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Advancements in surgical and radiotherapy techniques have enhanced locoregional control (LRC) in head and neck squamous cell carcinoma (HNSCC), yet 30–40% of patients still experience recurrence within 2–3 years. Salvage surgery can result in significant morbidity and often fails to achieve optimal LRC as a standalone treatment. Modern radiotherapy (RT) techniques support highly conformal re-irradiation for small local recurrences with acceptable toxicity. The role of positron emission tomography (PET-CT) based contouring is under evaluation for re-irradiation settings. This retrospective study included patients treated with re-irradiation at a tertiary care center, focusing on those with prior HNSCC in the oral cavity, pharynx, or larynx, who had received radical or adjuvant RT and presented with biopsy-confirmed recurrences or second primary tumors. PET-CT was used for metastatic workup, with rigid image registration on planning CT scan employing a significant 40% SUVmax cut-off for tumor delineation. From January 2019 to June 2022, 85 patients underwent re-irradiation, with a median RT dose of 60 Gy (range: 44–66 Gy); 32 patients received concurrent chemoradiotherapy (CRT). Treatment planning used the volumetric modulated arc technique (VMAT), with the median Dmax for critical structures ranging from 7 Gy to 63 Gy. Acute grade 3 or higher mucositis, dysphagia, and odynophagia were observed in up to 23.5% of cases. At a median follow-up of 23 months, the 2-year disease-free survival (DFS) and overall survival (OS) rates were 55.2% and 63.5%, respectively. These promising results support PET-CT contouring-based planning as a potential standard of care in re-irradiation.

Oral cavity squamous cell carcinoma (SCC) is conventionally treated with surgery followed by adjuvant radiation therapy. Multiple studies have demonstrated clinical utility of interstitial brachytherapy (BT) alone or external beam radiotherapy (EBRT) with BT boost for T1-T2N0 cancers of lip and buccal mucosa. In case of combined EBRT and BT, dose summation and optimizing doses received by planning target volume (PTV) and organs at risk (OARs) remains challenging.The aim of this study was to generate and evaluate dosimetric parameters of PTV and OARs as a sum of high-dose-rate (HDR)-BT boost and EBRT in early T1-T2N0 cancers of lip and buccal mucosa, using deformable image registration (DIR) software (Velocity ). 2 Gy equivalent dose (EQD ) calculated manually (EQD -D BT + EQD -D EBRT) was compared with that estimated using DIR. An analysis was performed in patients with histopathologically proven T1-T2N0 SCC of lip and buccal mucosa, who underwent interstitial BT boost followed by EBRT. Planning computed tomography (CT) images and respective treatment plans of both BT and EBRT were imported into Velocity software, and DIR was employed to fuse these images for all patients. A synthetic plan incorporating both plans was generated. Dosimetric parameters of both PTV and OAR (mandible) were analyzed. This study included a total of 10 patients (cT1N0: = 6, and cT2N0: = 4), with median age of 57 years (range, 30-69 years) and male : female ratio of 7 : 3. The median dose to PTV using HDR-BT was 21 Gy (range, 20-21 Gy), delivered in 5-6 fractions, 3.5-4 Gy per fraction. The median dose to PTV using EBRT was 44 Gy (range, 40-46 Gy), delivered in 20-23 fractions, 1.8-2 Gy per fraction. DIR software-based dose summation provides accurate dose delivery to target and OARs. If performed prospectively, it can potentially enable optimization of limiting the doses to critical OARs, thus, reducing post-RT morbidity.

Carcinosarcomas of the salivary gland with osteosarcoma component are very rare, with only 17 cases reported. Despite multiple poor prognostic factors, our patient's outcome was favorable, highlighting the importance of early diagnosis and aggressive treatment in improving prognosis for this aggressive tumor variant.

Anatomical changes during adjuvant radiotherapy (RT) for post-operative oral cavity squamous cell carcinoma (OCSCC) have greater dosimetric effects with highly conformal techniques, thereby necessitating plan adaptation. We compared conventional adaptive RT (cART) with deformable image registration (DIR)-based ART (dART). Post-operative OCSCC patients receiving adjuvant RT with a ≥ 5 mm change in skin contour on cone beam computed tomography (CBCT) were enrolled. After re-simulation, planning CT (pCT) and extended CBCT were imported into Velocity to generate a synthetic CT (sCT) using DIR. Separate plans were created on the re-simulation CT (rCT) and sCT. The initial plan he was also projected onto the sCT anatomy and compared with the original plan on the pCT. Geometric (volume, Dice similarity coefficient [DSC], mean distance to agreement [MDA]) and dosimetric (mean dose, dose-volume histogram [DVH]) differences were evaluated between rCT- and sCT-based plans. Twenty-five patients were prospectively enrolled. Based on DSC and MDA, DIR showed acceptable geometric accuracy for all structures except the spinal cord (DSC = 0.75). Compared to pCT, most structures had significant volume reduction on sCT, except the low-risk planning target volume (PTV ) (p = 0.14) and the larynx (increased, p = 0.04). Projection of the initial plan onto sCT revealed significant loss in PTV coverage (V p = 0.001; D p = 0.01) and a non-significant loss for the high-risk PTV (PTV ). Organs at risk (OARs) doses increased non-significantly, except for the mandible (p = 0.007). Comparison of rCT and sCT volumes showed a 3.7% increases in PTV (p = 0.009) and 5.7% in PTV (p = 0.049), with non-significant OAR volume increases (2.4%-6.3%) except for the larynx (decreased). DVH comparison showed non-significant dose reductions to the parotids (0.6%), the mandible (0.5%), and the larynx (5.8%), but slight increases for the spinal cord (2.6%) and its planning organ at risk volume (PRV) (3.7%). Target coverage was significantly lower with sCT-based plans (PTV V by 3.2%, D by 3.8%, PTV V by 4.1% and D by 4.3%). dART improved OAR sparing but was compromised in a few target coverage parameters. Further enhancement of DIR accuracy is needed. Currently, DIR is primarily used in ART for dose accumulation to assess the need for plan adaptation.

