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Year : 2019  |  Volume : 15  |  Issue : 9  |  Page : 279-295


Date of Web Publication28-Nov-2019

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How to cite this article:
. Miscellaneous. J Can Res Ther 2019;15, Suppl S2:279-95

How to cite this URL:
. Miscellaneous. J Can Res Ther [serial online] 2019 [cited 2021 May 16];15:279-95. Available from: https://www.cancerjournal.net/text.asp?2019/15/9/279/271711

 > Abstract: 122: Radiation for palliation: Role of palliative radiotherapy in allevieating pain/symptoms in a prospective observational study over at two tertiary care centers Top

Ashok Kumar

Army Hospital RR Dental Centre, Delhi, India, E-mail: [email protected]

Purpose: Approximately one third patients attending the tertiary care center require palliative management. The purpose of this study was to investigate the role of palliative radiation in alleviating the pain and symptoms and improvement in quality of life (QOL). Methods: It was a prospective study aimed to evaluate patients attending two oncology centers and those who require palliative radiation. During a period of three years, 1365 patients attended radiation oncology center for various malignancies. out of these patients 304 patients were treated with palliative radiation for various indications. These patients were followed up for a period of up to 06 months for symptom relief and improved QOL. Results: 22% of patients received palliative radiation primarily for carcinoma lung, breast and prostate malignancy. Analysis revealed elderly patients in the age group of 50 – 70 being most commonly affected, most common presentation was pain, swelling and headache. Most common site of metastases was bony including spine and brain. Most commonly employed schedule of palliative radiation was 30 Gy in 10 fractions and 20 Gy in 5 fractions. Patients responded well to palliative radiation and had had improved pain relief and QOL.

 > Abstract: 131: Second new primary PNET of kidney in a treated case of carcinoma breast: Case reported at rural cancer centre, Loni, Maharashtra Top

Nanki Bakshi, Vandana Jain

Pravara Institute of Medical Sciences, Ghaziabad, Uttar Pradesh, India, E-mail: [email protected]

Background: Primitive Neuroectodermal tumor is a member of small round cell “Blue tumor” family. The overall incidence of PNET is <1%. Renal PNET was first reported in 1975, it exhibits highly aggressive behavior and less than 100 cases have been reported in literature till date. It usually affects young adults and has a male predominance of 3:1. Only 6 cases of PNET of kidney have been reported in older patients and PNET of kidney as a second new primary has rarely been reported [only three cases of renal pPNET with history of an earlier or synchronous primary cancer were reported in literature from the USA, GERMANY and CHINA ]. Case Summary: We are reporting a case of renal PNET in a 48 years old female who has been treated for right breast Cancer by surgery, adjuvant chemotherapy and radiotherapy 3 years prior to diagnosis of PNET of left kidney. Upon diagnosis patient underwent left nephrectomy. Post operatively, patient was started on EFT 2001 protocol.Patient completed induction therapy followed by radiation to tumor bed with concurrent weekly single agent Vincristine. After one cycle of maintenance chemotherapy patient developed severe pancytopenia, was admitted in the ICU, even after aggressive medical line of management, patient expired in January 2019. Conclusion: The current treatment modality for renal PNET is a combination of surgery, chemotherapy and radiotherapy. Owing to the high aggressiveness and strong tendency of recurrence and metastases, the overall prognosis of renal PNET is very poor. To the best of our knowledge, this case report is very rare.

 > Abstract: 135: Geriatric head and neck squamous carcinomas treated with modulated radiotherapy: Preliminary single institution outcome Top

Trinanjan Basu, Pradip Kendre, Nirmal Raut, Hirak Vyaas, Bhavya Patineedi, Deepika Nayek, Indu Ambulkar, Satish Rao, Basant Kamwal

HCG Cancer Centre, Mumbai, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): Geriatric head and neck squamous carcinomas (GHNC) treatment remains challenging due to multiple patient and treatment related factors. We analysed preliminary data for seventy HNC patients beyond 70 years of age treated by modulated radiotherapy (MRT). The objective was to realise the learning curve ahead. Materials and Methods: There were 100 patients (M:86, F:14) with median age of 78 years (70-96) treated by MRT at our centre. They were analysed for efficacy and acute side effects. Besides demographic and disease related parameters compliance to treatment, rate of hospitalisation, dependency of WHO ladder 3 analgesia and early clinico-radiological outcomes were analysed. Results: The median follow up was 15 months. 65% patients were locally advanced stage and 65% received radical MRT. For radical MRT the dose ranged between 66-70 Gy in 30-33 fractions and 5 patients received palliative MRT. 83% completed intended treatment with 30% had MRT interruptions. 48% patients required hospitalisation. 60% had comorbidities with 35% two or more types. 13 patients had concurrent chemotherapy and 48% had hospitalisation and 60% had feeding tubes.65% and 30% had post MRT endoscopic evaluation and imaging respectively. Among them 80% are loco-regionally controlled. 30% patients are long term (more than 3 months) tube dependent and morphine dependent. There were 5 deaths while on MRT both due to associated cardiac and pulmonary comorbidities. 40% and 65% of palliative and radical MRT patients respectively had complete response post MRT. All patients underwent psychological counselling and dietician evaluation. The median G8 screening score was 15. Conclusion: GHNC are a unique group with its own challenge. The learning curve was need of specialised setting and modern MRT for effective outcome. Non disease related concerns like alteration in daily quality of life, social engagement related issues, dementia and end of life care emerged as prominent issues beyond disease control.

 > Abstract: 139: Primary extramedullary plasmacytoma: A diagnostic challenge Top

Karthika Nageswararaj

Sri Ramakrishna Hospital, Coimbatore Tamil Nadu, India, E-mail: [email protected]

Purpose and Objective(s): Presented for the rarity of the case. Materials and Methods: Fifty four years old woman, presented with right hypochondrial pain to multiple hospitals and repeated imaging procedures like ultrasonogram and CT scan of abdomen since Dec 2017. The findings were wall thickening in body of stomach in contiguity with left liver lobe lesion and gastric lesser curvature growth or hepatic left lobe malignancy, respectively, suggesting biopsy. Patient underwent biopsy at government general hospital which was reported as Plasma cell dyscrasia and was referred to us for further management. We evaluated the patient complete myeloma work up, and PET scan, which showed uptake in liver lesion and Right Supraclavicular node. FNA of the node was negative for malignancy. Repeat biopsy was done at our centre and sent for Histopathology, Immunohistochemistry and FISH tests before confirming it as a case of Primary Hepatic Myeloma. Conclusion: Extramedullary myeloma is a rare, rather underdiagnosed entity which has poor prognosis. Liver involvement, either primarily or secondarily is extremely rare.

