Dodul Mondal

Accelerated hypofractionated adjuvant whole breast radiation with simultaneous integrated boost using volumetric modulated arc therapy for early breast cancer: A phase I/II dosimetric and clinical feasibility study from a tertiary cancer care centre of India

BACKGROUND Hypofractionation has become standard of care after Breast Conserving Therapy (BCT) in many European and few others western countries. Though still debatable, tumor cavity boost is routinely practised in our centre. Hypofractionation is not yet the current standard of practice in Asian countries. Employing hypofractionation and simultaneous integrated boost to lumpectomy cavity with conformal technique is not the current practice in this region. Hence the study was performed to see whether accelerated hypofractionation and simultaneous boost can be combined using volumetric modulated arc therapy (VMAT) in treating early breast cancer (EBC) patients. PATIENTS AND METHODS Female patients with EBC treated by whole breast radiation and boost were treated simultaneously to a dose of 40.5Gy and 48Gy in fifteen fractions over three weeks to entire breast and tumor cavity respectively with VMAT. Dosimetry including target coverage, OAR (organ at risk) sparing and acute radiation toxicity were evaluated. RESULTS Ten consecutive patients were treated. Planning target volume (PTV) coverage and OAR sparing were mostly satisfactory. Mean volume of PTVWB and PTVBoost were 786.18cm3 and 228.9cm3 respectively. Mean Dmean to PTVWB and PTVBOOST were 41.9Gy and 49.1Gy respectively. Dmax to PTVWB and PTVBOOST were 127.56% and 110.67% respectively. Ipsilateral lung mean dose and V20 were 13.92Gy and 21.53% respectively. V40 and V25 of heart were 0.17% and 2.25% respectively. All patients are disease free after a median follow up of two years. Most acute toxicities were Grade1. Only two patients out of ten developed Grade 2 skin reaction during radiation. Early cosmesis using Harvard cosmesis scale is good to excellent. CONCLUSIONS Accelerated hypofractionated RT using SIB-VMAT is a clinically feasible technique with acceptable initial result. Initial results are encouraging. MINI ABSTRACT Simultaneous integrated boost with accelerated hypofractionated whole breast radiotherapy using Volumetric Modulated Arc Therapy is a novel approach. Patient selection and technical considerations are of paramount importance. The present study describes successful implementation of this approach.

Impact of post-operative radiation on coronary arteries in patients of early breast cancer: A pilot dosimetric study from a tertiary cancer care center from India

BACKGROUND The significant impact of postoperative radiotherapy (PORT) on cardiac morbidity in patients of early breast cancer (EBC) undergoing breast-conserving surgery has been shown in different studies. The present study was conducted to assess the impact of surgery and the side of involvement on radiation dose to left anterior descending artery (LAD) and Left circumflex coronary artery (LCx). MATERIALS AND METHODS Totally, 58 patients of EBC were randomly chosen for this dosimetric study and planned with tangential field technique without intensity modulation (IM). Heart, LAD, and LCx (n = 55) were contoured. Dose volume histograms were analyzed to determine the Dmax (maximum dose) and Dmean (mean dose) of LAD and LCx. Students t-test was used for comparative analysis of the means. RESULTS The mean Dmax of LAD for left (L) EBC was 3.17 Gray (Gy) while for right (R) EBC it was 0.86 Gy (P = 0.007; 95% C.I, 1.14-3.48). The mean Dmean of LAD for L-EBC and R-EBC were 1.97 Gy and 0.79 Gy, respectively (P = 0.029; 95% C.I, 0.77-1.60). The mean-Dmax of LCx for patients with L-EBC (2.9 Gy; range: 1.2-4.35 Gy) was statistically higher than that for R-EBC (1.3 Gy; range: 0.7-3.2 Gy) (P = 0.045). The mean-Dmean of LCx for L-EBC (2.1 Gy; range: 0.6-3.6 Gy) was also significantly higher than that of L-EBC (0.9 Gy; range: 0.7-2.1 Gy) (P = 0.03). There was no significant impact of the pattern of surgery on LAD dose, but significance was noted for LCx dose parameters (P = 0.04 and 0.08 for m-Dmax and m-Dmean of LCx). CONCLUSION This pilot dosimetric study confirms the assumption that patients with left-sided EBC are at higher risk of developing long-term cardiac morbidity when treated with PORT due to increased dose to LAD.

External beam radiation techniques for breast cancer in the new millennium: New challenging perspectives.

Radiation therapy in breast cancer has evolved dramatically over the past century. It has traveled a long path touching different milestones and taking unprecedented turns. At the end, a fine tune of clinical understanding, skill, technological advancement and translation of radiobiological understanding to clinical outcome has taken place. What all these have given is better survival with quality survivorship. It is thus prudent to understand breast irradiation in a new perspective suitable for the current millennium.

Primary Neuroendocrine Tumor of Seminal Vesicle: An Extremely Rare Clinical Entity Emphasizing Diagnostic Role of 68-Ga DOTANOC PET-CT Scan and Therapeutic Potential of Long-Acting Depot Octreotide Injection in Maintenance

Primary malignancies of seminal vesicles are rare, difficult to diagnose, and generally associated with poor prognosis because of absence of early symptoms. Primary neuroendocrine tumor (NET) of this site is extremely rare in the medical literature. We report on a middle-aged gentleman with metastatic primary seminal vesicle NET. To the best of our knowledge, this is the first reported case of primary NET of the seminal vesicle with shortterm follow-up showing the importance of 68GaDOTANOC (68Ga-labelled [1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-Nal3-octreotide) whole body positron emission tomography computed tomography scan in diagnosis and long-acting depot intramuscular octreotide injection in treatment.

