In the last few decades, there have been major improvements in diagnosis, staging, and management of cancer which has translated into better disease outcomes and longer survival rates and with better quality of life. This improvement in the quality of life is by better normal tissue sparing caused by the increasing use of newer techniques and technologies, especially in surgery and radiotherapy. Along with higher survival, there is now greater acknowledgment of the need to treat local recurrences and hence the increased use of re-irradiation. Better technology such as intensity modulated radiotherapy translates into better sparing of normal tissue, but at the same time, late toxicity is still of concern. Factors such as residual late damage, total dose, fraction size, technique, type of tissue, and time interval to re-irradiation still guide prescription of the re-irradiation dose. Knowledge of long-term recovery of organ at risk is hence of importance in re-irradiation. This review article has emphasized on the recovery and tolerance of organs at risk such as Spinal cord, Brainstem, and Brain. This is important in prescribing doses for the target volume for re-irradiation and in setting constraints for surrounding critical organs during the planning process.

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Survival of patients with multiple myeloma has increased significantly during the past two decades. This has been attributed to a better understanding of biology, the introduction of novel agents (immunomodulators, proteasome inhibitors), autologous stem cell transplantation, and maintenance therapy. Supportive care is an important component of overall care for these patients. Most patients have a high burden of symptoms at initial presentation in form of bone pains, fatigue, anemia, renal impairment, and infections, etc. Almost 10–20% of patients may have serious complications in the first 4–6 weeks. A high index of suspicion and timely intervention is important to reduce morbidity and mortality. Therapy-related complications, e.g., neuropathy, thromboembolism, cytopenias, GI symptoms (constipation/diarrhea), and relapse of disease, pose therapeutic challenges. Protocol-based approach, systematic assessment with respect to the quality of life and functioning and coordination with a palliative care team from the beginning may improve overall functioning and outcome.

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Objective: Cancer is a leading health problem of today’s world and radiotherapy (RT) is an integral modality to treat cancers. Unfortunately, RT remains an underutilized specialty worldwide because of the lack of knowledge and wrong perceptions among referring physicians toward this specialty. These concerns and fear may discourage physicians from referring patients for RT. This study was conducted to explore the knowledge, attitude, and perception of non-radiation oncology physicians toward this specialty. Materials and Methods: This was a questionnaire-based study including 63 participants conducted at a tertiary care hospital in New Delhi, India. Results: Although the survey completion rate of 95% was encouraging, our study revealed deficiencies in training and knowledge about cancer, principles of RT, and its beneficial effects. Although most of the participants appreciated the role of RT as a core specialty, many underscored its true potential and cost-effectiveness in cancer care. There were significant concerns regarding its side effects (most important reason for non-referral) and lack of familiarity with this specialty. Conclusion: Fortunately, in spite of knowledge gaps, there was a positive attitude toward learning in future among participants.

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Radiotherapy (RT) in relapsed brain tumors has been used sparingly because of the risk of toxicity, particularly white matter necrosis. However, evidence from preclinical animal models and increasing data from clinical series show that brain and spinal cord have marked repair potential, and re irradiation should be considered a valid option in selected patients. The choice of technique and dose fractionation for re irradiation depends on tumor characteristics (volume and location), previous RT dose and volume, and patient characteristics (age and performance status). For small volume tumors in noneloquent areas, single fraction SRS and brachytherapy may be good options. For small and intermediate volume tumors in eloquent areas, FSRT or hypofractionated RT may be used. For large volume recurrences, requiring partial brain irradiation, conventional fractionation is safer and offers palliation with minimal risk of radiation induced toxicitie.