 > Abstract: 140: A prospective study on prognosis of patients with advanced soft tissue sarcomas treated with different chemotherapy regimens Top

Saikat Bhowal, Santanu Pal, Aloke Ghosh Dastidar, Koushik Chatterjee

IPGME and R, Kolkata, West Bengal, India, E-mail: [email protected]

Background: Soft tissue sarcomas (STSs) are a rare form of cancer which can involve various sites of the body & complete surgical resection can be difficult in advanced cases. Systemic chemotherapy is often administered & there are many regimens. However, prognostic comparision after different chemotherapy regimen administration remains controversial. Other prognostic factors associated with STSs are also unclear. Aim: To assess the prognosis of patients with advanced soft tissue sarcomas treated with different chemotherapy regimens. Materials and Methods: A prospective study with 8 patients (10- 70 years of histopathologically confirmed cases of advanced soft tissue sarcoma was conducted. Baseline characteristics, investigations of the patients & tumor were noted along with photographs. Four of them were treated with Gemcitabine 900 mg/m2 i.v D1 & D8, Docetaxel 100 mg/m2 i.v D1 & remaining four were treated with CYVADIC (cyclophosphamide 500 mg/m2, vincristine 1.5 mg/m2, Doxorubicin 50 mg/m2, Dacarbazine 750 mg/m2 all i.v D1) for a total of 6 cycles. Overall survival (OS), overall response rate, time to treatment failure (TTF) were evaluated using Kaplan Meyer curve & potential prognostic factors evaluated using multivariate cox regression analysis in SPSS software. The median follow up time was 6 months.


  • Histopathologically, 3 patients were diagnosed with rhabdomyosarcoma, spindle cell sarcoma (2 patients), pleomorphic sarcoma (2 patients ) & liposarcoma (1 patient).
  • The median OS was 16.2 months, median TTF was 5.4 months, overall response rate was 26% & 43% patients had PD.
  • Patients receiving chemotherapy with CYVADIC showed better TTF, OS & response than patients receiving Gemcitabine & Docetaxel (p=0.032).
  • Low NLR (<3.0, p=0.016), good PS (p=0.003), no bulky mass (?5 cm, p=0.02), less number of organs involved (?2, p=0.01) were favourable prognostic factors.


  • Patients receiving CYVADIC show better prognosis than patients receiving Gemcitabine & Docetaxel.
  • Good PS, low NLR, no bulky mass, less number of organs involved are independent favourable prognostic factors.

 > Abstract: 143: Prevalence of Vitamin D deficiency in cancer patients and the need for routine screening and supplementation of Vitamin D in cancer patients Top

Ravishankar Bellala

Omega Hospital, Visakhapatnam, Andhra Pradesh, India, E-mail: [email protected]

Background: The prevalence of Vitamin D deficiency in the general population in India ranges from 60%-90% depending on the dietary habits, occupation, and cultural practices. Deficiency of Vitamin D has been associated with an increased risk of colon cancer, breast cancer, prostate cancer, and ovarian cancer. The anti-cancer effects of Vitamin D have been attributed to its anti proliferative, anti-inflammatory and anti angiogenic actions. The aim of this study is to observe the magnitude of Vitamin D deficiency in cancer patients and stress the importance of routine screening and supplementation of vitamin D. Materials and Methods: Methods A consecutive observational case series study was conducted at Queen's NRI hospital, Visakhapatnam from September 2018 to November 2018. Blood samples of 57 patients attending to our OP comprising of newly diagnosed, on radiation treatment, on chemotherapy and on follow up were collected. Serum total Vitamin D was estimated using electrochemiluminescence (ECL) method on Cobas E411 autoanalyzer. They were categorized into 1) deficient (vitamin D 20 ng/ mL), 2) insufficient (vitamin D between 20-29 ng/ mL), 3) sufficient (vitamin D 30-100 ng/mL) and 4) toxicity and analyzed statistically. Results: Of the 57 patients included in the study, 7 (12.3%) were having sufficient level, 8 (14.0%) insufficient, 42 (73.7%) deficiency of vitamin D. Of the 57 patients included in the study, 14 are Breast cancer patients, 10 are cervical cancer patients, 7 are colon cancer patients and the rest comprised of cancers of other sites. Conclusion: Assessment of Vitamin D is essential and it is very prudent to estimate in all patients. In our study the incidence of deficiency is seen in 73.7% patients irrespective of the site.

 > Abstract: 158: Malignant melanoma with metastases to the bone marrow: A case report Top

Vineeth Mathew John, K. L. Jayakumar, M. B. Jayaraman

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

Purpose and Objective(s): Malignant melanoma arises from the malignant transformation of the melanocyte. Although melanoma represents less than 5% of skin cancer cases diagnosed, it is responsible for 70% of mortality attributable to skin cancer in the United States. Metastases from melanoma is to the adjacent skin & draining lymph nodes initially; after which it extends to the distant sites of which lung is the most common. Metastases to the bone marrow are rare; occurring in about 5% of cases. Review of available literature yielded reports of about 45 cases of bone marrow metastases from malignant melanoma. Bone marrow involvement by Melanoma carries a dismal prognosis unless aggressive therapy is instituted at the earliest. Melanoma was mostly found in the Western Hemisphere, with fewer Indians being affected. There has been an increase in the incidence of Melanoma in recent years in India. This report presents the case of a patient diagnosed with Malignant melanoma, who was found to have bone marrow metastasis on evaluation. Materials and Methods: 68-year old lady, D, presented with a small, painless black swelling on the dorsal aspect of left foot which was increasing in size progressively for 3 years. She underwent excision biopsy at a hospital close to her home. Histopathological examination and Immunohistochemistry suggested Malignant Melanoma (Clark level V, Tumor cells positive for S100, Melan A, HMB45 and negative for CK, SMA). She was referred to our hospital for further management. Examination revealed a well healed scar at the site of biopsy on dorsum of left foot close to great toe. No tumor in transit or inguinal nodes. CECT Abdomen & Thorax showed multiple lesions in the liver and the lung suggestive of metastases. Blood evaluation showed bicytopenia (Hb-5.7 g/dL, Platelets-58,000/μL), which could not be corrected with repeated transfusion of blood products. Repeat evaluation after two weeks showed pancytopenia (Hb-7.2 g/dL, TC-3700/μL, Platelets-32000/μL). Hence, Bone Marrow Trephine study was done & it showed infiltration from Malignant Melanoma. Palliative chemotherapy was planned for; but patient refused treatment.Follow-up by phone call revealed patient had expired within a week after discharge from the institution. Conclusion: With change in epidemiological trends, Indian Oncologists are bound to encounter cases of Malignant Melanoma more often. It is imperative that we be aware of the rarer manifestations of the disease so as to prognosticate and counter them effectively; as our eyes will not see what our minds do not know.

 > Abstract: 163: A retrospective analysis of epidemiological pattern of non-Hodgkin's lymphoma in a tertiary care center of Eastern India Top

Arundhati Mondal, Biswamit Bhattacharya, Premnath Dutta

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

Purpose and Objective(s): Non-Hodgkin's Lymphomas (NHL) is diverse in its presentation, morphology, histology, and immunophenotyping. Indian data is lacking regarding epidemiologic pattern of disease.The aim of this study is to analyze the clinicopathological features and assess treatment modalities utilized and their outcomes in patients with NHL and also the outcome with involved field radiotherapy (IFRT). This is a retrospective observational study from prerecorded hospital data. Materials and Methods: Cases of primary extranodal NHL attending the radiotherapy outpatient department of our institute during the last 2 years (July 2017-June 2019) were taken for this study. Hospital recorded data were taken and analyzed regarding the demography, clinical features, histopathological features, and treatment modalities and their outcomes. Results: Total 106 patients were identified with mean age of 47.6 years (Range: 14-78 yrs). There was a definite male preponderance (Male:Female ratio being 2.8:1). Most common histopathological sub-type was Diffuse large B cell lymphoma (54.7%). 45.3% patients had extranodal involvement with stomach, nasopharynx, and testis being the most commonly encountered extranodal sites in our series. Most common stage at presentation was stage II (49.05%). 67.9% patients were CD20 positive, thus were candidates for Rituximab. Almost all patients (102 out of 106, 96.22%) received chemotherapy while only 15% patients received involved field radiotherapy. Conclusion: Immunohistochemistry is essential in all cases to identify the subset which would respond excellently to rituximab (CD20 positive). Role of IFRT is shrinking in the management of NHL due to advent of better options of systemic therapy and now considered only in patients having residual disease following systemic therapy.

