efficacy of CCRT in the palliative setting. The literature search was performed on electronic databases using appropriate keywords. Studies evaluating untreated patients, treated recurrent cancers, second primaries localized in the head and neck or metastatic HNC were all chosen. Five studies were selected which met our selection criteria. Palliation of symptoms, response rates, and toxicities of these studies was evaluated. Role of such concurrent regimes at other sites have also been discussed. All the evaluated studies demonstrated good rates of symptom palliation and response rates with tolerable adverse effects. In addition, our literature review has identified a paucity of evidence that warrants large-scale longitudinal studies to derive conclusive remarks on the use of palliative CCRT.
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Association of Augmented Immune-Staining of G-Quadruplex Tertiary DNA Structure in Chemo-Tolerant TNBC with Downregulation of WNT/Epidermal Growth Factor Receptor Pathway receptor Genes: A Pilot Clinicopathological Study p. 14
Saimul Islam, Mukta Basu, Anup Roy, Neyaz Alam, Chinmay Kumar Panda
Purpose: The aim of the study is to understand the involvement of G-Quadruplex (G-Q) structures in altering the expression profile of WNT/epidermal growth factor receptor (EGFR) pathway receptor genes in chemo-tolerant Triple Negative Breast Cancer (TNBC) samples. Materials and Methods: At first, Gene Expression Omnibus datasets were mined where the expression profile of WNT/EGFR pathway genes in TNBC samples and MDA-MB-231, a TNBC cell line, were checked in response to doxorubicin, a chemotherapeutic drug. Next, to unveil the probable mechanism of regulation, the presence of G-Q structure was checked in in silico study and later validated by immunohistochemical analyses in our pool of sample. These observed results were correlated with patient's demography and survival status. Results: Expression of the receptors (FZD7, LRP6, EGFR) of the WNT/EGFR pathway were found to be differentially expressed in TNBC samples; further emphasized in our samples (n = 61). Notably, these G-Q structures were found in the promoter region of the WNT pathway receptor genes (FZD7, LRP6, and EGFR). Validating in our patient sample pool, a significant increase in G-Q immunostaining was observed in samples, after neoadjuvant chemotherapy (NACT) samples (n = 17) than the pretherapeutic samples (n = 44). Similar pattern of G-Q immunostaining was noticed in doxorubicin-treated MDA-MB-231 cell line. Intriguingly, low staining of G-Q among the pretherapeutic samples, but NACT TNBC samples, was found to be significantly correlated with lymph node metastasis. Conclusions: This study showed that the augmented immunostaining of G-Q structure might have an important involvement in regulating the expression pattern of the WNT/EGFR pathway genes in response to doxorubicin treatment of TNBC.
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Fate of 177Lu-CHX-A”-DTPA-Rituximab: In vitro Evaluation in Raji Cell Line p. 21
Saloni Arun Samant, Chandan Kumar, Usha Pandey
Context: Radioimmunotherapy is an emerging treatment modality for various types of cancers. While immunotherapy using monoclonal antibodies has shown promising results, particularly in hematological malignancies, a significant number of patients develop resistance to the treatment, which may be overcome using monoclonal antibodies labeled with suitable therapeutic radioisotopes. Aim: In this study, in vitro evaluation studies of 177Lu-CHX-A''-DTPA-rituximab were performed in Raji cells that overexpress CD20. The extent of internalization of 177Lu-CHX-A”-DTPA rituximab inside the target cell as well as the impact of cellular toxicity in Raji cells was studied. Materials and Methods: The monoclonal antibody rituximab was labeled with 177Lu using CHX-A”-DTPA as the bifunctional chelator. In vitro cell binding and inhibition studies were performed in Raji cells to ascertain the specificity of the radioimmunoconjugate toward the CD20 receptors. The immunoreactive fraction was determined to evaluate the integrity of the radioimmunoconjugate. A cellular internalization assay was performed to evaluate the extent of internalization of the radioimmunoconjugate, and the extent of cytotoxicity was determined using flow cytometry in comparison with unlabeled rituximab. Results: Radiochemical purity of 177Lu-CHX-A''-DTPA-rituximab was determined to be 97.4% ± 1%. In vitro cell-binding studies in Raji cells showed a cell concentration-dependent increase in the percent cell binding, which surged from 11.7% ± 0.7% to 22.7% ± 0.9%, as the cell concentration increased from 0.94 × 10^6 to 7.5 × 10^6 successively. Inhibition in binding was observed in the presence of unlabeled rituximab (11.7% ± 0.7% to 7.8% ± 1.2% and from 22.7% ± 0.9% to 12.1% ± 1.3%). The immunoreactive fraction was found to be 78.5%. A time-dependent increase in the cellular internalization from 25.21 ± 1.7 to 60.47 ± 0.20 was observed. The percent cell viability decreased from 56% to 41% when the cell was treated with rituximab compared with 177Lu-rituximab. Conclusions: Thus, the results show a potential of 177Lu-rituximab as a promising radiopharmaceutical against non-Hodgkin's lymphoma.