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Introduction: In craniospinal irradiation (CSI), prone position has been commonly used but, in some patients, especially pediatric cases where anesthesia is needed prone position may not help. In planning CSI by supine technique, beam geometry and field matching have to be considered, and immobilization is essential to ensure reproducibility of treatment. Materials and Methods: Data of four patients (3 with medulloblastoma and 1 with lymphoma) treated between March 2012 and October 2013 were included in this retrospective dosimetric study and analyzed. Patients were evaluated for dose coverage, organs at risks (OARs) sparing, number of monitor units, and daily table position shifts. Results: All patients underwent CSI by volumetric-modulated arc therapy (VMAT) technique in supine position. All four cases developed Grade 1 skin changes, and only one case developed a Grade 2 change at the end of radiotherapy; also both pediatric cases developed Grades 2 and 3 anemia and leukopenia toward their 4^th week of treatment onward. The Rapid Arc®-CSI plans were able to generate dose distributions with high planning target volume (PTV) conformity and homogeneity and with sparing of OAR. The cumulative conformity index for all patients was 0.986, and homogeneity index was 0.1007. The mean PTV doses were within 108% with V110% of <12%, and V107% was 20%. On the evaluation of patient setup errors, a maximal shift of 3 mm in longitudinal direction was noted. At 3 years, all medulloblastoma cases except 1 were in remission. One adult patient with medulloblastoma had multiple spinal metastases at 1 year. Conclusions: Treatment of patients in supine position is reproducible and easily maintained with minimal acute reactions. VMAT technique helps avoid junctions, field-matching, and benefits with image guidance for precise dose delivery, conformity, and OAR sparing.

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Reirradiation, in combination with systemic therapy or biologicals, in recent years, has become a popular option for locally recurrent cancers and for infield second malignancies in cases where surgical salvage is not feasible. However before embarking onto such a course of second radiation a systematic approach is needed to avoid undesirable consequences and to gain meaningful advantage in terms of survival and local control. An decision making approach for common cancers where re-irradiation is commonly used like the head and neck cancers, the gliomas and in cases of gynecological cancers has been discussed. Proper selection of the cases and the choosing the intention for re-irradiation is probably most important initial step. Care of the details of the initials course of radiation like the dose fractionation schedule, volume irradiated, dose to the Organs at risk along with patient's present general condition is of utmost importance. Issues like dose memory, threshold time interval, maximum effective cumulative dose etc are still areas of research and their importance in each individual site needs to ascertain in future. Finally, the aim is to have a perceived benefit over the potential of harm in a successful course re-irradiation.

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The treatment options for recurrent tumors are limited. Re irradiation is being increasingly considered as an option, in view of the advances in treatment techniques, particularly the ability to document doses, overlay plans, intensity modulation, and image guidance. preclinical and clinical studies has been to estimate the total cumulative doses (EQD2) also termed as normalized total dose (NTD) that can be delivered to various tissues. In this review article reirradiation radiobiology of different tissues and dose fractionation have been discussed.

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Acinic cell carcinoma (ACC) of the salivary glands is a low grade malignancy which can present with late recurrences and distant metastasis. Being relatively resistant to chemotherapy, managing metastatic ACC is a clinical challenge, especially considering the long duration of survival of these patients. A 33-year-old female presented with recurrent ACC of the left parotid, eighteen years after initial presentation; with incidentally detected asymptomatic lung metastases. She remained stable after six cycles of triple agent chemotherapy and continues to be clinically asymptomatic at nine months post chemotherapy. We hereby, report this case to highlight the late recurrence and metastatic pattern of ACC and the benefit of achieving stable disease with triple agent chemotherapy. Further clinical studies on other anticancer agents are required to achieve better treatment outcomes.

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Primitive neuroectodermal tumors (PNETs), a part of Ewing’s sarcoma family of tumors (ESFT), are small round cell tumors, arising from embryonic neural crest cells. They usually present with chest pain , and dyspnea. There is tenderness of chest wall. Primary pleural PNETS are a rare entity. We present a rare case of primary PNET which was incidentally diagnosed in a young patient with blunt chest trauma.

