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Year : 2019  |  Volume : 15  |  Issue : 9  |  Page : 263-278

Thorax and Abdomen

Date of Web Publication28-Nov-2019

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How to cite this article:
. Thorax and Abdomen. J Can Res Ther 2019;15, Suppl S2:263-78

How to cite this URL:
. Thorax and Abdomen. J Can Res Ther [serial online] 2019 [cited 2021 May 7];15:263-78. Available from: https://www.cancerjournal.net/text.asp?2019/15/9/263/271713

 > Abstract: 124: Renal metastases of oesophageal squamous cell carcinoma: A case report Top

Indu Sasikumar, A. Sajeed, Lekha Nair, R. Jayasree

Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]

Background: Esophageal cancer commonly metastasize to the liver, lung, bone and adrenal glands. Renal metastases of esophageal cancer is rare clinically, with only 18 cases being reported in the literature. We report a case of squamous cell carcinoma of the esophagus with renal metastases. Case Description: A 53 year old lady was evaluated for complaints of dysphagia. She was of good performance status and had no significant findings on clinical examination. Oesophagogastroduodenoscopy showed oesophageal growth at 20 cm and biopsy from the growth suggested moderately differentiated squamous cell carcinoma. Metastatic workup was done with PET CT scan which showed uptake in both kidneys. Ultrasonogram guided Fine Needle Aspiration was done from the lesion in left kidney and cytological examination reported as metastatic squamous cell carcinoma. She received palliative radiotherapy to primary at a dose of 30Gy in 10 fractions following which dysphagia was relieved. She was started on palliative chemotherapy with single agent capecitabine. However, she progressed symptomatically while on treatment and expired within 8 months. Discussion: Clinically, renal metastases of esophageal cancer is rare, likely due to its asymptomatic presentation. Histopathological diagnosis is needed for confirmation in such cases as renal secondaries are rare. Treatment is mainly systemic chemotherapy as in case of other visceral metastases , but prognosis is dismal.

 > Abstract: 126: Prospective study on radiation dose escalation in the treatment of squamous cell carcinoma of oesophagus with definitive concurrent chemo-radiation using three dimensional conformal radiation therapy Top

Ashwini Lakshmaiah, K. N. Pradeep Kumar

Srinivasam Cancer Center, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose: Radiation and chemotherapy have been established as the standard of care in the management of locally advanced carcinoma of oesophagus, when the patient is unsuitable for surgery due to medical reasons or tumour characteristics. Poor local control and survival rates have encouraged the implementation of radiation dose escalation. In this study, we intend to analyse the outcome and tolerance of radiation dose escalation with concurrent chemotherapy as definitive treatment in nonmetastatic squamous cell carcinoma of oesophagus. Aims and Objectives: To evaluate the local response to radiation dose escalation with concurrent chemotherapy, 3 months after completion of treatment. The oral intake status and quality of life assessment were also assessed at 3 months and compared to baseline values. Radiation-related toxicity was assessed to find out the tolerance of high dose. Materials and Methods: Patients diagnosed with stage I-III squamous cell carcinoma oesophagus that were intended to be treated with radical chemo-radiation due to inoperability or denial for surgery, between August, 2015 to August, 2017 were included in this study. Baseline endoscopy, oral intake score and FACT E-QOL score were documented for comparison after treatment. All patients were treated with radiation dose of 60Gy in 2Gy per fraction schedule (initial 46Gy followed by 14Gy boost to tumour alone) with concurrent 3-weekly 5-FU/Cisplatin or weekly Cisplatin alone regimen. Results: A total of 20 eligible patients were evaluated. The median age at presentation was 64 years (34-74 years), with mostly middle thoracic oesophageal tumour (60%), having grade 2 dysphagia (75%) on oral intake scale. Patients with tumour length of </=5 cm (55%) or >5 cm (45%) were categorised. Following treatment, 17 patients (85%) were found to complete response at 3 months post treatment. One patient had residual disease and 2 patients had progressive disease within the first 3 months.10% (2) of the patients had Grade 3 dysphagia requiring stent placement. The oral intake score and quality of life improved in most of the patients evaluated (55% and 85%, respectively). An association between the length of the tumour and dysphagia was assessed and it was statistically not significant (p=0.157). At the time of analysis, the median follow up was 14.5 months, 10 (50%) patients had disease progression in the form of distant metastases (35%) or loco-regional with distant metastases (15%). The median disease-free survival was 16 months (95% CI, 10-21 months). Out of the 20 patients, 12 patients were alive at the time of analysis and 2 of them were with disease progression. 40% of the patients succumbed to the disease following progression. No patient developed oesophageal fistula, radiation-pneumonitis or cardiac toxicity. The median overall survival was 28 months (95% CI, 13-42 months) in this cohort. The 1-year and 2-year survival rates were 72.4% and 53.7%, respectively. Conclusion: Radiation dose escalation in the management of stage I-III, non-metastatic squamous cell carcinoma oesophagus, with concurrent chemotherapy yields a good local control rate at 3 months with less severe complications and improved quality of life. The radiation sequalae following treatment are acceptable owing to reduced treatment volume. Further randomized control studies comparing the standard dose and dose escalation by careful external beam radiation planning and with longer follow up may be required to predict the late sequalae of radiation.

 > Abstract: 146: Comparison of internal target volume generated with lung optimization treatment and maximum intensity projection by four-dimensional computed tomography scan in radiosurgery treatment of early lung cancer Top

G. R. Divya, Ram Madhavan, Debnarayan Dutta

Amrita Institute of Medical Sciences, Kochi, Kerala, India, E-mail: [email protected]

Purpose and Objective(s): Comparison of internal target volume (ITV) generated with lung optimization treatment (LOT) and 4-dimenstional computed tomography (4D-CT) measured maximum intensity projection (MIP) methods in lung tumour treatment. Materials and Methods: 18 patients with lung cancer (n=8, stage T1A: 2, Stage T2: 6 pt, mean GTV 12.6 cc) and lung metastasis (n=10) accrued. 13/18 (72%) had right sided tumour, 12/18 (66%) had upper lobe tumour and 11 (61%) had 2-views on LOT. CT simulation (inhale & exhale phase) done for LOT based ITV generation (ITV-L). Same patient cohort underwent ITV generation with 4D-CT measured MIP methods (ITV-M). Comparison was done between the ITV in these two different methods. Results: Mean GTV was 12.6cc, ITV-L and ITV-M was 29.1 and 57.6 cc. Mean GTV, ITV-L and ITV-M in 1-view, 2-view, right lung, left lung, upper lobe, middle, lower lobe and primary lung cancer and lung metastasis were 3.2, 18.5, 13.4, 10.7, 16.5, 6.3, 3.6, 25.5, 2.4 cc; 15.1, 38.1, 30.6, 25.1, 35.9, 19.7, 11.3, 49.9, 12.4 and 24.1, 79.1, 49.2, 79.8, 73.7, 34.1, 17.2, 106.4, 18.7 cc respectively. In 1-view and 2-view, ITV-L and ITV-M were 29.1, 57.6 (p-value: 0.001) and 38.1, 79.1 (p-value-0.009) respectively. Right lung tumour ITV-L and ITV-M were 30.6, 49.2 (p-value-0.001) and in left lung tumours 25.1 and 79.8 cc (p-value- 0.0.14) respectively. In upper, middle and lower lobe tumour, ITVs were 35.9, 73.7 (p-value-0.004); 19.7, 34.1 (p-value-0.474) and 11.3, 17.2 (p-value-0.001) respectively. In primary lung tumour and metastasis disease, ITVs were 49.9, 106.4 (p-value-0.071) and 12.4, 18.7 (p-value-0.001). Increase in mean ITV volume with MIP in all patient cohort was 49% [(ITV-M - ITV-L)x100 / ITV-M], in 1-view cohort 37%, 2-view 52%, right lung 38%, left lung 68.5%, upper lobe lung 51%, middle lobe 42%, lower lobe 34%, primary lung cancer 53% and metastatic lung cancer 34% respectively. Conclusion: MIP generated ITV volumes are significantly larger compared to LOT generated volume. ITV-M is larger in relation to lobes, side of tumour and type of tumour. There may be higher lung tissue necrosis when treated with ITV-M, as the 'high dose' volumes are more in this patient cohort.

 > Abstract: 148: Prospective evaluation of fiducial placement in liver tumours in respect to effectiveness, “quality” of placement, toxicities of fiducial placement and factors influencing the “quality” of fiducial placement Top

Ram Madhavan, Kaushik Jagannath Kataki, G. Shibu, R. Rajesh Kannan, Rupa Das, Tushar Tatineni, O. C. Clinto, Shalet Palliparambil Gulam, Jishan Jaladharan, Raghavendra Holla, Debnarayan Dutta

Amrita Institute of Medical Sciences, Kochi, Kerala, India, E-mail: [email protected]

Purpose and Objective(s): Evaluate morbidities and 'quality' of fiducial placement in primary liver tumours (HCC) for CyberKnife. Materials and Methods: 36 HCC patients accrued in prospective ethical & scientific committee approved study to evaluate 'Quality' of fiducial placement, placement time, pain score, complications, recovery time and factors influencing placement. Results: 108 fiducials were placed in 36 patients (Male 92%, mean age 60.2 yrs, ECOG 0-1 92%, CP A 89%, B&C 11%, majority in seg II & VI, PVT disease 64%, 14% segment V, 22% segment VI). Post-fiducial pain score 0-1 in 26 (72%) and score 3-4 was in 2 (6%). Five (14%) admitted in 'day-care' (2 mild pneumothorax, 3 pain). One patient (3%) admitted for hemothorax and died. Fiducial placement radiation oncologist (RT) score of 11-13 (good) was in 24 (67%), fair (9-11) in 4 (11%) and poor (7) in 3 (8%). Radiologist (RD) score of good, fair and poor in 27 (75%), 5 (14%) and 2 (6%). Concordance in 'poor', 'fair' and 'good' score was 2/2 (100%), 4/5 (80%) and 24/27 (89%) respectively (p-0.001). Poorer CP score (p-0.08), poorer PS (p-0.014) and accured during 'learning curve' (p-value: 0.013) had poorerplacement score. Mean placement time (p-0.055), recovery time (p-0.025) was longer and higher major complications (p-0.009) in patients with poor PS. Liver segment involved (p-0.484) and BCLC stage did not influence placement score. 'Good' placement score was 30% in 1st cohort whereas 93% in last cohort (p-0.023). Time for placement was 42.2 and 14.3 min (p-value: 0.069) respectively. Conclusion: Fiducial placement is safe and in experienced hands, 'quality' of placement is 'good' in majority. Major complications and admission after fiducial placement is rare. Complications, fiducial placement time, recovery time is more during the 'learning curve'. Poor CP Score, extensive liver involvement, poor PS have higher probability of complications.

 > Abstract: 149: Atypical presentation of adenocarcinoma lung as metastatic deposit in ulna bone Top

Ram Kamei, P. K. Maiti, Rajat Bandyopadhyay, Saurav Sau, Sanghamitra Saren

Burdwan MedicalCollege, Burdwan, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): To report a rare case of adenocarcinoma lung presenting as metastatic lesion in ulna bone. Materials and Methods: Case presentation. Results: Lung cancer often manifests with bony metastases. The primary manifestation of lung cancer with osteolytic lesion of ulna bone due to skeletal metastasis is very rare. An elderly male smoker presented with non-traumatic, non-tender swelling of the right forearm, which shows osteolytic lesion of the ulna in X-ray. MRI shows chronic osteomyelitis. Core biopsy from the swelling shows metastatic deposit of adenocarcinoma – right forearm. On subsequent evaluation, HRCT thorax reveals spiculated lesion in left upper lob. Fine needle aspiration from lung lesion confirmed adenocarcinoma of the lung. This case highlights the rare occurrence of ulnar bone metastasis as an atypical presentation in a case of carcinoma lung in absence of any pulmonary symptoms. Conclusion: Ulnar bone metastasis as an atypical presentation in a case of carcinoma lung in absence of any pulmonary symptoms is very rare.

 > Abstract: 155: To estimate the planning target volume margin in lung tumors using 4-dimensional cone beam computed tomography scan Top

Sai Snehit Chatakonda, V. Bhaskar, Namratha Sai Reddy, Geeta Narayanan

Vydehi Institute of Medical Sciences, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): Our objectives were to estimate the Planning target volume (PTV) margin in lung tumors using 4 Dimensional Cone beam Computed Tomography scan (4D CBCT) and to evaluate other factors which affect tumor motion. Materials and Methods: 43 patients presenting to the Department of Radiation Oncology, Vydehi Institute of Medical Sciences, Bangalore, between January 2017 till June 2018, with newly biopsy proven Carcinoma Lung planned and treated with definitive intent of treatment were enrolled in the study and all the investigations were performed. The radiation dose was delivered using 3DCRT /IMRT /VMAT plan to a dose of 6000cGy -6600cGy in 30 or more fractions to the whole primary. All patients underwent 2 sets of CT scan, first one was for the CT simulation where the patient underwent free breathing CT scan and the second scan was a 4 D CBCT scan on the ELEKTA machine where all the 10 phases of respiration in free breathing were recorded and later transferred to the treatment planning system of ELEKTA , the software segregates images into different phases using diaphragmatic motion , further these phases were fused with the images from CT and GTV will be contoured in all phases of respiration , following which an ITV was created and tumor motion was measured in superior , inferior , anterior , posterior , medial , lateral directions from the center of tumor & later the PTV had been concluded. Results: Of 43 carcinoma lung patients who underwent 4D CBCT and GTV contoured in 10 phases and later ITV was generated to which PTV margin of 0.5 cm was added, the mean ITV for tumor in all 6 directions i.e in superior, inferior, anterior, posterior, medial and lateral directions was 0.9 cm, 0.9 cm, 0.8 cm, 0.9 cm, 0.8 cm, 0.9 cm but for coverage of tumor for 90% of patients the standard margins required was 1.3 cm, 1.5 cm, 1.5 cm, 1.4 cm, 1.5 cm, 1.3 cm respectively. Conclusion: Lung carcinoma requires respiratory motion management technique for treatment purpose i.e 4D CBCT is recommended for patients individually because uniform PTV margins can't be recommended and 4D CBCT scan should be done at multiple sessions during the course of treatment i.e weekly once.