 > Abstract: 179: Incidence, clinical features, pathology, treatment, toxicity and outcome in gastrointestinal stromal tumours: An institutional audit Top

S. Neena Prasad, Suman Meyur, Souvik Paul, Sumana Maiti, Siddartha Basu

Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): This article is aimed to report the data of an audit, carried out on the morphological and clinical aspects of the disease and to review the present knowledge on GISTs. Materials and Methods: A retrospective study of GIST patients identified by histopathology and immunohistochemical criteria, attending the department of radiotherapy of IPGME&R and SSKM Hospital from 2016 to 2019, collected by reviewing the clinical records. Results: A total of 38 patients with GISTs were recruited. The median age was 49.5 yrs. Male predominance was seen (73.7% male, 26.31% female). 15.8% had comorbidities ( hypertension, n=5; diabetes, n=1). 21.1% of the patients were smokers and 7.89 % had history of alcoholism. Main presenting symptom was abdominal pain (42.1%). Most common site was jejunum (31.6%), stomach (26.3%), duodenum (15.8%). 5 patients had liver metastasis and 1 patient had peritoneal mets. Most common histological type was spindle type (78.9%), epthelioid was 18.4% and mixed type was 2.6%. The mean tumour size was 6.54 cm. Immunohistochemistry showed positive expression for CD117 (65.8%), CD34 (31.6%), DOG1 (28.9%), CKIT (19.4%), SMA (7.9%). 13 patients were in the high risk group. 76.3% patients had adjuvant chemotherapy after surgery with imatinib. Dose reduction was done in 5 patients. Recurrence was seen in 5 patients. Median follow up was 13 months. Conclusion: From this study, it was found that the incidence of GIST is higher in males. The most common location of tumor is the jejunum followed by the stomach. Patients with GIST generally present with symptoms of vague abdominal pain. Common histopathological variety is spindle cell type and CD117 is frequently present. Most of the patients receiving Imatinib post surgery is having good response with minimum toxicity.

 > Abstract: 181: Comparison of twice weekly palliative radiotherapy versus continuous hypofractionated palliative radiotherapy for painful bone metastasis Top

Dhiman Das

Medical College, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): Local radiotherapy has been proved to cause significant reduction in pain from bone metastasis in multiple trials. Various schedules are available namely 8 Gy in 1 fraction and 20 Gy in 5 fractions. In a state-run tertiary care Institution like ours, the choice of schedule is important, taking into consideration the limited resources and manpower. Single fraction treatment can result in re-treatments which can be cumbersome, and multiple daily fractions will not be easy, considering logistical issues. A third option was necessary, for the benefit of increasing numbers of palliative patients, without hampering regular treatments of patients receiving definitive RT. The purpose of this study is to compare the novel 20Gy in 5 fractions daily schedule to twice weekly 4Gy delivery of 20Gy in terms of pain control, re-treatments and Quality of Life. Materials and Methods: A prospective case control study was done in the Dept of Radiotherapy, Medical College & hospital, Kolkata from july '18 to May '19 among total 30 patients (18 of metastatic breast ca, 9 of metastatic prostate ca, 2 Of metastatic lung ca, 1 of multiple myeloma) who is having painful bone metastasis. Palliative radiotherapy was given to all of them, 14 Patients were given with conventional regime of 20Gy/5# for continuous 5 days & 16 Patients were given 20 Gy/5# twice a week regime. Pain control was assessed by visual analogue scale & faces pain score before & about 2 weeks after completion of radiotherapy. Quality of life was assessed by EORTC QLC-C15-PAL (version 1) before & 2 weeks after completion of radiotherapy. Data was analyzed using IBM SPSS software. Results: In the arm with twice weekly fraction, the mean QLC C15 pal score before and after radiation is 32.62 and 24.15 ( p <0.001, paired samples t test). There was also significant reduction in VAS pain score and faces pain score (p< 0.001, paired samples t test). No significant difference of scores between male and female population was found. Comparing with the conventional daily fractionation arm, no significant difference between change in pain score was observed. In both the arms no retreatments were required in the same field during 6 months follow up. Conclusion: The palliative radiotherapy given in 20 Gy/5# as twice a week regime seems to be equally efficacious in terms of improvement in QOL and pain control in comparison to conventional palliative radiotherapy regime to bone as 20 Gy /5# for consecutive 5 days.

 > Abstract: 196: Software CobaCalcYY for calculation of treatment time for radiotherapy on telecobalt Top

Yashpal Verma, Yogesh Kumar, Nagappan Subramanian, Ashok K. Chauhan, Vivek Kaushal

Pt B D Sharma PGIMS, Rohtak, Haryana, India, E-mail: [email protected]

Background: While treating the patients with radiotherapy, physicist has to tackle enormous physics data and tedious calculations, keenly. Methodology: This software intends to make it easy and efficient; in simple table form, by entering input of intended external beam radiotherapy (EBRT) parameters; to get the required result, omitting the time consuming process every time for patients to be treated by radiotherapy. It uses inbuilt formulae, some being modified and designed to suit as per our requirement. While designing this software (CobaCalcYY), table segments have been color coded for ease of interpretation and operation. Red color is assigned for the fixed values/ parameters like prescription and the allotted radiation facility on which the treatment is to be carried out. Green color is for input data and yellow for the derived value, all in step by step manner. Blue color is for output of the radiation facility and sky-blue for beam modifying parameters like shielding etc. These combinations are not to remember but to differentiate the things and sooth to our eyes. For Example: In the process of treatment time calculation, we first come across to find the equivalent square area (ESF) for the given parameters. As we enter the values of X and Y variables and enter to ESF, it gives the ESF value immediately and simultaneously it shows the output of that particular radiation facility in the corresponding table (marked here with an arrow). Next step is to enter the value of depth at which the dose is prescribed. As we enter the numerical value of the depth and enter to percentage depth dose (PDD), it is immediately reflected. Third step is to enter the value of the prescribed dose and the number of days for which the decay factor is to be used. It will show the treatment time directly, if there is no shielding and we choose zero (0). But if shielding is used, we choose one (1) for it and assign the parameters accordingly. (In this format, we chose twelve combinations of three figures viz. triangle, square and rectangle along with the nil value. It will make the essential changes in PDD value for that particular parameter. Dropdown list of shielding tray of both types, that is, plain tray as well as perforated tray, along with the factor used for them is incorporated. Wedge factor dropdown list is also incorporated in the table along with the factors used for various field sizes, which are used clinically. Results and Conclusion: The software CobaCalcYY is easy to operate and promises efficient assistance in physicist's calculation work in busy radiotherapy set ups.