Background Radiotherapy along with chemotherapy is the gold standard treatment in locally advanced Ca Cervix, delivered via 3DCRT or newer techniques like IMRT. Although a superior target conformation and normal tissue sparing can be achieved with IMRT, geographical misses and temporal changes in the volumes of the surrounding organs might lead to unpredictable dosimetric changes. These may alter the therapeutic outcomes with reduced local control and increased toxicities. An evaluation of such variations is paramount to modify our treatment strategies in the future. Materials and Methods This prospective study was conducted between January 2021 and August 2022. Locally advanced carcinoma cervix patients were included and planned with IMRT. Kv-CBCTs were taken thrice weekly during the treatment with a strict bladder and rectal protocol. Targets and OARs were contoured on the CBCT. Volumes and doses were calculated in a bias plan. Results Thirty-nine patients were enrolled in this study with 408 CBCT scans taken. Analysis showed that the bladder V35Gy% and V50Gy% had a negative correlation with their respective volumes ( r  = − 0.08 and − 0.07, respectively) reaching statistical significance for V35Gy% ( p  < 0.001). The rectal doses were not significantly affected by their filling status but by bladder volumes. A statistically significant negative strong correlation with bladder volume and rectal V50Gy% ( r  = − 0.64, p  ≤ 0.001) was seen. Conclusion In the present study, bladder volume changes had a significant dosimetric impact on the organ and the rectum. Since these volume variations inadvertently impact the late toxicities, the scope of adaptive radiation planning should be further explored.

Introduction Pain management during brachytherapy application for cervical malignancy has evolved over the years; the choice of procedure varies worldwide due to each available option's unique features and limitations. In this study, we explore the benefits and limitations of the paracervical block and assess its value in the contemporary setting. Methods This retrospective study included patients of carcinoma cervix who underwent intracavitary brachytherapy (ICBT) from April 2021 to August 2022 at our institute. The primary objective being assessment of pain (using Numerical Rating Scale (NRS)) during ICBT of carcinoma cervix done under paracervical block. Secondary objectives were determining the difference in procedure time between ICBT done under paracervical block and spinal anaesthesia, difference in doses to organs at risk (OARs) and estimating patient preference for paracervical block for the next sitting of intracavitary brachytherapy. Results One hundred and forty-nine intracavitary brachytherapy insertions in 53 patients were analysed. During the tandem insertion into the uterus, none had severe pain (NRS ≥ 7), while only 11.4% experienced moderate pain (NRS 4–6). Looking at pain during the procedure, only 8.9% experienced severe pain, although 70.9% experienced moderate pain. Four hours post-procedure, none reported moderate or severe pain and only 5.1% experienced mild pain. Paracervical block took a median time of 45 min for the entire procedure, while spinal anaesthesia required 65 min. Brachytherapy application with Paracervical block was found to be symmetrical. Bladder D2cc dose was significantly lower with paracervical block, and rectum and sigmoid D2cc doses were equivalent to spinal anaesthesia. About 95% of the patients preferred a paracervical block for the subsequent application. Conclusion Paracervical block offered adequate pain control and good intracavitary brachytherapy application. With the additional logistical advantages (lesser workforce requirement, no hospital admission, and patient convenience), paracervical block is valuable and viable as a pain management strategy in the intracavitary brachytherapy applicator insertion for gynaecological malignancies.