 > Abstract: 162: Epidemiology of lung cancer in Eastern India with focus on histopathological subtypes and smoking history: A single rural tertiary center experience Top

Madhusudhan Perumandla, Biswamit Bhattacharya, Premnath Dutta

Burdwan Medical College and Hospital, Burdwan, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): Background: Lung cancer has variable epidemiologic pattern according to the geographic region. Worldwide we are observing important changes in incidence trends amongst men and women, histology, and incidence in non-smokers. Indian epidemiological data on lung cancer is scarce, more so from the eastern parts of the country and rural scenario. Aims: We aim to study the epidemiological patterns of lung cancer in India, and find out whether global trends in changing patterns of epidemiological profile of lung cancer is also applicable for Indian population. Materials and Methods: We enrolled all the patients attending Radiotherapy OPD of Burdwan Medical College and Hospital having histopathological diagnosis of lung cancer between 2017 and 2018. Demographic data, smoking history, place of residence, histology, stage at presentation, and treatment details were collected. Data was entered and analyzed in SPSS. Results: There were 484 patients, with a median age of 59.5 years (Range: 33 to 79 yrs), of which 132 (27.3%) were non-smokers and 352 (72.7%) were smokers. The male-to-female ratio was 4.7:1. 12.4% of patients had small-cell carcinoma; of the 87.6% patients with non-small-cell carcinoma (NSCLC), the most common histology was adenocarcinoma (44.6%), followed by squamous cell (38.4%). 4.5% of patients were diagnosed by cytology, therefore were diagnosed as NSCLC, without further histopathological sub-typing. Most patients (53%) were in Stage IV at presentation. Lung followed by bone were the common sites of metastases. The majority of the patients (49%) received palliative chemotherapy. Conclusion: Majority of rural Indian patients with lung cancer are smokers. India is not an exception to the global trend of rise in the incidence of adenocarcinoma. The proportion of small cell carcinoma of lung patients in our series is slightly more than other Indian data, which needs to be collaborated by further multi-centric studies.

 > Abstract: 170: A prospective comparative study of neoadjuvant concurrent chemoradiation with single agent capecitabine versus capecitabine-oxaliplatin combination in locally advanced adenocarcinoma of rectum Top

Arindam Chaudhury, Biswamit Bhattacharya, Premnath Dutta, Sanatan Banerjee

Burdwan Medical College and Hospital, Burdwan, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): Colorectal cancer is a major cause of morbidity and mortality globally. Rectal cancer represents a distinct disease entity that needs carefully optimized multimodality treatment strategies. Although surgical resection is the mainstay of treatment, preoperative neoadjuvant therapy with either short course radiotherapy (25Gy in 5 fractions) or long course chemoradiation (50.4Gy in 28 fractions) with concurrent 5–Flurouracil/Capecitabine based chemotherapy has emerged as the standard of care. Oxaliplatin is commonly used along with 5- Flurouracil/Capecitabine in the adjuvant or metastatic setting for Colorectal carcinoma although its role in the neoadjuvant setting as an add-on, remains questionable. This study aims to evaluate whether Capecitabine-Oxaliplatin combination is superior to single agent Capecitabine as radiosensitizer for neoadjuvant long course chemoradiation, in downstaging locally advanced rectal adenocarcinoma to achieve better treatment outcome. Materials and Methods: This is a prospective, single-institutional, randomised, non-crossover study. Cases of histopathologically proven locally advanced Adenocarcinoma of rectum, attending the Radiation Oncology OPD of Burdwan Medical College and Hospital, from June 2017 to May 2019, were selected as per pre-defined inclusion and exclusion criteria, and segregated into the study and control arms by simple randomization method. Both arms were treated with neoadjuvant, external beam radiotherapy with 50.4Gy in 1.8Gy/fraction in 28 days over 5½ weeks along with concurrent Tablet Capecitabine (825 mg/m2/day) from Day 1 to Day 28 of treatment. Patients in the Study arm received additional intravenous chemotherapy with Inj. Oxaliplatin (85 mg/m2) on Day 1 and 14 of RT. Toxicities in both arms were assessed by appropriate methods and compared as per CTCAE v5.0. The patients then proceeded for definitive surgery. Post-operative histopathological reports were assessed for pathological response. The patients were regularly followed up and the treatment failures were documented. Results: Out of 32 patients in the study arm aged between 19-65 years (median 46.5 years), 15 (46.9%) were males and 17 (53.1%) were females. Out of 31 patients in the control arm aged between 24-66 years (median 45 years), 19 (61.9%) were males and 17 (38.1%) were females. Both the arms were statistically found to be age and sex matched. At the end of definitive surgery, 14 patients (43.8%) in the study arm versus 6 patients (19.4%) in the control arm, achieved pCR. The difference however, failed to show any statistical significance (p=0.052). During the study period, 5 patients (15.6%) in the study arm and 9 patients (29.03%) in the control arm had treatment failure (p=0.328). 14 patients (43.4%) in the study arm had grade 3 febrile neutropenia while only 3 patients (9.67%) in the control arm had so (p=0.005). 10 patients (31.25%) in the study arm and only 4 patients (12.9%) in the control arm had grade 3 diarrhea (p=0.15). 3 patients in the study arm, and 1 patient in the control arm had treatment related deaths (p=0.63). Conclusion: Addition of Oxaliplatin to neoadjuvant concurrent Capecitabine based long course chemoradiation in locally advanced adenocarcinoma of rectum causes improvement in pCR rates, and decrease in treatment failure rates, at the cost of significant increment in toxicities. The study protocol should therefore be tried in larger multi-institutional trials and considered only for patients who have preserved performance status and no or minimal co-morbidities.

 > Abstract: 173: Oesophageal cancer in North East India: Analysis from high incidence area Top

Anthialisha Nongkynrih, Vikas Jagtap, Purnima Devi, Caleb Harris, Vandana Raphael, Baphiralyne Wankhar

North Eastern Indira Gandhi Regional Institue of Health and Medical Sciences, Shillong, Meghalaya, India, E-mail: [email protected]

Aims: Analysis of Epidemiology and treatment characteristics of carcinoma oesophagus at high incidence area in North East. Materials and Methods: Records of patients with carcinoma oesophagus who attended department of oncology from January 2016 to July 2019 was retrieved and analysed for the study. Results: Records were available for total 161 patients. The presentation was 52 years (range 31-82 years). Fourth decade of life was the commonest presentation. Male to Female ratio was 3:1. 64% patients had a history of smoking tobacco, while 61% had history of alcohol consumption and 51% consumed betel nut. The most common presentation was Dysphagia (89%). At presentation, 73% had ECOG 1 performance status. Most common site was lower thoracic oesophagus (32%). Squamous cell carcinoma (83%) was most common histology while only 2% had adenocarcinoma. Invasion of airway was seen in 4% patients. Thirty-nine percent patients presented in locally advanced stage III and IV while only 2% patients presented in stage I. Regional lymphadenopathy was seen in 30% patients while 16% had distant metastasis. The common sites of distant metastasis were lung (35%) and liver (27%). Intent of treatment was Curative in 46% and Palliative in 16%, remaining patients (38%) defaulted before the work up or intent of treatment was decided. Chemotherapy (Adjuvant, Neo adjuvant or Palliative) was given in 32% patients; surgery was done in 7% while 8 % received radiotherapy. Median duration of follow up was 4 months (1 to 24 months). Six percent patients each had No evidence of disease, residual and progressive disease while 2 % had recurrence. Disease status of 80% patients was unknown due to default at various levels. Conclusion: Squamous cell carcinoma is still the commonest histology in our region with stage III & IV being commonest presentation. Although intent of treatment was curative in most cases, the high default rate resulted in bleak outcomes. Further study is needed to reason the high default rates at our centre.

 > Abstract: 176: Skeletal muscle metastasis from poorly differentiated gastro-esophageal junction adenocarcinoma Top

M. Arun, S. Roshni, A. L. Lijeesh, T. R. Preethi

Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]

Background: Gastric carcinoma is one of the most common causes of cancer-related death in the world. The most frequent metastatic sites of gastric carcinoma are regional lymph nodes, liver, peritoneum, lung, and bone. In the literature, skeletal muscle metastases from gastric carcinoma have been reported rarely. We report here a case of swelling in the thigh that was diagnosed as skeletal muscle metastasis from gastro oesphageal junction carcinoma. Case Report: A 58 year old male presented with complaints of dysphagia. He was of good performance status and had no significant findings on clinical examination. Oesophago-gastro-duodenoscopy revealed a Sievert II lesion in gastro esophageal junction, biopsy from which came as poorly differentiated adenocarcinoma. A CT scan showed circumferential wall thickening in lower esophagus, extending to fundus and cardia of stomach, along with a perigastric node abutting splenic vessels with local infiltration. Due to significant disease along coeliac bifurcation, he was planned for neoadjuvant chemotherapy with 3 cycles of Epirubicin, Oxaliplatin and Capecitabine followed by re-assessment. During neoadjuvant chemotherapy, patient presented with a hard swelling on the left calf. FNA from the swelling came as metastasis from poorly differentiated adenocarcinoma. A PET-CT scan showed increased FDG uptake in the esophagogastric junction and perigastric node and left calf region. Due to poor response of primary lesion, patient was planned for 3 more cycles of chemotherapy. However, after a total of 5 cycles, chemotherapy was stopped due to poor tolerance. Palliative radiation 30 Gy over 10 fractions was delivered to the primary. Due to increase in size of swelling and pain, palliative radiation to a dose of 8 Gy over single fraction was delivered to swelling. Patient is currently symptomatically stable and is being followed up clinically. Discussion: Skeletal muscle metastases are rare with incidences of 0.16-0.003% in clinical practice and 0.8% in an autopsy study. The most common primaries of skeletal muscle metastases are lung cancer (25%), gastrointestinal tumors (21%), urological tumors (13%), genital tumors (9.3%) and breast cancer (8.2%). Muscle metastases most commonly occur in the lower limb. Esophago-gastric junction carcinoma rarely metastasizes to skeletal muscle and even when muscle metastases occur, it occurs in the setting of widespread metastatic disease. However, in this case muscle metastasis occurred without synchronous metastasis to any other site. Because of their rarity and particular clinical characteristics, these metastases are challenging to diagnose and are frequently part of a widespread metastatic disease. The management of muscle metastases depends upon the clinical scenario. Radiotherapy can relieve the pain and decrease size of such lesions. Surgical excision requires careful patient selection. Chemotherapy is usually indicated in the setting of multiple metastatic sites. Conclusion: Solitary skeletal muscle metastasis from gastro-esophageal junction adenocarcinoma is extremely rare. In patients who are not candidates for surgery, palliative radiotherapy could be an option.

 > Abstract: 183: Role of adaptive radiotherapy planning in carcinoma oesophgus and dosimetric review Top

Aafreen Khan, Virendra Bhandari, Shashank Singh, Sahaj Palod, Tauseef Ali

SAMC and PGI, Indore, Madhya Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): Esophageal cancer is advanced at the time of presentation and delivering a tumoricidal dose of radiation to target structure, large volumes of normal tissues get irradiated including lung, heart, and spine. Adaptive radiotherapy increases the accuracy of RT delivery to the tumor and sparing the surrounding normal tissue. Materials and Methods: Histologically proven 24 patients of inoperable cancer esophagus were studied. All patients received induction chemotherapy followed by concurrent chemotherapy and radiotherapy. CT simulation with proper immobilization was done and images were transferred to the treatment planning system. Delineation of target volumes and organs at risk (OARs) was done and planned for 60 Gy in 30 fractions with IMRT keeping the doses to OARs within tolerance limits. Replanning was done on repeat CT scan during 4th week of radiotherapy treatment and potential reduction in doses to OARs and target organ volume was assessed. Results: A total of 24 cases were analyzed for the adaptive plan with the coverage of the 95% prescription isodose for PTV was given. (t-test) Left Lung V20 (mean 19.23 Gy vs. 17.35 Gy) and Dmean (mean 16.03 Gy vs. 14.25 Gy), right lung V20 (mean 18.38 Gy vs. 16.66 Gy) and Dmean (mean 15.70 Gy vs. 13.97 Gy), heart V25 (mean 38.72 Gy vs. 35.32 Gy) and Dmean (mean 26.40 Gy vs. 22.74 Gy), spine 1% vol (mean 36.54 Gy vs. 33.39 Gy) and Dmax (mean 39.81 Gy vs. 34.34 Gy), GTV volume (mean 67.37 cm3 vs. 24.58 cm3) were significantly smaller for the adaptive plan. Conclusion: By doing adaptive radiotherapy in 4th week of treatment using repeat CT-scan, response evaluation can be done as there was a significant reduction in the volume of GTV and replanning of treatment on repeat CT scan also helps us in reducing doses to the OARs resulting in reduced toxicity and better patient convenience.

 > Abstract: 186: Metastatic hepatocellular carcinoma presenting as scapular lesion without a primary lesion in liver: A case report Top

Parvathy Rajasekharan, S. Roshni, A. L. Lijeesh, Sindhu Nair

Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]

Case Background: Hepatocellular carcinoma is one of the most common cancers worldwide. However , the reported cases of extrahepatic hepatocellular carcinoma without a primary liver lesion are very rare , with only 6 cases being reported worldwide. Thus , due to insufficient data on such cases , the diagnosis and further treatment for these patients are highly demanding. Here , we describe a case of metastatic hepatocellular carcinoma presenting as scapular lesion without a detectable primary lesion in the liver. Description: A 66 year old gentleman , with history of smoking and alcoholism , was evaluated for complaints of swelling on the right shoulder. On examination , performance status was poor and systemic examination was within normal limits. Local examination showed a hard swelling in the right scapular region of size 7 x 8 cm. Ultrasonogram of the right scapula showed a fairly well defined heterogeneous hypoechoic lesion with echogenic calcifications , cystic areas and vascularity. Biopsy taken from the lesion showed atypical cells with abundant eosinophilic cytoplasm with round to oval nuclei with prominent nucleoli in nests and trabeculae separated by fibrous septa. In immunohistochemical staining these neoplastic cells were diffuse strong positive for Hepatocyte Paraffin 1 ( HepPar 1 ) , cytoplasmic weak positive for TTF 1 , CK 7 negative and CK 20 negative which confirmed the diagnosis of metastatic hepatocellular carcinoma. Ultrasonogram of abdomen and pelvis showed coarsening of hepatic parenchymal echoes with no focal lesions in the liver. To locate the primary lesion and for further metastatic workup, PET CT scan was done which showed skeletal metastasis involving left parietal bone, bilateral scapulae, sternum, multiple ribs, pelvic bone, bilateral proximal femur and knee joints , however , no primary lesion could be detected in the liver. The S.AFP level was 43.1 IU. Child Pugh score was calculated as 8 and patient was categorized as Class B. He was started on targeted therapy with Sorafenib. However, he progressed symptomatically while on treatment and expired within 3 months.