 > Abstract: 207: On the horizon: Accelerated approvals and current status of pembrolizumab in oncology Top

Jyoti Kaushal, Anil Kumar Dhull, Vivek Kaushal

Pandit B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Purpose and Objective(s): Pembrolizumab is a human immunoglobulin G4 (IgG4) monoclonal antibody, immune checkpoint inhibitor that binds to and blocks Programmed cell Death 1 (PD-1) expressed on activated T cells. Many cancers make proteins that bind to PD-1, thus shutting down the ability of the body to kill the cancer by immune surveillance. Inhibiting PD-1 on the lymphocytes prevents this, allowing the immune system to target and destroy cancer cells. In 2013 Merck won a breakthrough therapy designation for the drug. Materials and Methods: Tumors having mutations that cause impaired DNA mismatch repair (dMMR), often results in microsatellite instability (MSI), tend to generate many mutated proteins that could serve as tumor antigens; pembrolizumab appears to facilitate clearance of any such tumor by the immune system, by preventing the self-checkpoint system from blocking the clearance. Results: Developmental studies of pembrolizumab are usually preceded by the acronym KEYNOTE. Many studies are ongoing, as monotherapy or combination in almost all types of cancer. First in list, KEYNOTE-001 demonstrated the activity of pembrolizumab in non-small cell lung cancer (NSCLC). While KEYNOTE-158 data led to an FDA granted accelerated approval for pembrolizumab in MSI-H or dMMR solid tumors progressing on treatment. This is the first time that a drug has a tissue-agnostic market authorization. KEYNOTE-522 is currently evaluating pembrolizumab + neoadjuvant chemotherapy followed by adjuvant pembrolizumab in triple negative breast cancer. Approved indications of pembrolizumab are malignant melanoma, non small cell lung cancer, bladder cancer, cervical cancer, gastric cancer, hepatocellular carcinoma, head and neck cancer, malignant pleural mesothelioma, thymic carcinoma, breast cancer, esophageal carcinoma, kidney cancer, prostate carcinoma, colorectal carcinoma, endometrial cancer, ovarian cancer and cholangiocarcinoma. NCT03012620 is a multi-cohort phase II study designed to propose secured accessed to pembrolizumab for patients with rare cancer. Seven cohorts are recruiting rare sarcoma, rare ovarian cancer, primary central nervous system lymphomas, rare thyroid cancer, rare malignant neuroendocrine cancer, germ-cell cancer, and NK/T-cell lymphoma. Conclusion: Immunotherapy is a major breakthrough in cancer therapy leading to the award of the 2018 Nobel prize in medicine to immunologist James Allison. The role of pembrolizumab in the management of cancer is fast emerging. Indeed, many accelerated approvals have been granted to pembrolizumab by the FDA in various types of cancer. Multiple studies are currently testing pembrolizumab alone and in combination with already approved therapies. Better tolerated and more effective than conventional treatments, this makes it a potential treatment of choice in many malignancies.

 > Abstract: 235: Localized electrons irradiation in a primary cutaneous marginal zone lymphoma of face Top

Sandeep Jain

Madras Medical College, Chennai, Tamil Nadu, India, E-mail: [email protected]

Background: PCMZL is a rare cutaneous lymphoma characterized by its origin in skin without any evidence of extra cutaneous disease. PCMZL is a multifocal disease most of the time while in a much smaller percentage of the patients it's solitary or localized. Skin lesions are preferentially located on trunk and extremities and are quiet uncommon over head and neck region. Optimal treatment of PCMZL is not very clear however radiotherapy and surgical excision have been suggested as preferred choice of treatment for localized skin lesions. Purpose: We Present a 51 Years aged Lady with localized erythematous nodular lesions over left side of the cheek for 6 months duration, biopsy from the nodule was reported as Primary Cutaneous Marginal Zone Lymphoma Tumor was LCA positive, CD20 and CD79 positive, BCL2 positive, CD 10 negative, BCL 6 negative. Whole body PETCT and bone marrow examination was done to rule out any systemic disease. Patient was planned for curative external beam radiotherapy with electrons. Methods: Patient was immobilized with orfit cast tumor area was localized with lead wire around the treatment target, a margin of two cm of normal tissue was included in the target volume , 5 mm wax bolus was placed to adequately cover the target at the surface and computerized CT planning was done to ensure the adequate coverage of the target. Patient has received external beam radiotherapy to a dose of 36 Gy in 18 fractions by 6 mev electrons. Results: Patient is on regular follow up, she had complete response at the end of the treatment but developed suspicious erythematous nodule over the treated area for which biopsy was done to rule out recurrent disease the histopathology was reported as benign cutaneous lymphoid hyperplasia of inflammatory nature and immunohistology showed heterogeneous B and T cells with no clonality and the cells were negative for cyclin D1 and CD43 confirming benign pathology. She was treated with a course of antibiotics , anti-inflammatory drugs and moisturizing creams and the suspicious patch resolved in due course of time. Patient is disease free and with good cosmesis at six months from end of the treatment. Conclusions: PCMZL is a rare lymphoma of skin particularly in head and neck region with no clear guidelines for treatment. Treatment with electrons is quiet effective with good local control and excellent cosmesis.

 > Abstract: 265: A case of immune thrombocytopenic purpura with brain tumour: A mere association or paraneoplastic manifestation? Top

Barnini Ghosh, Bodhisattwa Dutta, Debottam Barman, Asit Ranjan Deb

Medical College, Kolkata, West Bengal, India, E-mail: [email protected]

A 13 year old prepubertal female child from rural Bengal presented to us with history of one episode of epistaxis, for which she was investigated and diagnosed to be suffering from Immune Thrombocytopenic Purpura (ITP). Her bone marrow findings at that time showed hypolobulated megakaryocytes, adequate in number. She was treated with steroid and platelet count improved. After about 3 months from the event, the child developed one episode of convulsion for which a CT scan of brain was done, reported as intracerebral haemorrhage in right frontoparietal area. Her platelet count at that time was 1,50,000/cmm. So it was thought that intracerebral haemorrhage due to ITP will be a remote possibility. Hence for better visualisation of the lesion, MRI brain (Contrast) followed by MR spectroscopy was done which suggested a heterogenous enhancing lesion involving right fronto-parietal region with areas of necrosis within it and haemorrhagic component. MRS showed reduction in NAA, altered choline / creatinine ratio. MR angio of brain did not reveal any abnormalities in major cerebral blood vessels. All features suggested a necrotic glioma. The child was operated and histological findings revealed a Diffuse fibrillary astrocytoma (WHO Grade II). Discussion: Immune-mediated haematological diseases are rare manifestation of paraneoplastic syndromes. ITP is one of them. One possible mechanism of ITP associated with cancer is tumour- induced autoimmunity. A review of 68 published cases of an association of ITP and solid cancers revealed that most common associated tumours were lung and breast cancers. Other common associations were with lymphoma, renal cell and ovarian cancers. Association was rare in prostate cancer. In most patients ITP responded to steroid treatment. Only few patients had a complete response of ITP after surgical removal or chemotherapy of the cancer. Case reports of ITP associated with brain tumors are very sparse. 2 case reports suggested that patients had ITP with brain tumors but authors did not mentioned whether it was mere asoociation or paraneoplastic manifestation. As mentioned earlier, we are not in a position to prove whether ITP in our patient is a mere association or a paraneoplastic manifestation. But a review of literature definitely suggest a paraneoplastic ITP associated with solid tumors. A continued vigil on brain tumors associated with ITP will be of help to find out the exact relationship between the two.