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Comparative Study between conventional EBRT alone and EBRT followed by intraluminal brachytherapy in local advanced cancer esophagus p. 28
Kapil Kumar Soni, Vansh Arora, Amita Chaudhary, HS Kumar, Rajendra Kumar Tanwar, Neeti Sharma, Shankar Lal Jakhar, Bhuvanesh Narayan Purohit
Aim: The purpose of this study is to compare local tumor control, dysphagia-free survival, and complication in patients with locally advanced carcinoma esophagus using external beam radiotherapy (EBRT) alone (Arm A) and EBRT followed by intraluminal brachytherapy (ILBT) (Arm B). Materials and Methods: A total of 50 histopathologically proven patients of locally advanced unresectable cancer esophagus were taken for the study from March 2019 to February 2020 and were divided into two arms, 25 patients each. Arm A was treated by standard concurrent chemotherapy–radiotherapy (CTRT) alone (a total dose of 50 Gray (Gy) in 25 fractions (fr), 2 Gy/fr administered daily 5 days per week with weekly injection cisplatin 40 mg/m2) and Arm B received 44 Gy through two definitive radiation therapies along with computed tomography followed by ILBT (5 Gy/fr; 2 fr 1 week apart). Assessment was done weekly during RT and 3 and 6 months post treatment for local control of disease and dysphagia-free survival and complication. Results: The local tumor control was observed 80% and 84% at 6 months in Arm A and Arm B, respectively (P = 0.82). Six-month dysphagia-free survival was 52% versus 68% (P = 0.248) and stricture formation was found 16% and 24% (P = 0.479) in Arm A and Arm B, respectively. Conclusion: This study shows comparable results of CTRT-ILBT over CTRT alone in locally advanced esophageal cancer patients.
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Hypofractionated reirradiation by conformal radiotherapy techniques in recurrent anaplastic astrocytoma and glioblastoma multiforme: An observational study at a Tertiary Care Center in North India p. 33
Shahid Rashid Sofi, Tauseef Ahmad Tali, Waseem Aijaz Kitab, Mushtaq Ahmad Sofi, Mohammad Maqbool Lone, Arshad Manzoor Najmi, Nazir Ahmad Dar
Aim and Objectives: The aims and objectives of the study were to assess the progression-free survival (PFS) and overall survival, local tumor control rate (response rate), effect on the quality of life, and treatment-related toxicities in all patients diagnosed with recurrent high-grade gliomas (HGGs). Methodology: The present study was conducted between September 2017 and July 2019 in the Department of Radiation Oncology, Sheri Kashmir Institute of Medical Sciences and included a total of 22 patients. The study included recurrent HGGs (Grade III/IV) Operated Cases of Grade III and Grade IV. Results: The majority of our patients were between the age group of 40–60 years (45.5%). There were 12 males (54.5%) and 10 females (45.5%). GBM was the most common diagnosis in 13 (59.1) patients and 9 (40.9%) were anaplastic astrocytoma. Sixteen patients were diagnosed as recurrent HGG radiologically. Sixteen (72.7%) patients achieved partial response and 6 (27.3%) achieved stable disease. The median PFS was 2.8 months and the median overall survival was 4.2 months. Conclusion: Reirradiation is one of the treatment options for recurrent HGGs and conformal intensity-modulated radiotherapy can be effective treatment modality for recurrent high-grade brain tumors with only mild side effects. Although survival is better in patients with good performance status and young age.