 > Abstract: 195: Incidence of supracarinal lymph node positivity in operated cases of total esophagectomy for carcinoma esophagus: Short-term results from a tertiary cancer centre from Western India Top

Manish Sadhwani, Abhishek Jain, Ronak Vyas

Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): Adequate lymphadenectomy in middle and lower third esophagus cancer is still a matter of debate. This study aims to find out the extent of histopathological supracarinal lymph node positivity rate and its short term oncological outcome. We also aim to highlight feasibility and excellent role of minimally invasive thoracoscopic esophageal mobilization with complete mediastinal lymphadenectomy in dissecting these nodes with a relative ease and less complications. Materials and Methods: A prospective study was conducted after approval from our institutional board review from April 2017 to August 2018. Total 76 patients of having mid or lower third carcinoma esophagus and operated at our institute for partial/total esophagectomy with extended two field lymph node dissection were followed. Intra-operative nodal stations were harvested separately and indiviually labelled according to the Japanese Esophageal Classification and sent for histopathological examination. Results: Patients had an average age of 52 years. Histologically 73 were SCC and 3 were adenocarcinoma. 44 patients received preoperative concurrent radiotherapy plus chemotherapy while 18 cases were operated upfront. 14 patients were operated after palliatiev treatment (CT/RT). Average total Lymphnode yield was 22 nodes (range 3-69). In 26 patients (34.2%) lymphnodes were positive (N+ disease). Supracarinal nodes were positive in 20 cases (26.31%). Average Supracarinal LN yield was 10.33 nodes (range 2-32). 5 patients (6.5%) had only supracarinal lymph nodes positive on HPE. 17 patients had complete pathological response rate (pCR). Conclusion: In cases of mid third esophageal carcinoma extended two field with supracarinal lymphadenectomy is strongly recommended even after patient has received neoadjuvant treatment, though same for lower third / GE junction tumors should be considered.

 > Abstract: 199: Gastric schwannoma: A report of two cases and review of literature Top

V. S. Noufira, A. Sajeed, S. Roshni, T. R. Preethi, P. Sindhu Nair

Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]

Introduction: Gastrointestinal mesenchymal tumors are a group of tumors originated from the mesenchymal stem cells of the gastrointestinal tract, consisting of gastrointestinal stromal tumors (GIST), leiomyomas, leiomyosarcoma, schwannomas. Gastric schwannoma , a very rare gastrointestinal mesenchymal tumor, represents only 0.2% of all gastric tumors and 4% of all benign gastric neoplasms. They are usually asymptomatic or detected incidentally. The preoperative diagnosis via endoscopy or imaging is a challenging issue. Here we report 2 cases of gastric schwannoma. Case I: A 52 year old lady with multiple comorbidities was evaluated for acute right sided abdominal pain. Her preoperative imaging revealed acute calculus cholecystitis with a mass in stomach suspicious for gastrointestinal stromal tumour. she underwent laparoscopic cholecystectomy and wedge resection of gastric lesion and the final HPR turned out to be gastric schwannomma. Case II: A 45 year old lady with history of two previous caesarean section who was evaluated for dyspeptic symptoms and abdominal distension. Imaging showed soft tissue density lesion in body of stomach, suspicious of gastric GIST. Endoscopic examination revealed sub-mucosal swelling in body of stomach. She underwent sleeve gastrectomy and final histopathologic report came as gastric schwannoma. Conclusion: In both cases the pathologic examination revealed picture of spindle cell neoplasm with S-100 strong diffuse positivity, but lacked immune reactivity to CD 117, CD 34, smooth-muscle actin and desmin. MIB index was 4-8 %, consistent with benign gastric schwannoma. Complete margin negative surgical resection, as in these cases, is the curative treatment of choice. The clinical course is generally benign. So both the patients were decided to kept under follow up.

 > Abstract: 200: Metastases of rectal adenocarcinoma to mandible: A case report Top

Praseeda Govind, A. Sajeed, Sindhu Nair, Rari Mony

Regional Cancer Centre, Thiruvananthapuram, Kerala, India, E-mail: [email protected]

Mandibular metastases is a rare entity and comprise less than 1% of oral cavity tumours. The common primary sites are lung, breast and prostate. Rectal carcinoma metastazising to the mandible is rare and occurs in very advanced stages of cancer. Such a clinical scenario is associated with high morbidity, functional impairment and significantly affects the quality of life. Treatment is aimed at pain relief and improving the quality of life. A case of diagnosed metastatic rectal adenocarcinoma with supraclavicular nodal and mandibular metastases is presented. A 58 year old male with no co-morbidities was evaluated for complaints of bleeding per rectum for past 6 months. Clinical examination demonstrated an ulceroproliferative growth in the rectum 6 cm from anal verge and a palpable mobile clinically significant left supraclavicular lymph node. Biopsy from the rectal lesion was reported as well differentiated adenocarcinoma rectum and FNAC from the neck node was proven to be metastatic. Patient underwent transverse loop colostomy in view of an imminent obstruction. Considering it to be a low volume metastatic disease, was planned for palliative radiation treatment and chemotherapy with Capecitabine. While awaiting radiation therapy, he presented with an ulceroproliferative lesion in the left lower alveolus extending into adjacent soft tissue. Biopsy from this lesion was reported as metastatic adenocarcinoma (CK 7- negative, CK20- positive). He received palliative radiation therapy to the rectal lesion and mandibular metastases, both to a dose of 30Gy in 10 fractions. However disease progressed with worsening general condition making him unfit for further chemotherapy. Mandibular metastases sparing the liver and lung is rare but possible. Clinicians need to have a high index of suspicion while dealing with patients who present with bleeding, swelling or a non healing ulcer in the oral cavity in the presence of a diagnosed primary malignancy elsewhere. Such a presentation usually correlates with poor prognosis. A proper histopathological evaluation is mandatory prior to initiating appropriate treatment for maintaining a good quality of life in such patients.

 > Abstract: 217: Carcinoma stomach with metastasis to nose Top

T. R. Ravisankar, Jayakumar Krishnannair Lalithamma, Sharath K. Krishnan

Government Medical College, Thrissur, Kerala, India, E-mail: [email protected]

Purpose and Objective(s): Carcinoma stomach with metastasis the nose is very extremely rare, with no available reported cases. This report presents the case of a patient diagnosed with carcinoma stomach post surgery presented with disseminated metastasis including the nose. Materials and Methods: 56 year old gentleman, Satheeshan , presented with abdominal pain, loss of apeptite, loss of weight for the last 1 year. He underwent OGDscopy & biopsy showing ulceroproliferative lesion in the body of stomach extending to incisura and histopathology reveals adenocarcinoma of stomach. CECT shows irregualar circumferential thickening with body of stomach with ulceration and regional lympahdenopathy. He underwent distal gastrectomy, post op HPR : moderately differentiated adenocarcinoma, intestinal type, 1 out of 4 lymph nodes shows metastasis followed by 12 cycles of chemotherapy (CAPEOX) and patient was put on follow up. 6 months later he developed swelling on the nose about 4x4 cm, growing downwards, non tender, and does not bleed on touch. FNAC from the lesion suggestive of malignant cells from adenocarcinoma. MRI Nose/PNS was done and it defines a well defined thick walled granulomatous soft tissue mass lesion arising from anterior part of right nostril (4.3x3.2x3.1 cm) with central cystic/necrotic changes. No bone erosion/destruction of nasal septum. Diagnosed to have Liver metastasis and lung metastasis on further investigations. He was subjected to wide local excision + nasolabial flap repair of nasallesion. Post op HPR came as metastasis from adenocarcinoma. Later the patient was referred to pain and palliative care unit due to poor general condition and follow-up by phone call revealed patient had expired. Conclusion: Metstasis from a distant primary, although its been rare may be encountered by every oncologist in his career. This case report may be the first reported case of ca stomach with metastasis to nose and may be an eye opener for many oncologist who are in the battle against maligancies and its metastasis.

 > Abstract: 218: Feasibility of repeat stereotactic body radiotherapy for local recurrence in a case of nonsmall cell lung cancer Top

Mahima Kharbanda, Ritesh Sharma, Anshul Bhatnagar, Irfan Bashir, Sumit Pandita, Swarnita Sahu, Akanksha Chhabra, Manish Sharma

Batra Hospital and Medical Research Centre, Delhi, India, E-mail: [email protected]

Background: SBRT offers excellent locoregional control in patients with early stage NSCLC, who are deemed medically inoperable or refuse surgery. Due to the increased therapeutic ratio of SBRT, its role is being investigated in the treatment of locoregional relapse or second primary lung malignancy in patients who have previously received thoracic radiation therapy. Case Report: The patient is a 49-year-old, normotensive, non-diabetic male, with history of 20 pack year cigarette use. He was diagnosed with NSCLC in May 2016, CECT Thorax showing a heterogenous mass lesion in right juxta hilar region with extension into right middle lobe bronchus with axillary and mediastinal lymphadenopathy. In view of locally advanced disease, he was planned for neo-adjuvant chemotherapy and received 6 cycles of Paclitaxel and Carboplatin. Post chemotherapy PET CT scan done in October 2016 showed only right middle lobe lung lesion (1.6 x 1.4 cm, SUV – 1.4 bsa) with complete resolution of mediastinal disease. Case was discussed in Tumor Board and patient was planned for SBRT (50Gy in 10 fractions) to residual lung lesion. Patient had complete metabolic response on PET-CT at 3 monthly follow up. He was on regular follow-up and completely free of disease till Feb 2019 when he again started complaining of cough with hemoptysis. PET CT scan done revealed FDG-avid lung lesion in right middle lobe (3.4 x 3.0 x 2.5 cm, SUVmax – 30.5). In view of local disease without any sign of systemic, patient was offered re-SBRT to the lung lesion. The planning CT scan and treatment delivery was performed with the patient in a head-first supine position, with arms raised above the head. Immobilization was achieved using an orfit cast and abdominal compression technique was used for respiratory motion management. Tumor motion was observed on X Ray fluoroscopy and cuff pressure was adjusted to limit the tumor motion to <8 mm. Internal target volume (ITV) of 1 cm was created around the gross tumor volume (GTV) to account for tumor motion. Planning target volume (PTV) was created by adding 3 mm margins to the ITV in all directions. A dose of 60Gy in 10 fractions was prescribed to GTV and ITV; dose of 50Gy in 10 fractions was given to PTV. Normal tissue constraints used were as per guidelines defined in TG-101 protocol and considered the patient's previous radiation treatment. Before each fraction, treatment was verified using online CBCT and X Ray Fluoroscopy was done to assess tumor motion. Results: At 2.5 months post treatment, patient had no treatment related toxicities and PET CT scan showed complete metabolic resolution of the lung lesion. Conclusion: Patients re-treated with SBRT have been reported in the literature, but the numbers are few. The previous reports suggested the feasibility and relative safety of second SBRT and our case also confirmed it. Our case suggests that recurrent tumors are not necessarily more radioresistant, and that patients still have a chance of cure when recurrence is diagnosed early.

 > Abstract: 224: Retrospective study of nonsmall cell lung carcinoma patients treated by chemo-radiotherapy at a tertiary care cancer centre Top

Mukesh Jandu, Tej Soni, Anil Gupta, Lalit Sharma

Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, E-mail: [email protected]

Purpose and Objective(s): Retrospective analysis of NSCLC patients who were treated with chemo-radiotherapy and to report clinical-pathological characteristics, survival outcomes and prognostic factors. Materials and Methods: Retrospective analysis NSCLC patients who were treated with radical chemo-radiotherapy at our centre from May 2013 to May 2018, was done for demographic and clinical data, history of smoking, histological type, prognostic factors and outcome. Patients who received neoadjuvant chemotherapy were also included. Results: Total 124 patients of NSCLC were treated by radical concurrent chemo-radiotherapy. Median age was 55 years. 78% were males and 22% were females. Smoking was most common risk factor. Eighty percent of the patients were smokers. The histological distribution was 46% Squamous Cell Carcinoma, 38% adenocarcinoma, 9% poorly differentiated carcinoma/undifferentiated carcinoma and in 7% cases histologic subclassification was not done. 52% had stage 3A disease, 39% had stage IIIB and 9% patients had stage II disease. EGFR mutation assessment test was done in 36 (29%) patients. EGFR mutation was detected in 21% of those 36 patients. 57% patients underwent neoadjuvant chemotherapy followed by concurrent chemoradiotherapy. 43% patients underwent upfront concurrent chemoradiotherapy. Most common neoadjuvant chemotherapy regimens were paclitaxel with cisplatin or carboplatin and cisplatin with etopside. After neoadjuvant chemotherapy complete response in 8% patients, stable disease in 47% patients, partial response in 26% patients, and progressive disease in 19% cases. Mean number of neoadjuvant chemotherapy cycles was 3. All patients received radiotherapy to dose of 60-66 Gy (2Gy per fraction) by 3DCRT or IMRT (with image guidance) on Varian Clinac IX linear accelerator. Weekly concurrent cisplatin chemotherapy was given in 82% patients. Mean number of concurrent chemotherapy was 4. After radiotherapy complete response in 18% cases, partial response in 42% cases, stable disease in 31% cases and progressive disease in 9% cases. Median follow up period was 12 months (range 6 months to 30 months). 9 patients were lost to follow-up after radiotherapy. Median progression-free survival was 6 months and overall survival was 13 months. Large primary tumor and N3 nodal staging were associated with poor outcome of the treatment. Conclusion: Concurrent chemoradiotherapy with or without neoadjuvant chemotherapy in NSCLC is well tolerated by our population of patients. The result of our study parallels that of the various published retrospective reviews. Our study suggests the poor prognosis, outcome and challenges in the treatment of NSCLC. Further research and development of more effective chemotherapy and radiotherapy may be the way forward in improving the outcome of patients with NSCLC.