Synchronous orbital and mandibular metastases from squamous cell carcinoma of lung as initial disease presentation in a young female: First report of a rare occurrence

Metastatic tumor to orbit or mandible as initial presentation is rare. According to the available literature, majority of these described cases had its origin from lung and breast. Adenocarcinoma is the most commonly described histology. Concurrence of both of these metastases from a squamous cell carcinoma of the lung has not been reported in literature as initial presenting symptom. A young female patient with synchronous orbital and mandibular metastases as initial presentation of squamous cell carcinoma of the lung is being presented. The patient was treated with palliative radiation and chemotherapy but unfortunately died of progressive disease. To the best our knowledge, this is the first report describing such unusual presentation.

Solitary fibrous tumor of the sellar region treated with adjuvant radiation therapy

The solitary fibrous tumor of central nervous system is rare. Herein, a case of solitary fibrous tumor arising from sellar region is described. A 60-year-old man underwent subtotal excision of the tumor because of extensive infiltration of optical and vascular structures. In view of the presence of residual tumor, he was treated with adjuvant radiation therapy. After a follow-up period of 1 year, there was no progression of the lesion evident on magnetic resonance imaging of the brain. Solitary fibrous tumor should be considered as one of the differential diagnosis of a mass lesion arising in sellar region. Immunohistochemistry with CD34 is valuable for discerning the diagnosis. Complete surgery should be the goal of treatment and adjuvant radiation therapy may be considered for residual or recurrent disease.

Langerhans cell histiocytosis of atlantoaxial joint in a middle-aged man presenting with deafness as first symptom and soft-tissue mass at neck showing excellent response to radiotherapy alone: Report of an extremely rare and unusual clinical condition and review of literature

Langerhans cell histiocytosis (LCH) is a disorder of clonal proliferation of dendritic cell mainly occurring in children. Spine involvement is rare. This usually presents with pain and torticollis when neck is involved. Histopathology with immunohistochemistry is confirmatory. Local curative therapy with excision or curettage is used for localized disease. Radiotherapy is usually reserved for selected cases. Systemic chemotherapy is the treatment of choice for widespread systemic disease. In this article, we present an unusual presentation of atlantoaxial LCH with mastoid involvement resulting in hearing loss as the first symptom and quadruparesis in a middle aged male patient, which was also associated with soft-tissue mass at the nape of the neck and deafness. The patient was treated with radical radiotherapy, which provided excellent response to the disease. Involvement of atlantoaxial joint and temporal bone associated with soft-tissue mass neck and deafness in a middle-aged man is an extremely rare clinical situation.

An Uncommon Cause of Headache

A 45 year old male presented with chronic headache for the last six months, with recent aggravation. The headache was holocranial in nature and not associated with vomiting, aura or any other neurological complaints. On examination, he had no neurological deficit. Contrast enhanced Magnetic Resonance Imaging (MRI), was performed which revealed features suggestive of intraventricular neurocytoma with intraventricular hemorrhage (Figs. 1-​-3).3). He underwent gross total excision of tumor after frontal craniotomy and through anterior transcallosal approach. Histopathology suggested a diagnosis of neurocytoma WHO grade II. Figure 1a Axial T1 weighted image of the brain revealed a mass lesion in right lateral ventricle with heterogeneous signal intensity and hyperintensity in the frontal horn of right lateral ventricle suggesting intraventricular hemorrhage. Figure 3 Axial T1 weighted contrast enhanced MR image of the brain revealed heterogeneous enhancement of the mass lesion.

Synchronous papillary urothelial carcinoma of urinary bladder and adenocarcinoma of stomach in a middle-aged man: An extremely rare association with therapeutic dilemma

Synchronous occurrence of urinary bladder carcinoma and gastric carcinoma is very rare. A middle-aged Asian man presented with complaints of hematuria which was diagnosed due to muscle invasive papillary urothelial carcinoma of urinary bladder. Metastatic work-up revealed simultaneous presence of locally advanced gastric adenocarcinoma. He was treated with TURBT for the bladder cancer and was planned for radical gastric resection followed by radiation to urinary bladder and stomach with concurrent chemotherapy. However, due to very advanced nature of the gastric tumor patient was treated only with palliative gastric resection followed by palliative radiation to both urinary bladder and stomach due to his poor performance status. Lack of published English literature and evidence related to such clinical entity made this an extremely rare clinical entity and treatment decision difficult.

Peritoneal lymphomatosis mimicking peritoneal carcinomatosis - a clinical dilemma: Series of two cases and review of literature

Peritoneal lymphomatosis is a rare presentation of non-Hodgkin lymphoma and most often associated with abdominal organ involvement. The diagnosis is often difficult and needs to be differentiated from peritoneal carcinomatosis and tubercular peritonitis. Imaging, though helpful in disease staging, may not lead to a specific diagnosis; which rests on the histopathological findings. We present two cases of peritoneal lymphomatosis with different presentations and extranodal sites of involvement.