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Dosimetric comparative study of conformal radiation techniques in patients with glioblastoma multiforme p. 37
Sajad Ahmad Rather, Aijaz Ahmad Khan, Feroz Ahmad Mir, M Muhibul Haq
Purpose: The purpose of the current study is to determine whether patients diagnosed with glioblastoma multiforme (GBM) who underwent radiotherapy (RT) using intensity-modulated RT (IMRT) technique were benefitting from this highly conformal treatment in terms of doses received by planning target volume (PTV) and organs at risk (OARs) in comparison to three-dimensional conventional RT (3DCRT). Materials and Methods: Twelve patients treated with IMRT for GBM were selected for dosimetric comparison with 3DCRT. The prescribed dose was 60 Gy in 30 fractions and seven non-coplanner beams were used in IMRT to cover 95% of target volume. The irradiated patients of GBM were retrieved and replanned with 3DCRT techniques. Dosimetric comparison was done by performing two plans for the same patient; prescription dose and normal tissue constraints were identical for both plans. The dose–volume histograms of target volumes and OAR, dose conformity, and dose homogeneity with 3DCRT and IMRT planning were compared. Statistical analysis was performed to determine the differences. Results: The mean conformity index was 0.99 ± 0.001 for IMRT and 0.97 ± 0.002 for 3DCRT, P = 0.001. The mean homogeneity index was 1.03 ± 0.02 for IMRT and 1.06 ± 0.009 for 3DCRT, P = 0.003, which is statistically significant. The IMRT technique enables dose reduction of normal tissues including brainstem (Dmean by 33.78 ± 5.34 and Dmax 51.84 ± 4.43), optic chiasm (Dmean by 36.92 ± 1.99 and Dmax 44.61 ± 3.72), left optic nerve (Dmean by 28.97 ± 6.51 and Dmax 46.08 ± 10.58), right optic nerve (Dmean by 31.93 ± 11.68 and Dmax 44.63 ± 13.54), left eye (Dmean by 18.66 ± 8.92 and Dmax 37.43 ± 13.47), right eye (Dmean by 14.40 ± 4.87 and Dmax 40.37 ± 11.37), left lens (by Dmax 5.45 ± 1.85), and right lens (Dmax 5.07 ± 0.63). Conclusion: The IMRT provides a real dosimetric advantage, especially for normal brain tissue, and in terms of target coverage. It allows treatment of tumors while respecting OARs' dose constraints. The IMRT technique shows significant advantage in PTV coverage, dose homogeneity, and conformity. In IMRT, the coverage is better where PTV was overlapping with critical OARs.
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Plasmacytoma of nasopharynx - A rare case presentation treated with volumetric modulated arc technique radiotherapy p. 43
Sujata Sarkar, Irfan Bashir, Roopesh Reddy Yotham, Ritesh Sharma
Extramedullary plasmacytomas (EMPs) are solitary plasma cell neoplasms that involve sites other than bone or bone marrow. It constitutes only 0.4% of tumors of head-and-neck region. Surgery and radiotherapy are standard treatment, depending on the site. Radiotherapy promises 90–100% local control rate and prolonged survival. Here, we are reporting a case of plasmacytoma nasopharynx treated with volumetric-modulated arc technique (VMAT) radiotherapy, with contouring details, dose to target, and nearby structures. Patient had complete response and is relapse free for the past 3 years with minimal toxicity. In our case, the lesion is in nasopharynx and is about 1cm, as such it required precise radiotherapy technique like VMAT, to give targeted dose delivery and sparing the nearby critical organs.
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Paratesticular epithelioid sarcoma: A rare case p. 46
Aashita , Rajiv Sharma, Vikas Yadav, T Divya, Navpreet Kaur
Primary soft-tissue sarcomas of the paratesticular region are uncommon tumors comprising 1% of all adult sarcomas. Paratesticular epithelioid sarcoma (ES) is a rare subtype. Here, we report the case of a 68-years-old male with scrotal swelling who underwent high inguinal exploration and right orchidectomy. Histopathology and immunohistochemistry revealed paratesticular ES. Very few cases of paratesticular ES have been reported so far in the literature. Clinical presentation, investigations, treatment interventions, and prognosis have been discussed. As it can be confused with other benign and malignant conditions, diagnosis is often made on histopathological evaluation.
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A rare case of mantle cell lymphoma of nasopharynx and larynx with synchronous presentation treated with volumetric modulated arc technique radiotherapy p. 49
Sujata Sarkar, Irfan Bashir, Roopesh Reddy Yotham, Ritesh Sharma
Mantle cell lymphoma (MCL) or mature peripheral B-cell lymphoid neoplasm is a type of non-Hodgkin's lymphoma. It is more common in elderly males. It is very rare, accounting for less than 1% of head and neck malignancies. MCL is usually positive for CD20, CD5, CD43, cyclin D1 and negative for CD10, CD23, and BCL6. It is a very aggressive neoplasm, and hence, patients often present in advanced stage. Due to its rare incidence and short clinical course, there are limited data on standard treatment protocols. Even with the present treatment protocols, only 30% of patients achieve complete response. Here, we present a case of synchronous presentation of MCL of the nasopharynx and larynx in a 69-year-old male. We aim to discuss the investigations and treatment done with volumetric modulated arc technique radiotherapy that led to complete response.
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