 > Abstract: 226: Carcinoma esophagus with unusual bone metastasis: A rare presentation Top

Manraj Kang, Sonali Karnwal, Rajaparamjeet Banipal, Pardeep Garg, Romi Grover

G. G. S. M. C. H., Faridkot, Punjab, India, E-mail: [email protected]

Purpose and Objective(s): (1) To highlight the rarity of bone Metastases in carcinoma esophagus. (2) To study the location influence of primary esophageal cancer on metastasis distribution. Materials and Methods: A 72 year old Male presented with complaint of difficulty in swallowing solids from 1-2 months associated with weight loss in March 2018. Upper GI endoscopy reveals growth at 30 cm. Biopsy came out to be Squamous cell carcinoma Moderately differentiated with path No. 1209/2018 done on 23/03/2018. CECT scan revealed asymmetrical wall thickening involving mid dorsal approx. 6.5 cm length with thickness of 10 cm. After baseline investigation, patient received 56Gy/28#/6 wks to PTV and 50 Gy/28#/6 wks to PTV Nodal IMRT along with 3 weekly cisplatin 100 mg/m2 dated 12/04/2018 to19/08/2018. After that patient was on regular follow up monthly for first 3 months. Results: On regular follow up, he underwent CECT scan showing asymmetrical wall thickening -post RT changes. After 8 months, patient started complaining of swelling and pain in right lower thigh along with pus discharge. FNAC dated 24/06/2019 with patho no. C-2077/208 from right thigh came out to be positive for malignancy. MRI right thigh dated 20/06/2019 shows 22×18 mm lesion in mid thigh in intramuscular compartment sequence suggesting of neoplastic lesion. Patient currently is on salvage chemotherapy and regular follow up. Conclusion: Bone Metastasis in esophageal carcinoma is uncommon with late manifestation in the course of this disease. Esophageal sqmamous cell carcinoma had higher incidence of bone mets i.e. 8.6% as compared to Adenocarcinoma i.e. 5.6%. In advanced esophageal carcinoma , patient with bone metastases seems to have poorest overall survival. Our finding revealed the pattern of metastasis which could help clinicians to identify patient with metastasis and provide proper treatment.

Abstract: 228: Dosimetric analysis and toxicity comparision in intensity-modulated radiotherapy versus three-dimensional conformal radiotherapy for the treatment of mid and lower third oesophageal carcinoma: A randomised propective single institutional study

Luri Borah, A. K. Kalita, M. Bhattacharyya, P. P. Medhi, Shashank Bansal, Ghritashee Bora, Shasi B. Sharma, M. N. Moirangtham, G. S. Sarma, Jyotiman Nath, Moumita Paul

Department of Radiation Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India, E-mail: [email protected]

Background: Esophageal malignancy is endemic in northeastern region of India. About 30-40% of patients are not suitable for surgery due to technical, functional, or medical reasons and for these patients definitive chemoradiation is the standard of care but since esophagus is surrounded by several critical organs, higher dose cannot be delivered with conventional techniques. With the advent of newer radiation delivery techniques it is now possible to deliver higher doses to primary tumour. This study is an attempt to distinguish between dosimetric parameters and associated toxicities in patients treated with two different conformal radiation techniques (3DCRT and IMRT). Materials and Methods: 30 patients with biopsy proven esophageal cancer stage cT2-3 cN0-2 M0 , planned for concurrent chemoradiation in multidisciplinary tumor board were enrolled. All the patients received a total dose of 63Gy in 35 fractions in two phases. Two beams were used in 1st phase and 3 beams in the 2nd phase of 3DCRT plans whereas total of 7 beams were used in both the phases of IMRT plans and treatment was delivered to PTV with 6MV photons. The GTV, CTV, PTV and OARs were delineated and the homogeneity index (HI) and conformity index (CI) were calculated. Results: Significantly lower heart doses (V30, p <0.0001 and V45, p <0.0001) reported in the IMRT arm and similarly maximum spinal doses (p <0.0001) was lower in the IMRT arm. But the mean lung doses, V20 and V5 were found signifinicantly higher in IMRT arm than 3DCRT arm. No significant grade 3/4 toxicites were reported in both the arm. Three patients in the IMRT developed trachea-esophageal fistula during the treatment and were not available for assessment. Conclusion: Locally advanced unresectable esophageal cancers treated with concurrent chemoradiation, IMRT has shown better dosimetric profile. Toxicities were similar in both the arms, but higher number of patients has to be evaluated to arrive at a final conclusion.

 > Abstract: 230: Primary melanoma of small bowel: A rare case report Top

Kamal Bandhate, Subeera Khan

GMC, Nagpur, Maharashtra, India, E-mail: [email protected]

Malignant melanomas of the small bowel are usually metastases from primary cutaneous lesions. A primary melanoma of the gastrointestinal tract is very rare with reported incidence of just 3%. We present a rare case of metastatic small bowel melanoma. A 48 year old man presented with pain in abdomen and weight loss not responding to routine treatment. Simple Ultrasound done at private hospital revelead liver metastasis. So he was referred to our OPD for further management. Biopsy of liver lesions was suggestive of malignant melanoma. A thorough clinical examination failed to reveal any cutaneous or ocular lesions. Patient was processed for Contrast Enhanced CT of abdomen, which proved to be inconclusive. UGI scopy as a part of panendoscopy revealed melanotic lesions in duodenum. Biopsy from the dudoenal primary confirmed the diagnosis of Melanoma. Patient has been started on dacarbazine based Chemotherapy.

 > Abstract: 243: Preoperative versus postoperative chemoradiation in Stage III cancer rectum: A single institution experience Top

Rahul Sharma, Gagan Deep Singh, Shabab Lalit Angurana

Government Medical College, Jammu, Jammu and Kashmir, India, E-mail: [email protected]

Purpose and Objective(s): The optimal management of locally advanced rectal cancer requires a multidisciplinary strategy involving surgical resection with total mesorectal excision and combined use of radiotherapy and chemotherapy. The sequence of treatment can either be preoperative chemoradiation followed by surgery or upfront surgery followed by postoperative chemoradiation. Materials and Methods: This study compared survival outcomes of these two aforementioned approaches in 76 stage III rectal cancer patients, identified in the hospital database and treated between 2008 and 2014. Results: The median locoregional recurrence free survival in the preoperative group was 34 months whereas it was 33 months in the postoperative group (p=0.583). The median distant metastases free survival was 17 months in the preoperative group versus 38 months in the postoperative group (p=0.039). The mean survival in the whole cohort was 46.97 months with 27 deaths reported at the time of last follow up. The mean survival in the preoperative group was 35.927 months versus 51.519 months in the postoperative radiotherapy group (p=0.129). Conclusion: In our set of patients, the sequence of chemoradiation whether preoperative or postoperative does not lead to differential survival.

 > Abstract: 251: Case report: Lesion in scalp and skull: A rare presentation of hepatocellular carcinoma Top

Amol Kotalwar, Harsha Panchal, Asha Anand, Apurva Patel, Sonia Parikh

Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective: Rare case report. Background: Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver and predicted to be the sixth most commonly diagnosed cancer and the fourth leading cause of cancer death worldwide (GLOBOCON 2018). The most frequent sites of Extra hepatic metastases of HCC are regional lymph nodes (16%–40%) and lungs (34%–70%), but less commonly in the skeleton (1.6%–16%). The incidence of skull metastases from HCC is very rare (0.4%–1.6%). Materials and Methods: We reported a rare case of asymptomatic metastatic hepatocellular carcinoma (HCC) to the scalp and skull. Excision of the scalp lesion was performed and on histopathology found metastatic Adenocarcinoma, immunohistochemistry (IHC) reports were awaited. Meanwhile patient was given whole brain radiotherapy. Subsequently IHC report came, confirming metastasis from HCC. On further metastatic workup found two liver lesion, few periportal nodes with adrenal metastasis (inoperable), hence started oral Sorafenib. Results: A 49-year-old male visited the neurology department of our hospital with a painless mass in the central parietal region of the skull. The mass was found incidentally 2 month earlier by the patient himself and it had grown rapidly. He denied any head trauma or any significant medical problems except for chronic HBV related chronic liver parenchymal disease (on TENOFOVIR since 3 year). On neurological and physical examination revealed painless, firm, nonmovable mass two in number, in the midline of scalp, larger anterior lesion 7*5 cm in size in parietal region with no neurological deficits, hepatomegaly, or obvious abnormalities. His initial laboratory reports revealed Hb: 15.4 g/dL, Hct: 45.5, white blood cell count 6400, plt: 186000, prothrombin time (INR): 0.9, blood glucose: 98 mg/dL, urea: 17 mg/dL, creatinine: 1.0 mg/dL, AST: 107U/L, ALT: 44 U/L, alkaline phosphatase: 220 mg/dL, albumin: 3.9, globulin: 3.1, total bilirubin: 0.67 mg/dL. HBsAg was confirmed positive. Alpha feto protein was 16 ng/ml only. Ultrasonography of the abdomen revealed mild hepatomegaly with diffuse altered echo texture of liver. MRI brain with contrast showed large mixed intensity lesion (two in number) in midline in relation to parietal bone. The lesions were lytic in nature being hypointense on T2W/FLAIR image with intra lesional hyperintense area with iso to hypointense on T1W image. Anterior lesion was larger measuring 71x51 mm in size. Both of the lesions showed intra as well as extra cranial component. Excision of the scalp lesions was performed and histopathological examination revealed metastatic Adenocarcinoma. IHC reports were awaited Meanwhile patient was given whole brain radiotherapy. Subsequently IHC report came - AE1 +, Hepatocytes (Heppar) +, Glypican +, TTF1 - confirming metastatic HCC. On further metastatic workup CECT (abdomen) we found two liver lesion (37x45 mm, 23x22 mm), few periportal lymph nodes (13x8 mm) with large (66x48 mm) left adrenal metastasis - inoperable, hence patient started on oral Sorafenib. The patient is doing well since 2 months. Conclusion: There are only few case reports about skull and scalp metastasis from HCC. Although rare, this must be among the differential diagnosis and a diagnostic research based on these findings should be conducted. The treatment of these lesions should be individualized in order to control the symptoms, improve quality of life and survival.

 > Abstract: 253: A rare case of aggressive primary pulmonary synovial sarcoma: Case report and review of literature Top

V. S. Haritha, Rajesh Jain, Chandra Prakash

Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India, E-mail: [email protected]

Describe primary pulmonary synovial sarcoma, its rarity and aggressiveness as a malignancy in young adults with a rare presentation in elderly age group with poor prognosis and explain how its diagnosis is made by histology, immunohistochemistry and more recently by chromosomal translocation. Synovial sarcoma (SS) is a malignant mesenchymal tumour which accounts for 5- 10% of all soft tissue sarcomas mostly affecting young adults between 20 -40 yrs of age and is mostly seen in extremities. <10 % of synovial sarcomas arise from thorax and abdominal wall or intrathoracic site. Primary synovial sarcoma arising from the lung is rare, accounting for < 0.5% of all lung carcinomas. Most commonly it arises from the lung followed by pleura and mediastinum. Primary pulmonary synovial sarcoma is an extremely aggressive malignant tumour that can invade adjacent organs and give distant metastasis with overall 5- year survival rate of 30%. Histologically it is of two main types – monophasic and biphasic. IHC is a must for diagnosis following clinical examination and imaging. Here we report a rare case of an elderly male with right lung mass lesion infiltrating the visceral and mediastinal pleura. PET – computerized tomography (CT) guided biopsy was suggestive of synovial sarcoma monophasic type which was further confirmed by IHC. In IHC the cells were positive for vimentin, BCL-2, TLE-1 and CD- 99 and negative for Pan- CK , SMA, desmin, CD – 34, S-100 and TTF-1 which further confirmed the diagnosis of synovial sarcoma. Cytogenetic studies have to be done for further confirmation to look for specific translocation t(X; 18)(p11.2; q11.2) producing SS18- SSX fusion. The presentation of this malignancy in an elderly age is extremely rare. The multimodality treatment for this includes wide resection, chemotherapy and radiotherapy. New therapies targeting fusion oncogene, SS18-SSX derived peptide vaccine , epidermal growth factor receptor and vascular endothelial growth factor are the future hope is SS. Primary pulmonary synovial sarcoma is relatively chemosensitive though it is considered as a high grade tumour with a poor prognosis. Because of the advanced stage of the disease our patient was not a candidate for surgery and was taken up for chemotherapy with CYVADIC regimen followed by chemotherapy with docetaxel and gemcitabine as the disease was found progressive which again justifies its aggressive nature.