 > Abstract: 269: Our experience with TEACHH model to optimize use of palliative radiotherapy based on expected life expectancy Top

Pushpendra Hirapara, Arvind Kumar Patidar, Samir Batham, Meetu Jain, Maitri Gandhi, Kinjal Jani

HCG Hospital, Bhavnagar, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): Radiotherapy is an established modality for palliation of symptoms like pain due to skeletal metastasis, compressive symptoms in brain & vertebral metastasis, obstructive symptoms like dysphagia, dyspnoea as well bleeding/discharge from ulcerative/fungating mass, for which it is utilized for nearly 50-66% of cancer patients during course of their illness. Our Objective is to implement internationally published and tested tool (TEACHH) in our clinical practice to optimize use of palliative radiotherapy and improve patient and relatives convenience by predicting expected life expectancy. Materials and Methods: Patients were categorized for expected life expectancy after obtaining score of Patient Characteristics (T-type of cancer e.g. breast & prostate vs lung & other, E-ECOG performance status e.g. 0-1 vs 2-4, A-age of patient e.g. <60 years vs >60, C-prior palliative chemotherapy e.g 0-1 vs >2, H-prior hospitalization within 3 months before palliative RT e.g 0 vs 1, H-hepatic metastasis e.g. absent vs present), The TEACHH model has three groups with distinct median survival (1.7, 5, and 19.9 months) based on the prognostic variables as mentioned above. Patients and relatives were explained and counselled about disease status, expected life expectancy, effects, side effects, prognosis and morbidity of palliative radiotherapy. Results: 53 patients were referred to us for palliative radiotherapy from July 2018 to December 2018, 39.6% (21/53) had painful bone including vertebral metastasis, 11.3% (6/53) had metastatic brain tumour, 22.6% (12/53) had thoracic cancers (oesophageal & lung) & 26.4% (14/53) have recurrent/fungating head and neck tumours. Palliative Radiotherapy was delivered in 58.4% (31/53) patients. [38.7% (12/31) had painful bone including vertebral metastasis, 12.9% (4/31) had metastatic brain tumour, 19.3% (6/31) had thoracic cancers (oesophageal & lung) & 29% (9/31) had recurrent & fungated head and neck tumours] Of the total of treated patients, 29% (9/31) were in the life expectancy group of 1.7 months; 64.5% (20/31) in 5 months and 6.5% (2/31) in 19.9 months. The use of the model allowed us to advised best supportive care only in 10 (18.8%) patients and 22.6% (12/53) patients were not willing for palliative radiotherapy. 9.6% (3/31) patients could not complete planned course of palliative radiotherapy due to worsening of general condition/death (2 in 1.7 months and 1 in 5 months). Conclusion: In Our experience, TEACHH model assist us for choosing palliative radiotherapy wisely among patients depending upon expected life expectancy, though prognostication based on expected life expectancy is a complex process.

 > Abstract: 271: Case of dermatofibrosarcoma pertuberens residual disease treated with WLE and adjuvant interstitial brachy therapy Top

Akhila Bharathan, Priya Sinha, Siddanna Palled

T. D. Medical College, Alappuzha, Kerala, India, E-mail: [email protected]

Purpose and Objective(s): To report a case of dermatofibrosarcoma residual disease treated by WLE followed by adjuvant radiotherapy in form of interstitial brachytherapy. Background: Dermatofibrosarcoma is a rare monoclonal soft tissue sarcoma first described by Taylor in 1980.It account for 1.8 % of soft tissue sarcoma. It is a locally aggressive tumour having high potential of local recurrence if not treated properly. Wide local excision with adequate margins is preferred mode of treatment. In margin positive or residual disease adjuvant radiotherapy is recommended. Usually radiotherapy is delivered as external beam radiotherapy to a dose of 50- 60 Gy in 25 to 30 fraction. Adjuvant radiotherapy can be delivered in form of brachytherapy also. Case Report: 70'yr old male known diabetic and hypertensive presented with complaint s of swelling over right scapular region, initially small and progressively increased in size not associated with pain, and not associated with discharge, no history of fever or trauma. On examination patient was conscious and oriented, vitals were stable. Local examination of right shoulder showed a 6* 6 swelling in right scapular region firm in consistency smooth surface, no fluctuations, slip sign absent. Swelling was not compressible not reducible. Other systems were within normal limits. Wide local excision of tumour was done under general anesthesia. Post op histopathology report was showing encapsulated neoplasm composed of spindle cells, Suggestive of dermatofibrosarcoma protuberance with IHC correlation recommended. IHC was showing CD34, SMA positive, negative for S100, CK and desmin. Proliferation index ranging from10-40%. He underwent fluoro deoxy glucose pet CT in our centre revealed a residual disease. It showed 4.6 * 2.6 cm poorly marginated slightly metabolically active subcutaneous soft tissue in right lower posterior neck concern of residual disease. Again he underwent revision excision of the lesion under general anaesthesia. He was planned for adjuvant radiotherapy by interstitial brachytherapy. 6 interstitial brachytherapy catheters were placed intra op and wound closure was done. He was planned and treated with interstitial brachytherapy to dose of 56 Gy in 8 fractions. He tolerated treatment well and doing good on follow up. Conclusion: Compared to standard mode of external beam radiotherapy, interstitial brachytherapy is also a considerable option in treating case of dermatofibrosarcoma pertuberens local recurrence.

 > Abstract: 276: A prospective observational study evaluating pain response after stereotactic body radiotherapy using 24 Gy in 2 fractions for de novo spinal metastasis Top

Anwoy Dasgupta, Suman Mallik, Jyotirup Goswami, Sayan Das, Arijit Sen, Monidipa Mondal

Narayana Superspeciality Hospital, Howrah, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): Skeletal metastasis is a common complication of most cancers and spine is the most common involved site. Conventionally fractionated external beam radiotherapy provides significant palliation in painful bone metastases. Few studies have reported durable pain relief with good local control using Stereotactic Body Radiotherapy (SBRT) in symptomatic spinal metastasis. Here we report our experience on pain relief and local control with SBRT for oligometastases in spine. Materials and Methods: After accrual following informed consent, patients were clinically examined and pain/quality of life scores were assessed using BPI and EORTC QLQ questionnaires respectively. Patients were simulated using a vacuum immobilization device and CT scan. Target delineation was done according to guidelines of International Spine Research Consortium (ISRC). Plan was considered acceptable if D90 (minimum dose received by 90% of PTV) was 20 Gy. Dose delivered was 24 Gy in 2 fractions on alternate days keeping spinal cord Dmax less than 17 Gy. At follow up, response assessment was done in accordance to modified SPine response assessment In Neuro-Oncology (SPINO) group guidelines. Pain response was assessed using International Consensus for Pain Response Endpoints (ICPRE) as standard guidelines. Results: All consecutive patients with oligometastases in spine at our hospital, between September 2018 and February 2019 were screened and 13 patients were accrued. Median age of these patients was 62 years (6 male and 7 female). Lung and breast were the most common primaries (5 each). 6 patients had single dorsal vertebral metastasis, 5 had single lumbar vertebral metastasis and 2 patients had both dorsal and lumbar vertebral metastases. Median initial pain score was 67% which reduced to 22% at 3 months and 15% at 6 months. Only 1 out of 13 (7.7%) patients had local progression on MRI at 3 months. Local control rate at 6 months is 92.3% (8 partial response, 4 stable disease). One patient had vertebral compression fracture (VCF) in the treated spine but reported decrease in pain and analgesic requirement. Conclusion: Decrease in pain score and local control achieved at 6 months at our hospital following SBRT to oligometastatic disease in spine was comparable to that reported in literature.