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Head and neck cancer (HNC) is the sixth most common cancer worldwide, with approximately 650,000 patients newly diagnosed annually. In the late 1990s, surgery followed by postoperative radiotherapy (RT) or RT alone was the standard therapeutic modality for locoregionally advanced head and neck squamous cell carcinoma (LA-HNSCC). As chemotherapeutic agents were identified to have additional effects when combined with RT, chemoradiotherapy has become the standard treatment over the last decade for patients with LA-HNSCC who were not candidates for surgery. Despite the heterogeneity of both tumor location and genetic aberrations, 90% of HNCs are histologically squamous cell carcinomas. Hereby, we present a case series of patients with HNSCC who were benefited with anti-epidermal growth factor receptor therapy with a prolonged survival.

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Renal cell carcinoma accounts for 2% of adult malignancies in the Netherlands. Metastatic disease is often treated with vascular endothelial growth factor receptor tyrosine kinase inhibitors, such as pazopanib. This treatment is known to cause a slight increase in hemoglobin level during treatment. We present a patient who was diagnosed with metastatic renal cell carcinoma during analyses for erythrocytosis and who developed a further rise in hemoglobin level to 13.2 mmol/L 2 weeks after starting pazopanib treatment. Multiple phlebotomies were necessary before symptoms improved. Preexistent erythrocytosis should be considered as a risk factor for symptomatic erythrocytosis during pazopanib treatment and warrants timely laboratory follow-up and phlebotomies if indicated.

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Radiation therapy (RT) represents a important modality for treatment of malignancies in patients of xeroderma pigmentosa (XP). There are only few reports of radiation being primary treatment and thus we report a case of twelve year old female with XP presented with squamous cell carcinoma of tongue and lower lip treated with radiation at our institute. DNA damage by radiation is repaired by base excision repair, non homologous end joining and homologous combination in contrast to XP in which defect lies with nucleotide excision repair genes and therefore clinical and cellular response to RT is similar in XP as seen with other patients.

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All-trans-retinoic acid (ATRA) has shown a significant improvement in the outcome of patients of acute promyelocytic leukemia and is associated with certain unique adverse effects. We report one such case of APL, who developed ATRA syndrome on day 7 of ATRA, which was relieved after ATRA withdrawal and dexamethasone therapy. Subsequently, with the reintroduction of ATRA, patient developed an unexplained fever which was followed by multiple painless ulcers over the scrotum on day 28 of ATRA. ATRA was withdrawn so as not to induce Fournier’s gangrene, and ulcers were closely monitored without the administration of systemic or local corticosteroids. Eventually, ulcers improved and completely healed by 4 weeks. This is a rare case report, wherein the same patient develops ATRA syndrome followed by scrotal ulcers, suggesting that the scrotal ulcer is a rare specific adverse effect of ATRA and its monitoring is required especially in patients having unexplained fever and leucocytosis.

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Aim: To compare the analgesic efficacy of epidural ropivacaine–fentanyl with bupivacaine–fentanyl combination administered by patient-controlled epidural analgesia (PCEA) technique for postoperative pain relief after major abdominal oncosurgery. Materials and Methods: A prospective, randomized, interventional, parallel group, active control study was conducted on 60 patients with American Society of Anesthesiologists physical status I–III. Random allocation was carried out into two groups of 30 patients each. Intraoperatively, after administering a loading dose (10mL of 0.5% bupivacaine) in both the groups, continuous infusions of 0.1% bupivacaine plus fentanyl (2 µg/mL) (Group BF) or 0.1% ropivacaine plus fentanyl (2 µg/mL) (Group RF) were started at the rate of 5mL/h. Postoperatively, same drug concentrations were administered via PCEA pump at 4mL/h as a baseline infusion (bolus dose, 3mL; lockout interval, 15min). Visual analog scale (VAS) score at rest and on coughing was recorded at specific time points. Rescue analgesia was administered as per protocol. Results: VAS scores at rest and on coughing were higher in Group BF as compared to Group RF. Group RF had less drug consumption, required fewer PCEA boluses, and had minimal motor blockade as compared to Group BF. Conclusion: Good analgesic efficacy with lower drug consumption makes Group RF well suited for postoperative PCEA with hemodynamic stability and minimal motor blockade.