 > Abstract: 266: Epidermal growth factor receptor mutation status and site of metastatic involvement in adenocarcinoma lung – Its prevalence and prognostic implications: An institutional experience from Eastern India Top

Subhasis Mishra, Saroj Kumar Das Majumdar, Pritinanda Mishra, Dilip Kumar Parida

AIIMS, Bhubaneswar, Odisha, India, E-mail: [email protected]

Purpose and Objective(s): Carcinoma lung is the leading cause of death among all malignancies. Its prognosis depends on various factors like smoking history, histopathology, stage of presentation, distant organ involvement and molecular receptor status. Hence, we conducted a retrospective study on our experience with patients of adenocarcinoma lung to establish a clinicopathological correlation between EGFR mutation status, stage of presentation, site of metastatic involvement and its prognosis. Materials and Methods: A retrospective analysis was done from hospital files of patients with carcinoma lung presenting to our hospital from January 2015 to May 2019. Patients having histopathological diagnosis of adenocarcinoma lung with known EGFR mutation status were included in the study. Results: Out of 136 patients of lung carcinoma cases seen during this time period, 108 cases were of adenocarcinoma pathology. Among the 108 cases of adenocarcinoma lung, EGFR mutation analysis was done in 75 patients. Among them, 55 were male and 20 were female patients. Majority of the patients were in their sixth decade (29.3%) whereas 26.67% of patients were in their seventh decade during presentation. Upfront metastasis during presentation was present in 67 patients (89.33%). EGFR mutation was seen in 30 cases (40%) whereas in 45 cases (60%) it was non-mutated. Among all EGFR mutated cases, 14 cases (46.67%) had deletion of exon 19 whereas 14 cases (46.67%) had point mutation in exon 21 and 2 cases had mutation in exon 20. Similarly ALK was mutated in 6 cases, non-mutated in 65 cases (86.67%) and ALK mutation analysis was not done in 4 cases due to logistic issues. All cases of EGFR mutations received tyrosine kinase inhibitors (Erlotinib or Gefitinib) whereas non-mutated cases received chemotherapy ± radiotherapy according to the stage of presentation. The patients were followed up for a median period of 9 months (range:2-52 months). Out of 75 patients of adenocarcinoma in whom EGFR status was examined, 18 patients (24%) have lost followup, 26 patients (34.67%) have died during the course of disease/followup whereas 31 patients (41.33%) are on followup. The median overall survival (OS) was 9 months. On subgroup analysis of patients with ?12 months OS, it was found that among 26 such patients, 12 had EGFR mutations whereas 14 were nonmutated. On the other hand, 18 patients in this subgroup (69.2%) had no metastasis/metastasis to bone or intrathoracic site (pleural effusion, lung). Similarly on subgroup analysis of patients with OS ?24 months (n=11), it was found that 5 patients had EGFR mutation whereas 6 were nonmutated. Meanwhile 9 patients (81.8%) in this subgroup had no metastasis/metastasis to bone or intrathoracic site. Conclusion: Adenocarcinoma is the most common histopathological variety among lung malignancies. Though EGFR mutated patients show a favourable response, but stage of presentation and metastatic site of involvement are prognostically more significant in predicting the survival of lung malignancies. Bone and intrathoracic sites of metastasis fare better compared to metastasis to extrathoracic sites. Larger sample size and longer followup period can further validify the results.

 > Abstract: 275: Patterns of recurrence in resectable oesophageal carcinoma: Retrospective review from a tertiary cancer centre Top

Anindita Das, Balu Krishna Sasidharan, Richa Shukla, Manu Mathew, Rajesh Isiah, Subhashini John, Simon Pavamani

Department of Radiation Oncology, IDA B. Scudder Cancer Centre, Christian Medical College, Vellore, Tamil Nadu, India, E-mail: [email protected]

Background: The management of locally advanced carcinoma oesophagus has undergone a major evolution with widespread use of combined modality therapy. The accepted treatment has been greatly standardised since the long-term follow-up results of CROSS trial were published in 2015, confirming overall survival benefits for neoadjuvant chemoradiotherapy before surgery in resectable oesophageal or gastro-oesophageal junctional cancer (T1N1M0/T2-T3N0-1M0). However, the debate between elective nodal irradiation versus involved field irradiation remains open, with studies arriving at conflicting conclusions. Aim: To analyse the patterns of recurrence following neoadjuvant treatment and surgery in carcinoma oesophagus. Methodology: A retrospective review of the medical records of the patients who presented to our centre in a 5-year period (2014-18), with recurrence following sequential neoadjuvant treatment and oncological principle directed resection, was conducted in this single-institution study. The demographic details, site, extent of the disease at diagnosis, histopathology, details of neoadjuvant treatment received [chemotherapy (NACT), concurrent chemo-irradiation (NACTRT), or both], type of surgery, and post-operative histopathological staging, were recorded. The patterns of recurrence, i.e. local/anastomotic site, nodal [in-field or out of field if post-RT], or distant metastatic disease, as well as the duration of disease-free survival, were recorded and analysed. Results: 21 patients (14 men, 7 women) presented with recurrence, among whom 14, 6, and 1 patients had received NACT only, NACTRT, and both, respectively. 16, 4 and 1 patients respectively underwent McEwon's oesophagectomy, Ivor-Lewis oesophagectomy and gastro-oesophagectomy. 6 patients received adjuvant RT. Among the 13 patients who had received neoadjuvant or adjuvant RT, 6 and 3 patients had in-field and out of field nodal recurrences respectively, 1 had both out of field recurrence and distant metastasis, while 3 had distant metastasis only, at first progression. All 4 out of field recurrences were in the subgroup who received NACTRT. The distance from PTV margin to nodal recurrence was 5 cm or less for 2 patients, and more than 5 cm for 2 patients. Conclusion: Among the patients who presented with recurrence, 67% had not received neoadjuvant RT (treated in 'pre-CROSS era' or due to long-segment disease), reasserting the therapeutic superiority of NACTRT. However, 57.1% of patients who received NACTRT had out of field nodal recurrence, prompting the need for large scale, prospective studies evaluating the potential benefits of neoadjuvant elective nodal irradiation in carcinoma oesophagus.

 > Abstract: 295: A randomized prospective study comparing concurrent chemo-radiotherapy versus sequential chemo-radiotherapy in locally advanced squamous cell esophageal cancers Top

Abhishek Pratap Singh, Ramesh Arya

Mahatma Gandhi Memorial Medical College, Indore, Madhya Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): Historically definitive external beam radiotherapy (EBRT) when used alone in the treatment of unresectable locally advanced, esophageal squamous cell carcinoma (ESSC) have shown only symptomatic improvement in dysphagia, with very high locoregional failure rates and poor survival outcomes. Addition of Chemotherapy either concurrently or sequentially with radiotherapy has shown to improve outcome in such patients. So the objectives are to compare concurrent chemoradiotherapy (CCRT) and sequential chemoradiotherapy (SCRT) in unresectable ESSC and evaluate the response and toxicity assessment. Materials and Methods: Total 60 patients of unresectable ESCC stage (IIB-IIIB), coming to OPD Govt. Cancer Hospital, Indore between (May 2018 to May 2019) were randomized into two arms of 30 patients each. In CCRT arm patients received EBRT to the dose of 50 Gy/25# @2 Gy/# over 5 weeks with concurrent cisplatin (75 mg/m2) IV on day 1 and 5-FU (750 mg/m2) continuous IV infusion on days 1-4 given three weekly. While in SCRT arm patients were treated with two cycles of chemotherapy, cisplatin (75 mg/m2) IV on day 1 and 5-FU (750 mg/m2) continuous IV infusion on days 1-4 given 3 weekly followed by EBRT to the dose of 50 Gy/25# @2 Gy/# over 5 weeks. All the patients were followed weekly during treatment and monthly after completion of treatment for 1 year. For assessment of acute & late toxicities, RTOG toxicity criteria were used and RECIST Criteria v. 1.1 was used for assessment of treatment response. For Statistical analysis Chi-square test, Fisher's Exact test, & Kruskal- Wallis test were applied using SPSS v.25.0. Results: At end of follow up period, complete response was found in 21 (70%) patients vs. 10 (33%) and partial response was found in 4 (13.3%) vs. 9 (30%) patients in CCRT and SCRT arms respectively and this difference was statistically significant (p value- 0.035). For acute toxicity, grade 2 & 3 mucositis was found significantly higher in CCRT arm compared to SCRT Arm (83% vs 20%, p value < 0.001). Similarly significantly higher Grade 2 & 3 Gastrointestinal toxicity rates (70% vs 43.3%, p value - 0.037), Grade 3 & 4 Anemia (73.3% vs 30%, p value <0.001) and Grade 2 & 3 Neutropenia (93.3% vs 46.7%, p value <0.001) was found in CCRT arm compared to SCRT Arm. No statistically significant difference was found for Late renal (p value - 0.352) and lung toxicity (p value - 0.183) between two arms. Conclusion: CCRT shows better response rates than SCRT when used for the treatment of ESCC with significantly higher toxicity rates which are can be managed easily and are acceptable.

 > Abstract: 315: Long-term survival in inoperable carcinoma pancreas: A case report and review of literature Top

Karishma Sewaramani, Tejinder Kataria, Deepak Gupta

Medanta The Medicity, Gurgaon, Haryana, India, E-mail: [email protected]

Introduction: Pancreatic cancer is widely reported as a lethal and an aggressive cancer with a limited long term survival. Only about 20% of the patients with pancreatic cancer can be considered for surgical approaches at the time of presentation attributed to its late detection and metastatic nature. As new therapeutic options are being tried to improve outcomes, optimal combination of chemotherapy, radiation therapy and surgery are yet to be determined and optimized. However, the emergence of Stereotactic Body Radiation Therapy (SBRT) allowing precise delivery of high dose radiation by with image guidance and respiratory motion management has opened new avenue for treating this disease. Case History: A 52 year old male presented to our outpatient clinic in April 2012, with 2 month history of post prandial pain in abdomen, vague dull discomfort lasting from 40 minutes to a few hours. Pain was localized to upper abdomen, not associated with vomiting or hematemesis. There was a history of weight loss of 5 kg over a period of 2 months but no history of diabetes, hypertension, tuberculosis. The patient was diagnosed to have an adenocarcinoma of proximal body of Pancreas, T4N0M0 , stage III. Patient was deemed to be surgically inoperable. Patient received chemotherapy with Gemcitabine-Oxaliplatin every 3 weeks administered for 3 cycles that completed in 2012 as per NCCN guidelines. Contrast CT showed stable disease. He was further planned for concurrent chemoradiation followed by surgical evaluation. Post concurrent chemo radiotherapy there was reduction in size of mass from (4.5 x 3.0 to 2.4 x 1.7 cm). He was on maintainence therapy then. In 2017 follow up PET CT showed FDG avid nodule in left lung. Biopsy of left lung mass was done which showed a metastatic adenocarcinoma - from pancreas. He was planned for Cyberknife based Stereotactic body radiotherapy to lung lesion (45 Gy in 5 fractions). Post 6 weeks of Radiation, PET-CT was done, which showed interval reduction in metabolic activity of lesion in left lung. Contrast enhanced MRI brain was done for better evaluation and it showed 3 well marginated, peripheral enhancing lesion involving parasagittal cortex and white matter in right parietal lobe. He was then planned for Fractionated Stereotactic Radiotherapy to brain lesions. Total dose of 45Gy in 5 fractions was prescribed at 80% isodose. He completed his treatment successfully, doing well and is now on follow up.

 > Abstract: 317: Evaluation of active breath control in thoraco-abdominal tumor during stereotactic body radiation therapy treatment Top

Prapti Patel Desai, Devang Bhavsar, Malhar Patel, Maulik Bhensdadia

Care Institute of Medical Sciences, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): To evaluate setup accuracy and to present our finding of usage of Active breath control during Thoraco-abdominal tumor with SBRT Treatment. Materials and Methods: This is retrospective study including 7 patients undergoing SBRT treatment between year 2018 to 2019. Primary tumor location were in Thoracoabdominal region. Patient who were treated using Active breath control for SBRT treatment has been selected for study. Total number of fractions were 40 and we also analysed second CBCT, if positional error has exceeded, so total 51 CBCT images were analysed for all three dimension motion correction. Total treatment time has been assessed and Average breath hold time has also been calculated. Results: Average treatment time was 25 minutes with Active breath control. And Average breath hold time was 21.2+0.3 seconds. Mean intrafraction motion for patient population for vertical, lateral and longitudinal direction was 0.02, 0.1, 0.2 cm. second CBCT was taken if positional error exceeds 2 mm in any directional plane. Conclusion: Motion management and image guidance are essential to optimal delivery of Thoracic and abdominal tumor SBRT. Intrafraction tumor motion was more in longitudinal direction.

 > Abstract: 324: Ultracentral lung tumours: Flying carefully beyond the “No Fly Zone” Top

Ritika Harjani Hinduja, David Tiberi, Robert Macrae, Jack Zheng, Jason Pantarotto, Vimoj Nair, Graham Cook

P. D. Hinduja Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]

Background and Purpose: With acceptance of SBRT gradually in the “No Fly Zone”, a new class of tumours have raised concerns for being at still higher risk for toxicity- Ultracentral tumours. Most literature defines them as tumours abutting/ invading the proximal bronchial tree (Definition 1). There are few studies where they define them as tumours whose Planning Target Volume (PTV) abuts the proximal bronchial tree (Definition 2). The prospective SUNSET study also includes tumours whose PTV abuts the esophagus, pulmonary vein or artery apart from the PBT (Definition 3). In this study, we have seen the concordance rates between various definitions and have presented the outcomes of patients with ultracentral tumours treated with Stereotactic Ablative Body Radiation/Hypo-fractionated Radiation therapy in our institution. Materials and Methods: We retrospectively reviewed consecutive medically inoperable early 'central' NSCLC patients treated with SBRT in an ethics approved study. We identified the ultracentral tumours based on each of the mentioned 3 definitions and assessed for the concordance. Among ultracentral tumours, the end points of interest were Local Control (LC) and Overall Survival (OS). The outcomes were compared based on Performance Status (PS), age adjusted Charlson's Comorbidity Index (CMI), Tumour size (T ), histology, dose/fractionation, SUVmax and Biological Effective Dose (BED). Results: We identified 92 individuals with central lung tumours in our institution. Of these, 38 were classified as Ultracentral by at least one definition. All (38) tumours fitted the definition as per SUNSET protocol. 22 of 38 (57.9%) were ultracentral based on definition 1 whereas 32 of 38 (84.2%) were ultracentral based on definition 2. The median age was 75.5 years (57-89 yrs). 42.1% were males. The median age adjusted comorbidity index was 5.5 (2-11). 92.1% were current/former smokers. 9, 13, 15 and 1 patients had ECOG 0, 1, 2 and 3 respectively. 18 (47.4%) were squamous cell carcinomas, 16 (42.1%) were adenocarcinomas and remaining 4 included large cell and NSCLC-NOS. All patients were PET staged and the median SUVmax was 11.1. The most common dose schedule was 60Gy in 8 fractions (52.6%). The dose ranged from 50-60Gy in 3-25 fractions. The median BED was 105Gy. The median Overall survival was 37 months. The local control, regional control and distant control at 30 months was 80%, 88% and 72% respectively. When stratified by Performance status, PS0-1 had median survival of 50 months as compared to 21 months for PS 2-3 (p-0.03; Log rank test). Similarly, CMI </=5 was associated with better survival (median OS 47 vs 21 months (p-0.04; Log rank test). There was no statistical difference in the overall survival when stratified by T stage, histology, dose/fractionation, SUVmax and Biological Effective Dose (BED). 1 patient died of bronchial bleeding which was attributed to the radiation treatment. Conclusion: SBRT for ultracentrally located tumours is feasible with outcomes comparable to published literature. Individuals with better performance status and low Charlson Comorbidity index have a better survival.