 > Abstract: 279: Novel usage of image guided, surface mould HDR brachytherapy for extranodal cutaneous B-cell non-Hodgkin lymphoma relapse Top

R. Deepak, L. Padmanabhan, E. Varadharajan

Billroth Hospital, Chennai, Tamil Nadu, India, E-mail: [email protected]

Introduction: Cutaneous lymphomas represent a unique group of lymphomas which constitue the second most frequent subset of extra nodal involvement in lymphomas ; gastrointestinal involvement being the most frequent. To the best of our knowledge, only a few cases of cutaneous relapse of Non-Hodgkin Lymphoma (NHL) have been reported where there was an absence of primary cutaneous involvement. More importantly, the use of brachytherapy has been very limited with very few reported cases. Case Presentation: A case study of a 62-year-old male patient , known case of NHL was referred to our centre with a hyperpigmented papular lesion in the anterolateral left chest wall region lateral to the nipple. He had previously been diagnosed with NHL in 2012; disease involved the Nasopharynx extending into the oropharynx. The patient completed chemotherapy followed by radiation and was in remission.On follow up, he presented with PET positive mediastinal nodes in 2016 and was treated with chemoradiation for the same. A PET scan in 2019 revealed the above discussed chest wall lesion as FDG positive (SUV 5.4). A biopsy of the cutaneous lesion from left chest wall confirmed B cell NHL. The patient was planned for and received Image guided HDR Brachytherapy using a custom made Surface Mould Applicator for 5 fractions to achieve a curative dose. The treatment showed excellent clinical response with tolerable skin toxicities and very minimal dose to the critical structures in the proximity. Discussion: The majority of relapses of NHL occur in the first 2 years after the completion of treatment. Extra nodal lymphomas comprise 24–48% of cases of which those involving skin account for only about 10% of cases. Considering the limited cases reported, treatment options are mostly institution based. The use of a custom made surface applicator and the image guidance using CT made sure that optimal dose was delivered with excellent toxicity profile. Conclusion: By presenting this case for discussion, we would like to present Brachytherapy, preferably image guided as a strong and viable treatment option in relapsed cutaneous extranodal B cell lymphomas , with or without systemic therapy based on involvement of other sites.

 > Abstract: 297: Dosimetric comparison between 3-dimensional conformal radiotherapy, partial arc volumetric modulated arc therapy and full arc volumetric modulated arc therapy for involved site radiotherapy in early nodal diffuse large B-cell lymphoma Top

Swarnaditya Roy, Ahitagni Biswas, Ashish Binjola, Rajeev Kumar, Madhavi Tripathi, Chandrasekhar Bal

All India Institute of Medical Sciences, New Delhi, India, E-mail: [email protected]

Purpose and Objective(s): We performed a dosimetric comparison between 3-dimensional conformal radiotherapy (3D-CRT), partial arc volumetric modulated arc therapy (PA-VMAT) and full arc volumetric modulated arc therapy (FA-VMAT) for involved site radiotherapy (ISRT) following chemo-immunotherapy in the first 15 patients with early nodal DLBCL enrolled in a phase II clinical trial. Materials and Methods: 15 immunocompetent patients aged 18-70 years with biopsy proven stage I-II nodal DLBCL and ECOG performance status 0-3 underwent whole body 18F-FDG-PET/CT scan in radiotherapy treatment position apart from standard lymphoma workup. Subsequently, they received chemo-immunotherapy (R-CHOP21) for 3-6 cycles. Response assessment 18F-FDG-PET/CT scan was repeated after 3 and 6 cycles. Afterwards, patients underwent ISRT to a dose of 30.6-36 Gy at 1.8 Gy/fraction/day. For ISRT, contrast enhanced planning CT was electronically fused with baseline 18F-FDG-PET/CT scan. The gross tumour was contoured based on baseline 18F-FDG-PET/CT images and then edited to form the pre-chemotherapy GTV. To this, 1.5 cm anatomically constrained cranio-caudal expansion was given along the lymphatic chain to generate the CTV. A 5-10 mm site-specific isotropic expansion was given to form the PTV. For the first 15 patients enrolled in this trial, 3 sets of plans were generated by 3D-CRT, PA-VMAT and FA-VMAT techniques on Monaco treatment planning system, version 5.11.02 (Elekta, Stockholm). Dosimetric comparison was done pertaining to target coverage (PTVD95, CTVD98, GTVD100), coverage index (VPTVprescription dose/VPTV), conformity index (treated volume/VPTV prescription dose), homogeneity index (D5/D95) and irradiated body volume (IBV) at 5 & 10 Gy and dose to critical organs at risk (in head & neck lymphoma patients; N=11) was compared by Friedman test. In case of significant difference, subsequent pair wise comparison was done using Wilcoxon sign rank test (Bonferroni adjusted). P value less than 0.05 was considered statistically significant. Statistical analyses were done using SPSSv16. Results: The median PTVD95% were 95.42%, 96.06% & 98.69% of the prescribed dose (p<0.001), the median CTVD98% were 96.83%, 98.89% & 100.59% of the prescribed dose (p<0.001), and the median GTVD100% were 92.92%, 87.66% and 93.16% of the prescribed dose (p=0.032) in the 3D-CRT, PA-VMAT and FA-VMAT plans respectively. Similarly, median coverage indices were 0.73, 0.82 & 0.90 (p=0.001), the median conformity indices were 1.43, 1.09 & 1.09 (p<0.001) and the median homogeneity indices were 1.11, 1.10 &1.08 (p=0.005) in the 3D-CRT, PA-VMAT and FA-VMAT plans respectively. Comparing PA-VMAT and FA-VMAT plans, the coverage of PTV, CTV and GTV was significantly better in the FA-VMAT plans (p value=0.024, 0.024 & 0.099 respectively), but this came at the cost of significantly increased IBV at 10Gy (p value=0.018). Pertaining to OARs in H&N lymphoma (N=11), there was a significant reduction in the dose to the optic structures and spinal cord in the VMAT plans compared with the 3D-CRT. Also, the median value of the Dmax for brainstem was significantly lower in PA-VMAT technique compared with 3D-CRT (17.81Gy versus 26.39 Gy, p=0.048). Conclusion: Compared with 3D-CRT, VMAT lead to significantly improved target coverage, conformity and sparing of critical organs at risk and should be strongly considered in the context of ISRT. Comparing full arc versus partial arc VMAT, superior target coverage is achieved at the cost of increased low dose bath in the FA-VMAT.