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Objective: Androgen deprivation therapy (ADT) is an integral part of prostate cancer management but its clinical use remains controversial. Materials and Methods: We retrospectively analyzed 91 patients with prostate cancer treated between 2007 and 2014 to determine the factors that influenced our physician’s decisions regarding ADT prescription. Results: Of the 55 radically treated cases, the mean age was found to be 67 years with comorbidities present in 67% cases. Overall, 26% patients were symptomatic at presentation with 0%, 19%, and 81% cases in low-, intermediate-, and high-risk (HR) category, respectively. When divided into two groups, ADT (41 cases) and NADT (non-ADT, 14 cases), more HR cases (80% vs. 20%, P = 0.05) and all patients with positive nodes fell in ADT group (P = 0.05). Patients in ADT group had a significantly higher mean initial prostate-specific antigen (iPSA) than that of NADT group (54.2 vs. 13.9ng/mL; P = 0.02). Treatment outcomes and toxicities remained comparable between the two groups. Overall, 74% patients obtained response to primary treatment (75.6% in ADT and 71.4% in NADT) with 10 patients experiencing disease progression during follow-up (FU). Mean progression-free survival was 43 and 32 months in ADT and NADT group, respectively (P = 0.24). Median FU was 54.9 and 35.5 months in ADT and NADT group, respectively (P = 0.29). At last FU, 91% patients were alive (88% in ADT and 100% in NADT) with 67% in disease-free status. Conclusion: Prognostic risk grouping, node positivity, and high iPSA emerged as significant factors that influenced decisions regarding ADT prescription. Other factors such as age, comorbidities, symptoms, Gleason score, and T-stage were found to be insignificant.

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Background: Radiotherapy to a patient with cervical cancer can be delivered by four-field “box technique” with a benefit of much less dose to intervening tissues along with a better and homogenous dose distribution at the target location. An important ingredient for a good radiotherapy planning is the choice of beam energy. The present study aims to investigate the feasibility of a 4 MV photon beam for the treatment of cervical cancers. Materials and Methods: A population of 20 patients, with carcinoma cervix, was included in the study. All the patients were planned for a prescribed dose of 45 Gy in 25 fractions. Results: Plans were evaluated for planning target volume and found better in terms of coverage and hot spots using 6 MV. The homogeneity index (HI) was 1.1 for both the energies. Similarly, conformity index (CI) was 2.0 depending on the method used for 4 MV and 6 MV photons. Although the HI and CI were comparable for both the plans, yet it seems significantly better for 6 MV. This indicates that spillage in 6 MV plans is lesser as compare to 4 MV. The present study reveals that there is a significant reduction in total monitor units in the plans with 6 MV photon beams, leading to fewer chances of secondary malignancies. Conclusion: A 6 MV photon beam has some proven mileage over 4 MV in terms of target coverage, dose homogeneity, and conformity and remains the best suitable photon energy for the treatment of cervical malignancies.

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Background: Control of chemotherapy-induced nausea and vomiting is a crucial factor in ensuring patient’s compliance and adherence to cancer chemotherapy cycle. Fosaprepitant is a water-soluble N-phosphoryl derivative of aprepitant, which is often administered along with 5-hydroxytryptamine 3 antagonist and a steroid in patients with highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Materials and Methods: A single-centric, retrospective cohort study was conducted in HCG Cancer Centre in South India, where patients who were prescribed fosaprepitant as a part of standard therapy were enrolled. Results: Among the 290 patients who were included in the analysis, 41.72% were male, 58.27% were female, and 36.20% belonged to 51–60 years of age. Advanced breast carcinoma was the most common diagnosis in 38.96% patients. HEC was prescribed in 222 patients; moderate emetogenic drugs and regimen were prescribed in 62 patients. Among patients who were prescribed HEC and MEC drugs and regimen, fosaprepitant, palonosetron, and dexamethasone were prescribed on day 1 followed by dexamethasone on days 2, 3, and 4. No infusion site reaction, hiccups, or any other adverse reactions were noted. Complete response was noted in all patients (100%) with HEC and MEC regimen cases. The formulation was well tolerated with none reporting any persistent or delayed or breakthrough emesis. Conclusion: Single-dose fosaprepitant used in combination with palonosetron and dexamethasone was well tolerated and effective in preventing chemotherapy-induced vomiting in patients receiving highly and moderately emetogenic drugs and regimen.