 > Abstract: 339: Case report: Mucinous adenocarcinoma of peri-anal region treated with preoperative radiation-chemotherapy Top

Malhar Patel, Natoo Patel, Maulik Bhensdadia, Prapti Patel Desai, Chirag Desai, Devang Bhavsar

Care Institute of Medical Sciences, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): To report a rare case - mucinous adenocarcinoma of peri-anal region. Materials and Methods: Mucinous adenocarcinoma of the perianal region is an oncologic rarity posing a therapeutic dilemma for oncologists due to very few reported cases without definite therapeutic guidelines. It accounts for 2% of all gastrointestinal malignancies. We hereby report a rare and interesting case of perianal mucinous adenocarcinoma in a 58-year-old male investigated for discharging growth in perianal region, painful defecation associated with blood mixed loose stools of 3 months duration. Initially he was treated with repeated haemorrhoidectomy. He opted alternative medicines for 1 year. Recently he presented with aggravated symptoms of painful defecation, discharging growth protruding from anal verge and fresh blood in stool. Biopsy from the ulcer revealed mucinous adenocarcinoma. Contrast enhanced computed tomography (CT) scan, Magnetic Resonance Imaging (MRI) and whole body positron emission tomography (PET) scan showed a localized perianal growth. Without pre-set treatment protocol for this rare entity, case was discussed in multi-disciplinary manner including radiation oncologist, surgical oncologist and medical oncologist. After detailed review of literature decision was made in favour of pre-operative radiation therapy with concurrent chemotherapy followed by abdominoperineal resection (APR) and adjuvant chemotherapy. Presently he has received pre-operative radiation with concurrent chemotherapy followed by APR. He is due to adjuvant chemotherapy. Results: Patient has tolerated pre-operative radiation therapy with concurrent chemotherapy well. The final histopathology report of APR reported no evidence of viable tumour cells. No serosal involvement. Tumour perforation was absent. Treatment induced tumour necrosis noted in submucosa, muscularis propria and pericolic fat. All cut margins were free of tumour. All 21 regional nodes were free of tumour. No Lymphovascular invasion and perineural invasion. Conclusion: This single case report of mucinous adenocarcinoma of peri-anal region shows encouraging complete pathologic response with pre-operative concurrent radiation-chemotherapy on APR histopathology report. It can be recommended as an alternative to upfront surgery as the standard treatment guideline. However, more prospective data is required to establish the definite therapeutic guideline.

 > Abstract: 343: Prospective evaluation fiducial migration after placement for liver stereotactic body radiotherapy and influence on treatment delivery Top

Ajay Sasidharan, Kaushik Kataki, G. Shibu, Rajesh Kannan, Ram Madhavan, Tushar Tarani, Debnarayan Dutta

Amrita Institute of Medical Sciences, Kochi, Kerala, India, E-mail: [email protected]

Purpose and Objective(s): Fiducial placement in liver tumours (HCC) for Robotic Radiosurgery (CK) treatment is critical. There is a possibility of migration and related issues. Present study evaluating the impact of fiducial migration after simulation and during treatment. Materials and Methods: Between Mar 2017-Mar 2018, 53 HCCs accrued in the ethical & scientific committee approved prospective study for CK treatment. Three fiducials were place in liver (CT/USG guided) for tracking. Fiducials placed by radiologist with 'ideal' fiducials will be equidistance from each other (max distance 5 cm, min distance 2 cm). CT scan imaging was done at immediate post-placement (D0), at Day-3 and Day-8 to evaluate migration. During treatment (Day-4-8) intra-fraction imaging done to track the fiducials position. Results: Fifty three patients (Male 92%, mean age 60.2 yrs, ECOG 0-1 92%, Child-Pugh A 89%, B&C 11%, majority in seg II & VI, PVT disease 64%) with HCCs underwent fiducial placement under guidance (CT scan 69%). Among 159 fiducial placement, six (3.4%)[lung 2, spleen 1, Heart 1, abd 2] had displacement outside liver at immediate post-fiducial period (Day-0). Day-0 CT scan, min and max inter-fudicial distance, min & max distance from tumour, max & min inter-fiducial angle are 2.66 (0.819) & 4.8 (1.08) mm; 2.1 (0.7) & 5.12 (1.25) mm; 28.5 (11.8) & 83 (25.25) degree respectively. Maximum and minimum fiducial migration on Day 3 was 0.85 (0.22) and 028 (1.04) mm. Tracking range, co-linearity, tracking uncertainty on Day 1-5 of treatment was 5.07, 4.5, 4.9, 5.1, 5.1; 27.02, 25.9, 27.2, 27.6, 27.8; 40.9, 44.3, 47.3, 49.7, 47.06 respectively. Maximum migration during treatment (Day 1-5) was 0.29, 0.27, 0.27, 0.28, 0.31 respectively. Total migration after treatment (Day 8) from day 0 was 2.35 (0.271) mm. Conclusion: Displacement of fiducials occur at immediate post-fiducial period. There is no significant change in fiducial positions at Day-3 and Day 8 from baseline (D-0). Liver SBRT treatment after fiducial placement may be started immediate post-fiducial placement (Day 1). No additional advantage of waiting for 3 days or more for fiducial stabilization.

 > Abstract: 352: Intraluminal brachytherapy boost following concurrent chemoradiation in patients of inoperable carcinoma oesophagus; an institutional experience Top

P. V. Arunmohan, M. G. Janaki, Kirthi Koushik, T. R. Arulponni, Ram C. Alva, Mohan Kumar

Ramaiah Medical College Hospital, Bengaluru, Karnataka, India, E-mail: [email protected]

Introduction: The incidence of oesophageal cancer in india is 4.99%, according to Globocan 2018. The incidence increases with age, reaching a peak in 6th -7th decade. It's an aggressive malignancy with high degree of loco-regional and distant recurrence. Definitive chemoradiation therapy has been demonstrated as a curative approach for patients with squamous cell carcinoma (SCC). Keeping the patients in regular follow up of every 3 months and to consider for salvage resection if recurs. Intraluminal brachytherapy boost following chemoradiation seems to be a better option. ILBT can increase the tumour dose with sparing of normal structures because of high dose fall off according to inverse square law and there by improves the therapeutic ratio. Objectives: To assess the response of intraluminal brachytherapy in carcinoma oesophagus. To analyse the tolerance of ILBT in carcinoma of oesophagus. Materials and Methods: From 2014 to 2018, fourteen histologically diagnosed inoperable oesophageal cancer patients whom treated with concurrent chemoradiation followed by intraluminal brachytherapy were included. All lesions were located in the thoracic oesophagus, less than 10 cm in size with no metastasis. They were planned for radical chemoradiation 50.4 Gy in 28 fractions using 3DCRT technique along with cisplatin and 5 FU 3 cycles in every 28 days followed by intraluminal brachytherapy boost. The dose of brachytherapy was 2 fractions of 6 Gy delivered 1 week apart. Intraluminal brachytherapy was carried out after endoscopic guided ryles tube insertion in twelve patients and plastic bougie insertion in 1 patient. ILBT was delivered using high dose rate cobalt BE BIG system. The gap between chemoradiation and brachytherapy was noted. Based on the post brachytherapy endoscopy report their response was also documented. The outcome was analysed till the date of analysis. Results: Total number of patients accrued was 14. Eight female and six male. Median age was 56 years (45-66 years). 13 patients were squamous cell carcinoma and one patient was adenocarcinoma. Median length of tumour was 5.2 cm (Range 2.9 cm to 8.6 cm). 7 patients (50%) patients had complete response, 4 patients (28.57%) had partial response and 3 patients (21.42%) had progressive disease at the follow up endoscopy at 3 months. Two patients developed metastasis in the liver during the last follow up. None of the patients developed grade 3 or more toxicity. Three patients had progression of disease with worsening of difficulty in swallowing. Two patients developed stricture which was relieved by dilatation. 9 patients (64.28%) were alive at the time of analysis. Two patients died of aspiration pneumonia and two patients died after developing metastasis and one patient cause of death was unknown. Conclusion: Intraluminal brachytherapy can deliver higher tumoricidal dose with better therapeutic ratio with minimum toxicity. However larger number of patients and longer follow up are required to further substantiate this.

 > Abstract: 389: Comparison of different methods of internal target volume delineation in hepatocellular carcinomas on synchronized four-dimensional computed tomography contrast scans Top

Rishabh Kumar, Anil Gupta, Hanuman Yadav

Institute of Liver and Biliary Sciences, New Delhi, India, E-mail: [email protected]

Purpose and Objective(s): Four-dimensional computed tomography (4D CT) is the most accurate approaches to estimate and determine ITV for tumors with respiratory motion. ITV should be delineated by manually contouring GTV in all 10 breath phases of a 4D scan image sets to form ITV, this is a time-consuming and labor-intensive task. To reduce time in delineation and to minimize errors we evaluated the accuracy of various methods of ITV generation and compared it with all phase GTV (gold standard). Materials and Methods: 4D CT with synchronized IV contrast data were acquired from 20 hepatocellular carcinoma patients. ate arterial and a delayed 4DCT was taken and target delineation was done. We used seven approaches to determine ITVs: (1). ITVAllPhases: contouring gross tumor volume (GTV) on each of 10 respiratory phases of 4D CT data set and combining these GTVs; (2). ITV2phase: contouring GTV on CT of the peak inhale phase (0% phase) and the peak exhale phase (50%) and then combining the two; (3). ITVMIP: contouring GTV on MIP with modifications based on physician's visual verification of contours in each respiratory phase; (4). ITVMinIP: contouring GTV on MinIP with modification by the physician; (5). ITV2M: combining ITVMIP and ITVMinIP. (6) ITV AVG- Created by contouring on the Avg 4D scan. (7) ITV 3M- made by combning MIP, MiNIP and AVG phase contours. ITVAllPhases was taken as the reference ITV, and the metrics used for comparison were: Dice similarity coefficient and under- and over-estimated volume. Results: 4D CT images were successfully acquired from 20 patients and tumor margins were clearly contoured. After comparisons of metrics, the highest similarity of contours was found for ITV2phase followed by ITV3M, ITV2M, ITV MIP, ITV AVG, and the least similar was for ITV MiNIP (0.87, 0.6, 0.84, 0.76, 0.72 and 0.67 respectively). Motion management was not used in these cases and the average liver motion for all cases was 1.3 cm +/- 0.2. Conclusion: Various combinations of ITV generation had modest similarity when compared to the gold standard All phase GTV in patients with an average respiratory motion of 1.3 cm. GTV MIP or MINIP alone should not be used for delineating ITV in HCC patients when a synchronized contrast-enhanced scan is used. For the most accurate delineation of the ITV, all phases should be contoured to ensure the least systematic error.

 > Abstract: 390: Does inadvertent splenic radiation during SBRT in hepatocellular carcinoma patients result in lymphocytopenia? Top

Rishabh Kumar, Shipra Gupta, Hanuman Yadav

Institute of Liver and Biliary Sciences, New Delhi, India, E-mail: [email protected]

Purpose or Objective: Various studies have shown that radiation in hepatocellular carcinoma patients causes lymphocytopenia. The decline of peripheral blood lymphocytes induced by radiation might lessen the antitumor effect of Stereotactic Body Raadiotherapy (SBRT) due to reduced the immune response in cases of HCC who are treated with SBRT. We aim to investigate the correlation between the decline of peripheral blood lymphocyte and spleen irradiation dose in patients with HCC SBRT. Materials and Methods: 30 patients with HCC who had received SBRT from 2018 to 2019 were included in this retrospective study. Min ALC (minimum value of absolute counts for peripheral blood lymphocyte) was collected from the routine workup for each patient before and weekly during RT and also at one and 3 months. Spleen dose-volume variables including mean spleen dose (MSD) and Vn Gy (Vn, the percentage of organ volume receiving ? n Gy) were calculated from Monaco Treatment Planning system. Potential associations between dosimetric variables and Min ALC were assessed by regression analysis. Results: There was a consistent rise in the first week of SBRT followed by a fall for White blood cells, neutrophils and monocytes during RT (all P < 0.001). The lymphocytes decreased from the first week of SBRT. Min ALC were correlated with spleen dosimetric parameters. Min ALC were correlated with MSD (P = 0.005), spleen, V2, V5, V10, V15, and V20Gy. Out of this V5Gy, V10Gy (P = 0.001), spleen V15Gy (P = 0.026) and spleen V20Gy (P = 0.018) were found to be statistically significant and co-related with the fall of Lymphocyte count. Mean dose to the spleen >5Gy also correlated with Min ALC p value = .04. Controlling patients karnofsky performance status, gender, age, Child-grades, steroid use, and total dose, multivariate linear regression model showed that only spleen V5Gy correlated with the decline of Min ALC (HR= 1.42, P = 0.006). Conclusion: Higher spleen irradiation dose were significantly correlated with lower Min ALC during SBRT for HCC. Maximum sparing for spleen irradiation during RT is recommended to preserve peripheral blood lymphocytes, which may potentially cause immunosuppression and result in reduced tumor response.