Background Pulmonary rehabilitation (PR) is an integral part of non-pharmacological therapy in chronic obstructive pulmonary disease (COPD). Yoga therapy (YT) has been shown to be beneficial in COPD, but the lack of large well-designed trials and standardized modules restricts its acceptability. This randomized control trial compares these two modalities in COPD patients via supervised tele-intervention. Objectives The primary objective of the study is to compare a 45-minute, five-days-per-week series of tele-YT (T-YT) with tele-PR (T-PR) for three months in terms of exercise capacity (6-Minute Walk Distance (6MWD)) in COPD patients. Methods COPD patients were randomly assigned (1:1) to T-YT or T-PR groups in a parallel-arm single-blinded controlled trial. The primary outcome is 6MWD recorded at baseline and after three months and secondary outcomes were symptom scores, Forced expiratory volume in the first second (FEV1), health-related quality of life (HrQoL), and depression and anxiety scores. Assessments were conducted at baseline and at the end of the three-month study period with a sample size of 75 in each group. Results A total of 150 consecutive patients with COPD were randomly assigned to either the T-YT (n = 75) or T-PR (n = 75) group. Their mean ± SD ages was 62.5 ± 7.0 years. The T-YT group had 55.5% males and 34.47% females, whereas the T-PR group had 44.5% males and 61.53% females. The trial was completed by 123 patients; 88% in the T-YT group and 76% in the T-PR group. Pre-intervention, the median (range) of 6MWD in T-YT and T-PR groups was 240 (120-600) m and 240 (120-660) m, respectively. There was statistically significant improvement in both groups respectively (p<0.001) post intervention from baseline but no significant intergroup difference (p = 0.486). A similar trend was seen in secondary outcomes with significant intragroup improvements and non-significant inter-group differences except FEV1%, which showed neither intragroup nor intergroup significant improvement. Conclusion Using a validated module, a three-month T-YT improves exercise capacity, symptom scores, HrQoL, and depression and anxiety scores similar to T-PR. T-YT is an acceptable alternative to T-PR in the management of COPD.

Management of hypercalcemia is based on the manifestation of symptoms and serum calcium levels. It is considered an oncological emergency; therefore, management has to be done on an urgent basis. In the present study, we analyzed the clinicopathological profile, treatment, and outcome of patients with hypercalcemia in solid malignancies at our institute. We retrospectively analyzed the medical records of patients diagnosed with cancer and admitted to the department of radiation oncology with hypercalcemia. The parameters studied were age, gender, performance status, date of diagnosis, the primary site of cancer, stage, histopathology, time of presentation of hypercalcemia since initial cancer diagnosis, clinical symptoms, parathyroid hormone levels, liver and renal function tests, bone metastases, management, outcome, and present status. In the present study, 47 patients of hypercalcemia from various solid malignancies were admitted during the study period between 1st January 2018 and 30th April 2022. Head and neck cancer (14, 29.7%) was the most common site of the primary malignancy. Twelve patients had incidental hypercalcemia and were asymptomatic. Management of hypercalcemia included intravenous saline hydration, bisphosphonates, and supportive medication. At the time of analysis, 17 patients were lost to follow-up, 23 patients died, and seven were alive and on follow-up. Median survival was 68.0 days (95% CI: 1.7-134.3 days). Hypercalcemia of malignancy is considered a metabolic oncological emergency and requires urgent and aggressive management. It gets complicated by a deranged kidney function test. Despite available treatment, it portends an abysmal prognosis.

Background In chronic obstructive pulmonary disease (COPD), pulmonary rehabilitation (PR) is an integral component of the non-pharmacological management of COPD. Yoga has proven to be beneficial in COPD, although well-designed comparative studies between the two modalities are lacking. This pilot study aims to compare these two modalities delivered as supervised tele-intervention. Methods The outpatient department (OPD) of a tertiary hospital recruited consenting, consecutive, inclusion-eligible COPD participants who were randomly assigned to intervention and control arms of 30 patients each. The intervention arm received a 45-minute tele-yoga therapy module (T-YT) validated by content validity ratio (CVR), computed using Lawshe's methodology and responses from 24 yoga specialists. The control arm received a 45-minute standardized tele-pulmonary rehabilitation session (T-PR). T-YT and T-PR were both managed through an online portal. Exercise capacity as measured by the six-minute walk distance (6MWD), symptom score (COPD assessment test [CAT], modified medical research council [mMRC]), forced expiratory volume in one second (FEV1%), quality of life (QoL) scores, St. George respiratory questionnaire (SGRQ), depression and anxiety scores (patient health questionnaire [PHQ-9] and generalized anxiety disorder scale [GAD-7] scores), were recorded at baseline and at the end of three months. Results 6MWD, symptom scores, SGRQ, PHQ-9, and GAD-7 all improved significantly from baseline within each group, but there was no statistically significant difference between the groups. FEV1% did not differ significantly between or among groups. This study shows T-YT module can be a reasonable substitute for T-PR in patients with COPD. Conclusions T-YT is beneficial in patients of COPD in terms of exercise capacity, symptom scores, and depression and anxiety scores and can be a reasonable alternative to T-PR.

Metastasis occurs very rarely in glioblastoma cases. Diagnosing metastatic glioblastoma has to follow a strict protocol to avoid misdiagnosis. Weiss's 1955 criteria, which is in prevalence, needs to be modified to include current standards of investigation. We report an interesting case of metachronous osseous metastasis from a primary glioblastoma with a complete response at a local site. We also suggest modifications to Weiss' criteria, which may improve its utility in establishing the diagnosis of metastatic glioblastoma.