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Squamous cell carcinoma (SCC) of external auditory canal (EAC) is extremely rare. Although surgery followed by radio (chemo) therapy is the contemporary standard of care, radical radio (chemo) therapy has been successfully used as an anatomical as well as functional organ preservation modality. Radical brachytherapy is a promising alternative in early-stage SCC-EAC. We report our initial experience on the feasibility of using commercially available plastic earbud along with soft flexible earpiece of stethoscope as a radioactive source career applicator of remote after-loading high-dose rate radioactive sources (Ir¹⁹²).

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In clinical practice, survival curves show the fraction of patients who experienced the outcome of interest. As survival data contain “censored” observations where a patient is lost to scrutiny before experiencing the outcome, a sensible survival curve cannot be computed through simple division. This article aimed to provide various important aspects of survival analysis, censoring and various survival estimation techniques that are simple to calculate and understand, and a better visualization of statistical significance.

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The Hippo pathway was first discovered and linked to human cancers in the year 2002. It plays a crucial role in the majority of cancers, making it a censorious field for future investigation. Cancer is one of the major health issues, and there is no current cure accessible to efficiently medicate or treat the disease. The disease follows a process of oncogenesis, leading to the transformation of healthy cells (controlled and regulated growth) into cancer cells (uncontrolled and dysregulated growth). Previous studies reveal that the role of the Hippo pathway remains the center in the modulation of developmental biology. The mutated and altered gene expression of LATS1/2 (Large Tumor Suppressor kinase), MST1/2 (Member of Sterile-20 proteins kinase), and YAPs (Yes Associated Proteins), which are the chief factors of the Hippo pathway, basically promotes the invasion and migration of cancer cells. Therefore, targeting the hippo pathway genes is of utmost importance when considering new treatment strategies such as precision or personalized medicine. In this review, we aim at describing how microRNAs, hippo-signaling pathways regulate and maintain the whole hippo signaling.

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Until recently, improving treatment-related outcomes remained an unmet medical need for patients with extensive-stage small-cell lung cancer (ES-SCLC). Because of its rapid growth profile and tendency to metastasize early in the disease course, ES-SCLC accounts for approximately two-thirds of all SCLC diagnoses. Although treatment-naïve ES-SCLC is highly responsive to initial therapy with a platinum compound in combination with etoposide (EP), most patients experience disease recurrence within six months, and fewer than 5% survive to five years. In the platinum resistant/refractory settings, there are no standard guidelines for treatment, with various studies showing similar response rates (RRs) and survival outcomes for different single agent chemotherapies.Immune checkpoint inhibitors (ICIs) have been shown to improve outcomes in patients with a range of tumor types, especially in those characterized by high tumor mutational burden (TMB). The success of studies evaluating ICIs in multiple treatment settings and tumors, including SCLC, has led to trials assessing their role in ES-SCLC. Results from these trials suggest that this modality can improve outcomes, including in the first-line setting. Recent data show improved survival for patients with treatment-naïve ES-SCLC who received an ICI in combination with standard chemotherapy. Multiple trials evaluating a potential role for ICIs in the first-line setting are currently ongoing, with results expected within the next year.This paper incorporates clinical trial data and current guideline recommendations to show current evidence related to clinical decision making and patient management for those receiving ICI-containing regimens as first-line therapy for ES-SCLC.

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