 > Abstract: 392: Correlation of sarcopenia with pathological response rates in locally advanced rectal carcinoma patients undergoing neoadjuvant chemo-radiation followed by surgery Top

Sampuran Acharya, M. G. Janaki, Kirthi Koushik, T. R. Arul Ponni, Ram C. Alva, S. Mohan Kumar

M. S. Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): The standard of care in locally advanced rectal carcinoma involves neo adjuvant chemo-radiation followed by resection. Enteritis, nausea, vomiting, leading to dyselectrolytemias and dehydration contribute to the cachexic state of the patient. Enteritis occurs in 20% to 49% of patients receiving pelvic radiotherapy. Cancer cachexia is characterized by muscle wasting which can be seen even in absence of weight loss and even in overweight and obese patients. This may be associated with poor tolerability to treatment. Hence, assessment of the cachexic state of the patient on a pretreatment CT scan can help predict the tolerability of the cancer therapy where low muscle attenuation reflects the state of cachexia. This study aims to find an association with the change in SMI to the pathological response rates. Materials and Methods: Histopathologically proven cases of carcinoma rectum after detailed history taking, physical examination underwent routine baseline investigations followed by CT simulation scan. The following muscles were determined and analysed on a single axial cross-sectional CT image at the L3 level as estimation from this cross-sectional area.: rectus abdominus, abdominal (lateral and oblique), psoas, and paraspinal (quadratus lumborum, erector spinae) in the abdominal window of the viewer application. Total cross sectional muscle area (cm2) was measured. The muscle area was normalized for height (meters squared; m2) and reported as lumbar skeletal muscle index (SMI) (cm2/m2). Following planning patients would be treated with external beam radiotherapy to a dose of 45Gy in 25 fractions with concurrent chemotherapy. 4-6 weeks post EBRT the patients would be undergoing curative resection before which they will undergo a CT scan and there again the SMI would be calculated as before. The difference would be noted among the pre and post EBRT SMI and correlated with post-operative histopathology reports. Results: Fourteen patients were included which included 10 males and 4 females. The mean SMI in the pre EBRT group was 55.97 cm2/m2 and the mean SMI in the post EBRT group was 51.96 cm2/m2. One patient (7%) showed complete pathological response, 3 patients (21.4%) showed near total pathologic response (with less than 20% of residual tumour) 7 patients (50%) had partial response and 3 patients (21.4%) had stable disease. There was a significant correlation found between the percentage change in SMI with the amount of residual tumour in this group of patients using the one way ANOVA test with a p value of 0.022 suggesting higher the loss of SMI, more chances of the patient having a residual tumour at the end of neoadjuvant chemo-radiation. Conclusion: Patients who develop greater sarcopenia with preoperative chemo-radiation are likely to have poorer response.

 > Abstract: 393: Delay in diagnosis and treatment in patients of lung cancer at a tertiary cancer centre Top

Sankalp Singh, Nishant Lohia

Command Hospital, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): Majority of lung cancers in our country are diagnosed at an advanced stage where treatment options and probability of cure is limited. The reasons behind the delayed presentation are manifold and include patient related delays like ignorance of symptoms, reluctance to seek medical help and doctor related delays like delay in investigations and misdiagnosis as inflammatory and infectious pulmonary diseases. Materials and Methods: All patients diagnosed with lung cancer between June 2018 and May 2019 at our centre were included. Through a questionnaire based system, time between onset of symptoms, first report to medical setup, histopathological diagnosis and start of treatment were calculated. Association of delay was evaluated against stage of disease, rural-vs urban place of residence, age and gender. Results: The average time to diagnosis from onset of symptoms was 148 days while the average time to start treatment from histopathological diagnosis was 166 days. There was no relation of age, gender or place of residence with delay in diagnosis but advanced stages of diseases were diagnosed earlier than early stages. Conclusion: Early detection and treatment is paramount towards the successful treatment of lung cancer. The time to diagnosis and treatment in our study population is extremely long and is likely to negatively affect survival outcome of our patients. Measures such as increasing health awareness among common population and sensitizing primary healthcare providers towards importance of early diagnosis of lung cancer can help improve the situation tremendusly.

 > Abstract: 398: Compliance to radiation in upper gastrointestinal malignancy in intensity-modulated radiation therapy era Top

Sneha Ujjayani

M. S. Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): To assess toxicity and patient compliance to IMRT in GI malignancies. Materials and Methods: Ten histologically diagnosed cases of GI malignancies consisting of pancreas, stomach, liver and gall bladder treated with IMRT technique between Dec 2017 and Sep 2019 were included. Patients received RT either in adjuvant /neoadjuvant setting along with concurrent chemotherapy to a dose of 45-60Gy in 25-30 fractions. All were treated with IMRT technique. PTV coverage , OAR doses were recorded. Image verification was done for all patients with CBCT first three days and then weekly. Patients were assessed weekly for toxicity. At treatment completion OTT was recorded. Results: Mean age of the patient was 60.2 yrs. Six were male and 4 female. Two patients were diagnosed as carcinoma stomach, two as carcinoma liver and gall bladder and the rest of cases were of carcinoma pancreas. PTV coverage was between 95%-99.5% (mean-96.85%). Two of 10 cases had liver doses slightly higher than constraint as PTV was in close proximity. Two patients had rotational error on the first day of treatment. Subsequent days were within the prescribed CTV to PTV margin. 7 patients reported grade II nausea and vomiting. Grade II diarrhoea was reported by 3. None of the patients had >10% weight loss. All patients completed the treatment in time. Mean Overall treatment time was 38 days among all subsets. Conclusion: Chemo-radiation to upper abdomen is precise and safe with image guidance.

 > Abstract: 409: Predictive factors and survival outcomes with stereotactic body radiation therapy in treatment of oligometastases in colorectal cancer Top

Vibhay Pareek

NCI, AIIMS, New Delhi, India, E-mail: [email protected]

Purpose and Objective(s): Colorectal cancer (CRC) presents among leading causes of death and oligometastases presents a dilemma in treatment options. If treated, CRC with oligometastases can present improved survival. Our study aims to evaluate predictive factors associated with survival when treated with stereotactic body radiation therapy (SBRT). Materials and Methods: A total of 125 metastases in 50 patients were treated with SBRT. Oligometastases was defined as up to 5 lesions in lung in proven primary histopathology of CRC. Survival outcomes in terms of local control (LC), progression free survival (PFS), and overall survival (OS) were assessed along with association of various predictive factors associated with survival outcomes. Results: Among the 50 patients, Lung was the most common site of metastases (52.5%), followed by liver (34%). Thirty patients had received prior systemic therapy in form of chemotherapy. Median follow-up time was 24?months (6-84 months). The LC rates at 1, 3 and 5 years were 96%, 72% and 69%, respectively. The first site of failure was local only in 20%, distant only in 34%, and local and distant in 16% of the patients. Median PFS was 9.8?months. The overall survival at 1, 3 and 5 years was 87.2%, 62.3%, and 41.4%, respectively. On assessment of predictive factors, metastases more than 3 cm (p?=0.012), presence of non-lung metastases (p<0.001) and progression of treated metastases (p?=?0.021) predicted for worse overall survival. Multiple lung metastases and synchronous oligometastatic disease were significantly associated with worse PFS and worse metastases-free survival. On toxicity assessment, no Grade 3 toxicities were found in the cohort. Conclusion: Stereotactic body radiation therapy presents longer survival in oligometastases in CRC and is a proven treatment modality. Treatment and control of oligometastases predicts for improved overall survival. Further prospective cohorts would better evaluate effective fractionation for patients with oligometastatic CRC.

 > Abstract: 411: Assessment of role of intraluminal brachytherapy as a palliative treatment in advanced esophageal cancer Top

Vibhay Pareek, Rajendra Bhalavat, Manish Chandra

NCI, AIIMS, New Delhi, India, E-mail: [email protected]

Purpose and Objective(s): This study aims to assess the improvement in dysphagia, associated complications and overall and disease free survival with intraluminal brachytherapy (ILRT) as palliative care in advanced esophageal cancer. Materials and Methods: Thirty-four patients were treated with high dose rate ILRT with or without external radiation therapy from 2009 to 2017 at our institute. Patients were assessed for various parameters including disease stage, length of lesion, KPS and as per grade of dysphagia at presentation. The patients received median dose of 6Gy at 1 cm off axis for 2 fractions one week apart. Fourteen patients were treated radically and 20 patients post EBRT. Multivariate analysis was used to assess the predictors for dysphagia improvement. Remissions of dysphagia and other clinical and radiological factors were assessed in the first month post-treatment, and then in the third, sixth, and twelfth months. The survival rate was compared with some chosen clinical factors using a log-rank test and the Kaplan-Meier method. Results: Patients were followed up as per standard institute protocol. Median dysphagia free survival was 12 months. Stricture was seen in 3 patients and ulceration noted in another 2 patients. However, no tracheoesophageal fistula or procedure related complications were noted. Complications were seen with the post EBRT group. The overall survival in the cohort was 12 months and was better post EBRT as compared to radical ILRT (p <0.001). On multivariate analysis, stage of disease (p=0.02), size of lesion (p=0.018) and grade of dysphagia (p=0.023) were found to be predictors for improved outcomes with use of ILRT in palliation. Conclusion: Brachytherapy in the form of ILRT in advanced esophageal cancer provides good palliation with minimal complications and improved survival and quality of life to patients.

 > Abstract: 413: Stereotactic body radiation therapyfor nonsmall cell lung cancer: An analysis on fractionation schedules, dosimetric parameters and clinical outcomes Top

Vinodh Kumar Selvaraj, Deleep Kumar Gudipudi, A. Krishnam Raju

Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India, E-mail: [email protected]

Purpose and Objective(s): Stereotactic Body Radiation Therapy delivers highly precise and effective treatment in node negative, medically inoperable early stage (I/II), recurrent and metastatic NSCLC. Based tumor size, location and patient's performance status, a wide range of dose-fractionation schedules are used. To compare and analyse different fractionation schedules, dosimetric parameters and clinical outcomes in NSCLC patients treated with SBRT. Materials and Methods: Clinical records, radiotherapy treatment plans and charts of ten histologically proven NSCLC patients, who received SBRT to lung in our department from October 2017 to January 2019 were reviewed. Patients were assessed for acute and present toxicities according to CTCAE 4.0 from clinical records and telephonic survey. Radiobiologic, dosimetric and clinical parameters were calculated/recorded and analyzed using statistical methods. Results: Median age was 67.5 years (56-81). 70% were males and 30% were females. Adenocarcinoma (8) was the common histology, followed by squamous cell carcinoma (2). Out of the ten patients, there was 4 early stage (I/II), 4 metastatic (stage IV) and 2 recurrent cases. Lesions were left sided (6), right sided (3) or bilateral (1); and 80% were peripherally placed. EQD2 (alpha/beta ratio = 10) ranged between 83.33-99.17Gy. The BED8.6(oxic), BED10(standard) & BED20 (hypoxic) for 12Gy/4#(48Gy) was 114.98, 105.60 & 76.8Gy while for 7Gy/10#(70Gy) was 126.98, 119 & 94.5Gy respectively. Other fractionation schedules were 10Gy/5#(50Gy), 8Gy/7#(56Gy) and 7.5Gy/8#(60Gy). According to Nitin model, all the fractionation schedules had a 2 year estimated tumor control probability of around 90%. All patients were planned in ECLIPSE TPS based on 4D CT images. Patients were treated with either VMAT (4) or IGRT (6) technique. VMAT (1-2 arcs) provided a higher MU per arc (694-1636) and shorter treatment time, than IGRT (8-14 fields with static MLC). Median tumor size & PTV volume was 3.65 cm (1-6) and 74.95 cm3 (47.6-143.4). Mean dose to PTV, Standard deviation & Conformity index was 100.53% (98.9-104), 4% (2.5-5.3) and 0.706 (0.48-1.25) respectively. D2cm% and R50% was lower in VMAT plans compared to IMRT. Both the recurrent cases expired in 6 months, while mean DFS for stage IV cases was 12 months. Post SBRT, there was no local recurrence/progression in early stage cases. Conclusion: SBRT fractionation schedules with BED >100Gy have a 2 year projected TCP of around 90% which translates into good local control clinically with reduced morbidity. The choice of fractionation regimen is to be based on tumor location and adjacent organ at risk. Fractionated SBRT regimens with low dose per fraction to be considered for central tumors & vice-versa. The dosimetric parameters between IMRT & VMAT plans donot differ significantly; except for better dose fall-off, greater MU delivered per arc and reduced treatment time with VMAT. Therefore, larger prospective studies with longer follow up are warranted.

 > Abstract: 417: Neoadjuvant radiation therapy for retroperitoneal sarcoma Top

Sharief K. Sidhique, B. Rajkrishna, S. Patricia, S. Beulah Roopavathana, Betty Simon, Anne Jennifer Priscilla, Suchita Chase, B. Selvamani

Christian Medical College, Vellore, Tamil Nadu, India, E-mail: [email protected]

Background: The Overall survival rates for retroperitoneal sarcoma range from 50% to 60% at 5 years and the predominant pattern of failure is locoregional recurrence in the retroperitoneum. Surgical resection is the primary treatment of which extended or compartmental resection offers lower locoregional recurrence rates improving overall survival. In postoperative radiation therapy (RT) setting, the bowel falls into radiation field receiving higher doses causing poorer tolerability whereas in neoadjuvant setting the Gross tumor volume (GTV) can be precisely defined which displaces small bowel from the treatment volume resulting in less toxicity. Boosting of high risk regions (the portion of the tumor judged to be at risk for positive resection margins) can also be considered. The dose of 60 Gy in postoperative setting is higher is difficult to achieve. Purpose: (1) To assess the radiological response of retroperitoneal sarcoma to neoadjuvant RT using RECIST Criteria version 1.1. (2) To assess the pathological response of retroperitoneal sarcoma to neoadjuvant RT. (3) To assess toxicity profile while on and in the perioperative period. Methodology: The patients with non-metastatic retroperitoneal sarcoma were prospectively recruited into the study. Neoadjuvant conformal RT to a dose of 45Gy in 25 fractions followed by a boost of 5.4Gy in 3 fractions to the high risk region was delivered. We added retrospective data of 7 patients to the analysis. There was no boost of 5.4 Gy in the retrospective cohort. Surgery was after 6 to 8 weeks. The RT side effects during, after and prior to surgery were noted as per RTOG common toxicity criteria. The pathological response was noted based on the necrosis and graded accordingly. The surgical complications were recorded as per CALVIEN DINDO classification. Results: Six patients were recruited prospectively and 7 patients' retrospective data were analysed. 10 patients have undergone surgery so far. One patient died post RT due to cardiac comorbidity. One patient defaulted surgery. One patient is due for surgery. One patient clinically progressed post RTand peroperatively was found to have inoperable disease. The histology of the tumours were liposarcoma, leiomyosarcoma and poorly differentiated sarcoma. The mean tumour size was 15.7 cm (rang: 6.4 to 27 cms). The mean GTV volume was 3409cc. They were either treated with 3DCRT or IMRT/VMAT technique. While on RT, grade 3 enteritis was seen in 2 patients and one of them had severe abdominal pain requiring opioids leading to interruption of RT. Out of the nine evaluable patients, 8 had stable disease (radiologically and pathologically). Thepatient who had inoperable disease preoperatively had stable disease radiologically. Among these 10 patients, 1 had grade 3 complication requiring re-laparotomy and 3 had grade 2 complications which were managed conservatively perioperatively. Conclusion: Neoadjuvant RT for retroperitoneal sarcoma is well tolerated and also has an advantage of delivering a boost to the high risk region. The response was stable based on Radiological and Pathological assessment with acceptable surgical morbidity.