 > Abstract: 302: To determine the predictive significance of pretreatment levels of system inflammatory markers for postneoadjuvant treatment response in patients of carcinoma rectum Top

Kavita Sehrawat, Kishore Singh, Arun Rathi, Sundeep Saluja, Anurita Srivastava

Lok Nayak Jai Prakash Hospital, Hazaribagh, Jharkhand, India, E-mail: [email protected]

Background: Rectal cancer ranks as the seventh most frequently diagnosed malignancy in India with male predominance. Primary treatment is surgery, however, use of neoadjuvant chemoradiation (NACTRT) has shown improved outcomes in these patients. Objective: This prospective study attempted to assess utility of systemic inflammatory markers to predict outcome in patients undergoing preoperative chemoradiation for carcinoma rectum. Materials and Methods: Biopsy proven, locally advanced non-metastatic patients of rectal cancer, with normal hematological and biochemistry parameters and deemed fit for radical treatment were included in the study. Patients were treated with capecitabine based (825 mg/m2 BD) neoadjuvant chemoradiation to a total dose of 45 Gy/25 fractions by 2 or 4 fields on Theratron 780E with Co60 gamma rays. After 6-8 weeks of NAT, patients were reassessed radiologically for response, followed by surgery in resectable cases. Response was also seen in post-operative histopathological specimen by using modified Ryan's score. Levels of inflammatory markers was assessed at three times i.e. pretreatment, post-NACTRT and post-surgery in those who got operated and 3 months post NACTRT in inoperable patients. Results: Twenty-four biopsy proven rectal cancer patients were registered from October 2017 to December 2018, out of which, a total of 17 patients were eligible for analysis. Mean age (± SD) at diagnosis was 44 years (± 12.4, range 22-70), with a male:female ratio of 9:8. At presentation, the symptoms were bleeding per rectum associated with diarrhea or tenesmus (76%), moderate to severe pain (VAS 7-10) in 90% and history of weight loss in 83% of which 59% had significant weight loss (>4.5 kg in 6 months). All patients had adenocarcinoma on histological evaluation with poor differentiation in 23 % and mucinous histology in 41% of the cases. Treatment was well tolerated without any toxicity related treatment breaks. Post treatment evaluation revealed partial response in 30% patients and progressive disease (PD) in 23% patients, overall 53% were operable post NAT. Out of seventeen, nine patients underwent curative surgery (7 APR out total 9), 1 patient denied surgery, 3 patients were lost to follow up before surgery, 1 patient expired prior to surgery and 3 were deemed inoperable. On statistical evaluation, the levels of pretreatment SIM and modified Glasgow prognostic score (mGPS) and serum CEA levels were not significantly different when compared with post NACTRT levels. There was no significant difference between pretreatment levels of SIM (c-Reactive Protein, Neutrophil-Lymphocyte Ratio, Platelet-Lymphocyte Ratio), mGPS when compared with respect to pathological response except serum CEA levels which were found to be significant when compared with pathological response. Conclusion: We failed to find any significant correlation between the SIM except serum CEA with respect to post NAT response. However, this may be due to a short follow up and small number of patients who have undergone surgery. Further studies with longer follow up are recommended to evaluate the predictive value of SIM.

 > Abstract: 312: A comparative analysis of different planning techniques of prone versus supine position in locally advanced carcinoma rectum Top

Sanjay Hunugundmath, Surya Prakash Vakina, Kantaram Darekar

Sahyadri Super Speciality Hospital, Pune, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): To compare different planning techniques and to evaluate doses to bladder and bowel with supine and prone positions in locally advanced carcinoma rectum planned for neoadjuvant radiotherapy. Materials and Methods: Ten patients with similar planning objectives diagnosed with locally advanced carcinoma rectum were considered. Each patient had 3 plans generated using 3DCRT, IMRT and VMAT in supine position and similarly 3 planning techniques were used in prone position. Dosimetric indices were generated and analysed for bowel and bladder for all the ten patients using different treatment techniques. Results: VMAT in the prone position provided the optimal dose homogeneity in the target volume with the value close to 0. When compared to 3DCRT , VMAT and IMRT had a better conformity. Dose reduction was significantly reduced in prone position , in all the 3 planning techniques compared to supine position.Pairwise comparison revealed significantly higher small bowel protection by VMAT in the prone position in the high-dose area (V75, V45Gy). Similarly, superior bladder sparing was found for 3D-CRT in the prone position at higher doses (V50, V75). Conclusion: All the treatment techniques provided better organs at risk sparing in prone position using prone belly board , compared to supine position. When treated in prone position , bladder sparing was more with 3DCRT and bowel sparing was maximum achieved with VMAT planning technique.

 > Abstract: 334: Primary orbital ewing sarcoma: A rare case presentation Top

Vipin Kumar Dubey, Preety Jain, Priyanka Raj Ahirwar, Ramesh Arya, Ayush Naik

MGM Medical College, Indore, Madhya Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): To Present a rare case of primary orbital Ewing sarcoma in young female. Ewing sarcoma are highly malignant tumor of Neuroectodermal origin arising within bone and soft tissue and most commonly seen in children and young adults under the age of 20 yrs. Mean age of presentation 10 – 14 yrs in males and 5 to 9 yrs in female. Male female ratio- in age less than 10 yr is 1.3: 1, more than 10 yr is 1.6: 1. Most commonly involves pelvis > femur> ribs. Involvement orbit is seen in only 2% of patients. Ewing sarcoma of orbit presents with initial symptom of headache and gradual vision loss. And at late stage Proptosis and vision loss may be seen. Materials and Methods: A 16 yr old girl presented with symptoms of headache and gradually decreasing vision for 3 years. Opthalmologist opinion was taken & symptomatic t/t and eye glass for low vision were prescribed, but no improvement was seen, Then MRI brain & orbit was done. Patient taken neurosurgery opinion for MRI brain and orbit in which-4.8*4.3*4.0 cm lobulated mass seen in roof of left orbit with expansion and erosion to lesser wing of sphenoid on left side.Than Patient underwent left fronto temporo parietal craniotomy and tumor decompression and with Duroplasty and biopsy taken. Hitopathology was suggestive of “malignant small round cell tumor / Ewings, for confirmation Immunohistochemistry was done which is MIC-2 positive, VIMENTIN positive, NEURON SPECIFIC ENOLASE positive, KI-67 positive (25%to 30)% that confirms the Ewings sarcoma. Then Patient Recieveded at our hospital 6 cycle of ICE ( ifosfamide + cisplatin +etoposide) at 21 days of intervals and has good response, after that 3 cycle alternate VAC (vincristine+Adriamycin+cyclophosphamide) and Ifosfamide+Etoposide at interval of 21 days. And received 54 Gray sandwich radiotherapy concurrent with Ifosfamide and Etoposide. Now Patient is on monthly follow up without any new complains. Results: In most cases with orbital involvement, ophthalmic symptoms consist of proptosis, pain, and occasionally visual loss and motility restriction. In our case patient after surgery and chemotherapy and concurrent chemo radiation had good response and still on monthly follow up without any significant new complaint. Conclusion: Ewing's sarcoma is a rare orbital tumor of bone mainly affecting children. Local treatment relying on surgical extirpation and radiotherapy alone has proven inadequate, with 5-year survival rates of <10%. The addition of chemotherapy has improved survival rates significantly to approximately 50%.