 > Abstract: 422: Correlation of sarcopenia with pathological response rates in locally advanced rectal carcinoma patients undergoing neoadjuvant chemo-radiation followed by surgery Top

Sampuran Acharya, M. G. Janaki, T. R. Arul Ponni, Kirthi Koushik, Ram Charith Alva, S. Mohan Kumar

M. S. Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Introduction: The standard of care in locally advanced rectal carcinoma involves neo adjuvant chemo-radiation followed by resection. Enteritis, nausea, vomiting, leading to dyselectrolytemias and dehydration contribute to the cachexic state of the patient. Enteritis occurs in 20% to 49% of patients receiving pelvic radiotherapy. Cancer cachexia is characterized by muscle wasting which can be seen even in absence of weight loss and even in overweight and obese patients. This may be associated with poor tolerability to treatment. Hence, assessment of the cachexic state of the patient on a pretreatment CT scan can help predict the tolerability of the cancer therapy where low muscle attenuation reflects the state of cachexia. This study aims to find an association with the change in SMI to the pathological response rates. Methodology: Histopathologically proven cases of carcinoma rectum after detailed history taking, physical examination underwent routine baseline investigations followed by CT simulation scan. The following muscles were determined and analysed on a single axial cross-sectional CT image at the L3 level as estimation from this cross-sectional area.: rectus abdominus, abdominal (lateral and oblique), psoas, and paraspinal (quadratus lumborum, erector spinae) in the abdominal window of the viewer application. Total cross sectional muscle area (cm2) was measured. The muscle area was normalized for height (meters squared; m2) and reported as lumbar skeletal muscle index (SMI) (cm2/m2). Following planning patients would be treated with external beam radiotherapy to a dose of 45Gy in 25 fractions with concurrent chemotherapy. 4-6 weeks post EBRT the patients would be undergoing curative resection before which they will undergo a CT scan and there again the SMI would be calculated as before. The difference would be noted among the pre and post EBRT SMI and correlated with post-operative histopathology reports. Result: Fourteen patients were included which included 10 males and 4 females. The median SMI in the pre EBRT group was 55.97 (IQ range 50.75 – 60.36) cm2/m2 and the median SMI in the post EBRT group was 52.05 (IQ range 45.64 – 55.98) cm2/m2. One patient (7%) showed complete pathological response, 3 patients (21.4%) showed near total pathologic response (with less than 20% of residual tumour) 7 patients (50%) had partial response and 3 patients (21.4%) had stable disease. There was a significant correlation found between the percentage change in SMI with the amount of residual tumour in this group of patients using the one way ANOVA test with a p value of 0.022 suggesting higher the loss of SMI, more chances of the patient having a residual tumour at the end of neoadjuvant chemo-radiation. Conclusion: Patients who develop greater sarcopenia with preoperative chemo-radiation are likely to have poorer response.

 > Abstract: 444: Simultaneous integrated boost in anal canal carcinoma: A retrospective study Top

Soumitra Barik, Swarupa Mitra, Inderjit Wahi, Abhinav Dewan, Sumeet Aggarwal, Kiran Dobriyal, Maithili Sharma, Himanshi Khurana

Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India, E-mail: [email protected]

Background: Concurrent chemo-radiotherapy is considered as standard of care in patients with locally advanced squamous cell anal canal carcinoma (SCACC). In Simultaneous Integrated Boost (SIB) IMRT, differential dose is delivered to tumor and elective nodal volume in same total number of fractions by dose painting. Hence, SIB IMRT with lesser overall treatment time and less treatment interruptions will be beneficial for tumor control. RTOG 0529, a phase II trial used SIB IMRT with dose 42-45Gy to elective nodal volume and 50.4-54Gy to gross tumor and nodal volume in 28-30 fractions with overall treatment time of 6 weeks. Purpose: To retrospectively analyse and compare result of SIB IMRT in squamous cell anal canal carcinoma in our institution to historical data of RTOG 0529 trial. Methodology: Total 10 patients with SCACC treated with SIB IMRT at our institute from 2018 to 2019 were included in the study. Elective Nodal PTV consisting of external iliac, Internal iliac, mesorectal, presacral, Inguinal lymph nodal area was treated with 45Gy/25#, PTV primary and gross nodal PTV volume were treated with 55Gy/25#. All patients received 2 cycles of concurrent chemotherapy with Mitomycin and 5FU. Acute and chronic adverse events noted as per RTOG criteria. Treatment break during EBRT was noted. Response to treatment was evaluated clinically and with PETCT, MRI at 3 months and 6 months post treatment. Results: Median age of patients was 61 years. All patients had squamous cell histology. T stage wise: T1-10%, T2-30%, T3-50%, T4-10%. Node positive-90% and node negative 10% of patients. Stage II-10% (1 patient), stage III-80% (8 patients), stage IV-10% (1 patient). Median dose to elective nodal PTV was 45.28Gy/25#. Median dose to primary tumor and gross nodal PTV was 54.99Gy/25#. Acute toxicities: grade 2+ haematological-70%, grade 3 GI-10% and grade 3 dermatological-70%. At 6 months follow up, 80% had complete response and 20% patients had progressive disease. There was no treatment interruption in any patients. There was no late adverse effect observed during short follow up period in our study. Compared to RTOG 0529 study, in our study majority patients were Stage III or more (90% vs 56%). There was more grade 3 acute skin toxicity in our study population (70% vs 21%). The more acute skin toxicity may be attributed to two reasons, our study population had more extensive disease requiring more area of irradiation and BED delivered in our regimen is higher compared to dose delivered in RTOG 0529 trial (67.1Gy10 vs 59.4-63.7Gy10). Though there was higher skin toxicity in our study population there was no treatment breaks, as most grade 3 skin toxicity developed towards the end of treatment during 3rd or 4th week of treatment. Treatment break was required in 49% patients in RTOG study. Early response to treatment in our study was similar to historical data. Conclusion: In our study population, SIB IMRT resulted in similar early response to treatment while acute grade 3 skin toxicity was more. There was no treatment interruption due to acute adverse events, as treatment was completed early due to short overall treatment time.

 > Abstract: 457: Neoadjuvant chemotherapy followed by definitive chemoradiation in locally advanced lung cancer: A retrospective analysis Top

Astha Parmar, Maitrik Mehta, Ankita Parikh, U. Suryanarayan Kunikullaya

Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): Neoadjuvant chemotherapy, administered prior to definitive local therapy, has been found to improve survival in patients with stage IIIA (N2) Non Small Cell Carcinoma Lung. We present a retrospective audit of outcomes of patients of locally advanced lung cancer treated with neoadjuvant chemotherapy (NACT) followed by definitive chemoradiation (CTRT). Materials and Methods: A retrospective analysis of patients who treated neoadjuvant chemotherapy (NACT) followed by definitive chemoradiation (CTRT) between June 2014 and December 2017 was done , 28 patients (median age — 51 years, range, 35 to 67 years) with locally advanced non small cell lung cancer received neoadjuvant chemotherapy (NACT) using 3 cycles paclitaxel (175 mg/m2) and carboplatin (AUC-6) 3 weekly for 3 doses. After a mean interval of 21 days (range 11–41 days), the patients then received definitive radiation and concomitant chemotherapy. Radiation dose was 60Gy in 30 fractions in 2 phases. Response to concurrent chemo-radiation and toxicity were end points. Results: At median follow up of 2.7 years 6 patients had lost to follow up , results of 22 were included in final analysis. Following NACT, 14 (63.6%) of patients had partial response (PR), stable 6 (27.7%%) and 2 patients (9%) progressed. 14 (63%) had grade II toxicity during NACT. At the time of analysis (September 2019). 8 (36.4%) had stable disease, 5 (22.7%) had progressive disease and 9 (40.9%) had succumbed to disease. Conclusion: Neoadjuvant chemotherapy with three cycles of three weekly paclitaxel and carboplatin followed by standard chemoradiotherapy CTRT is a feasible approach and is associated with a high response rate with acceptable toxicity in locally advanced Non Small Cell Lung Cancer cancer. Whether neoadjuvant chemotherapy (NACT) is associated with survival benefit needs to be seen in a large prospective randomised trial.

 > Abstract: 460: Intraluminal brachytherapy boost following external radiotherapy in esophageal cancer: A single institutional retrospective analysis Top

Heena Rathod, Maitrik Mehta, Ankita Parikh, U. Suryanarayana

Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose: Palliation of dysphagia remains a challenge in advanced esophageal cancer. In addition to external beam radiotherapy (EBRT) intraluminal brachytherapy (ILBT) has shown significant improvement indysphagia relief and symptom scores. This retrospective study analyse the dysphagia free duration and toxicity associated with addition of ILBT boost. Materials and Methods: The medical records of 27 patients with advanced esophageal cancer were screened from January 2015 to April 2018. All patients had received 30Gy in 10 fractions external radiotherapy, at 2Gy/# once a day for 5 days a week, followed by two fractions of intraluminal brachytherapy, 7.5Gy/# once a week. Patients were assessed for the symptom scores of dysphagia, odynophagia, regurgitation, and chest pain and weight was recorded monthly. Results: Median age of presentation was 53.6 years. 73.2 % were males. 6 (26.9%) patients were lost to follow up , median OS was 8.3 months, the lost to follow ups were excluded from final analysis, final analysis included 21 patients. The median dysphagia free survival was 5.3 months. Following EBRT there was a significant improvement in dysphagia scores (p = 0.002) and also at 3 months after ILBT compared to baseline (p = 0.000). Overall 11 (56.5%) had improvement in dysphagia scores and 9 (43.5)% maintained the improvement of scores till last follow up. There was significant improvement in weight 3 months after completion of ILBT (p = 0.001). Most common complication was stricture 6 (31%), followed by fistula 2 (4.3%), and bleeding 1 (2.2%). Conclusions: In carefully selected population external radiotherapy followed by ILRT is effective for palliation of dysphagia, improvement in symptom scores being evident and sustained with acceptable toxicity.

 > Abstract: 461: A rare case of metastatic cardiac angiosarcoma Top

Krishna Ratanchandani, Jyoti Poddar, Maitrik Mehta, Niketa Thakor, Sonal Patel, Pooja Nandvani Patel, Ankita Parikh, U. Suryanarayan Sir

Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Background: Primary cardiac angiosarcoma is extremely rare malignancy with incidence being 0.056%. Hence it poses diagnostic challenge and are usually diagnosed on autopsy. The overall survival is poor due to late presentation, difficulty in surgery, metastasis and resistance to chemotherapy and radiation. Purpose: The purpose of reporting this case is to illustrate its unusual clinical outcome, as this case had better overall survival. Methodology: A 35 year old female presented with complaints of giddiness and dyspnoea in July 2018. Relevant investigations eg ECG, 2D Echo, CT thorax were done which showed pericardial effusion for which pericardiocentesis was done. The patient was then asymptomatic. In January 2019, symptoms reappeared. PET-CT scan revealed 9 x 8.25 x 7.3 cm lesion in right atrium causing encasement of right coronary artery (SUV Max-5.9) suggestive of malignant etiology with lytic lesion involving body of D2 vertebra (SUV Max-5.3) suggestive of distant metastasis. She underwent wide local excision of Right atrial mass on 24th March 2019. Histopathology report showed tumor mass measuring 13 x 9 x 4 cm composed of mainly blood clot with periphery showing proliferation of small to medium sized vessels along with spindle cells suggestive of well differentiated angiosarcoma. The Immunohistochemistry panel showed CD31 +, CD34 +, vimentin + and FLI1 + which confirmed angiosarcoma. Patient didn't receive any adjuvant treatment and was on regular follow up. In May 2019, the follow-up CT scan showed 59 x 45 mm residual lesion in right atrium with left lung metastasis. Later, she developed bilateral lower limb weakness with power 3/5 on examination. MRI spine dated 14th May 2019 showed central wedging of D2 suggestive of metastasis with pathological fracture. She received palliative radiation 30Gy/10 fractions, 3Gy per fraction as 5 fractions per week from 21/5/19 to 4/6/19. On regular follow up there was gradual improvement in power of both lower limbs to 5/5. CT Thorax of 14th September 2019 showed 54 x 64 mm residual lesion in right atrium with bilateral lung metastasis. Patient is on Sorefinib plus zoledronic acid. Result: Radiation can be used as a treatment option to improve the symptoms and increase disease free survival and overall survival in patients of cardiac angiosarcoma. Conclusion: We conclude that there is no definitive management for metastatic cardiac angiosarcoma, however resection of primary tumor and palliative radiation / chemotherapy for metastasis is an option to improve overall survival of patients.

 > Abstract: 462: Short course preoperative radiotherapy in management of carcinoma rectum: A pilot study in our institute Top

Dhwani Patel, Ankita Parikh, Jyoti Poddar, Maitrik Mehta, U. Suryanarayan Kunickullaiya

Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): To evaluate the role of short course radiotherapy in carcinoma rectum and its impact on survival and recurrence patterns and complications of radiation therapy. Materials and Methods: It is a retrospective study. Total 10 patients treated during a period of 1 year from April 2018 to March 2019 were included in the study. Preoperative radiotherapy 25Gy in 5# was delivered in 1 week followed by surgery. Patients were judged to have had a curative treatment based on the absence of distant metastases and R0 surgery (ie, the histopathologic report) and complications of radiation if any. Result: Out of 10 patients, 6 patients underwent curative surgery. Out of 6 patients, 2 patients had pathological complete response. All 6 patients are disease free locally as well as systemically. One patient developed peritoneal Metastatis and refused for curative surgery. One patient developed peritoneal adhesions and died due to its complication and two patients lost to follow up. Conclusion: Preoperative radiotherapy with 25 Gy in 5 fractions 1 week before curative surgery for rectal cancer is beneficial in terms of local control. Further randomized control trials are required to prospectively validate results in terms of late complications of radiation and DFS and OS.


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