 > Abstract: 335: Results of neoadjuvant chemoradiation in locally advanced rectal carcinoma: Institutional experience Top

Shreena Patidar, Ankita Parikh, Maitrik Mehta, Jyoti Poddar, Kushboo Jain

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

Objective: To examine clinical outcomes in patients receiving neoadjuvant chemoradiation before surgery which is now standard of care in stage II and stage III rectal carcinoma. Introduction: In India, colorectal cancer is the fourth most common cancer in men and third most common cancer in women in terms of incidence and mortality. In India annual incidence for rectal cancer is 4.1 per 100000 in men and 3.9 per 100000 in women. Preoperative radiotherapy in combination with 5- fluorouracil based chemotherapy has been proven both safe and effective in treatment of rectal carcinoma. Methods: A retrospective analysis is done on 25 patients who received neoadjuvant chemoradiation (Radiotherapy 50.4Gy/28# with concurrent Capecitabine) for biopsy proven locally advanced adenocarcinoma of rectum.Surgery was performed 6-8 weeks after completion of chemoradiation. Results: Median follow up was 24 months and mean age was 55 years (25 to 70 years). The chemotherapeutic regimens were well tolerated and and resection was performed in 16 patients. Sphincter sparing surgery was performed in 12 patients. Conclusion: Preoperative chemoradiation has a considerable downstaging effect on tumor and lymph nodes. In this study there was significant acute gastrointestinal toxicity which might be because of technique of treatment.Preoperative chemoradiotherapy is the treatment of choice of locally advanced rectal carcinoma.

 > Abstract: 337: A rare case of primary orbital lymphoma in early age group Top

Prabhakar Gupta, Jyoti Dane

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

Background: Lymphoma of orbit are rare tumor comprising only 1% of all Non - Hodgkin's lymphoma. The majority of non-hodgkin's lymphomas of orbit are extra nodal marginal - zone B- cell lymphomas of mucosa asssociated lymphoid tissue (MALT) type lymphoma. orbital lymphoma are usually unilateral but may involve both orbit approximately 85-90% of orbital lymphoma are low grade. Purpose: To present a rare case of primary orbital lymphoma. Methodology: A patient 17 yr old male came with complain of protrusions of left eye since 1 month patient was apperantly alright 1 month back then patient complaining of headache aggrevated at night and progressively proptosis of left eye. incision biopsy was done. HPR s/o Non -hodgkin's lymphoma and IHC show CD- 20 Negative. We give 40gy radiation in 20 fraction in 4 week and chemotherapy with CHOP regimen (cyclophosphamide, adriamycin, vincristin , prednisolone) 6 cycle. At completion of treatment patient are remain tumor free and patient kept on follow up. Discussion: Primary orbital lymphoma is an extremely rare condition and usually presents as a painless periorbital swelling with low grade proptosis and diplopia in a patient in his 6th or 7th decades. Conclusion: Primary orbital lymphoma is a rare tumor good response with chemotherapy (CHOP regimen) and radiation.

 > Abstract: 345: Early toxicity and outcome of 411 consecutive patients treated with CyberKnife radiosurgery: Amrita Institute of Medical Sciences, Kochi experience Top

Ajinkya Gupte, Ram Madhavan, Haridas Nair, Raghavendra Holla, K. Sruthi, Ajay Sasidharan, Debnarayan Dutta

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

Background: Demographic profile, patient parameters, early toxicity and response to treatment assessment of all consecutive patients treated with CyberKnife radiosurgery. Materials and Methods: 411 consecutive patients treated with CK in an Indian dedicated radiosurgery unit between January 2017 to July 2019. 368 patients were analyzable [male 213 (52%), mean age 57 (range 4-87 yrs)]. Brain tumour, GI tumour, oligo-metastasis, lung cancer and GU tumour were 207 (56%), 61 (17%), 65 (18%), 9 (3%) and 9 (3%) patient respectively. In brain tumour, 47 (13%) meningioma, 42 (11%) AN, 35 (9%) AVM & 33 (9%) brain metastasis. 50 (14%) HCC, 11 (3%) glomus tumour & 9 (3%) were prostate cancer patient. In rare tumours, 7 (2%) brainstem cavernoma, 2 patient each eye tumours, cholangiocarcinoma & pancreatic cancer. AVM dose18-24Gy/1fr, meningioma & AN 12Gy/1fr. Lung cancer dose 45Gy/3fr, HCC 45Gy/5fr, prostate 36.25Gy/5fr. Results: Among 35 AVMs, 2 patient had acute oedema requiring admission and recovered with supportive care, 6 patients required steroid for more than 1 month post CK. In AN patients, 4 required steriod >3 months. One pituitary tumour patient had acute steriod insufficency. 9 of 213 (4%) of brain tumour cases required admission after CK. No treatment related death or permanent neurodeficit. Among 34 brain metastasis, 15 (44%) had controlled disease at last follow up [Estimated OS 284 days (95%CI: 234-328; SEM: 22.5); >6 month actuarial OS 89%].29.4%(10/34) had intra-cranial progression, 18%(6/34) patients had new lesions and 12%(4/34) had recurrence within high dose region. Among, 41 HCC with PVT accrued in the study till date [mean age 61.4 yrs (38-76 yrs), 98% male; Child Pugh A 61%, B 34%; BCLC C 95% & D 5%; PS0-1: 71%, KPS>80: 83%; co-morbidities 39%; infective 15%, Alcohol intake 24%]. Mean follow up was 30.8 weeks (SD 25.8; range 2-107 weeks). Mean actuarial OS was 52.1 wks (95%CI: 38.4-65.5 wks). 6 month & 12 months actuarial OS 65% and 48% respectively. At last follow up, 22/41 (54%) were alive and 19/41 (46%) expired with disease progression. Among 34 patients evaluable for response assessment, 18 (45%) had complete PVT resolution. At last follow up, among 22 alive patients 9 (22%) had stable disease and 13 (32%) had progressive disease. Among 19 patients expired, 15 (85%) due to local progression, 4 (15%) due to metastasis. No death due to classical RILD. 19/41 (46%) patients had radiologically confirmed re-canalization [18 in PVT & 1 in IVC]. Mild GI toxicities (Gr-1-II) in 12 (29%), fatigue (Gr II-III) in 20 (48%) and grade III GI toxicity in 2 (5%) patient. Two (5%) patient had decompensation (<4 wk) after treatment. 108 fiducials were placed in 36 patients. Post-fiducial pain score 0-1 in 26 (72%) & score 3-4 in 2 (6%). Five (14%) admitted in 'day-care' (2 mild pneumothorax, 3 pain). 1 patient (3%) admitted for haemothorax and died. Conclusions: Acute toxicities after CK is less than 5%. Post-CK edema requiring long-term steroid is in 8% and admission required in 4% patients. Recurrence rate after brain metastasis SRS is 29% at 6 month follow up. HCC with PVT response is 40% at 2 month post-CK assessment.

 > Abstract: 347: The ideal screening platforms for drug therapies Top

Anjali Bhola, Anil Kumar Dhull, Ashok Chauhan, Vivek Kaushal

Pandit BD Sharma PGIMS, Rohtak, Haryana, India, E-mail: [email protected]

Background: Tumor models are approximations of a tumor, designed to recapitulate specific aspects of the tumor microenvironment. They are important tools for cancer research and serve as low-cost screening platforms for drug therapies. Tumor models are needed to assess effectiveness of various treatments, fractionation regimens, sensitizers and combination of radiation and chemotherapeutic agents. Methodology and Results: Explored the online available data to establish the screening platform and discuss about their types. Tumor models can be in-vitro tumor models and in-vivo tumor models. In-vitro tumor models can be further sub-classified as transwell based, spheroid based, hybrid platforms and tumor microvessel models. In- vivo tumor models are transplantable solid tumor systems in experimental animals, xenografts of human tumors and autochthonus and transgenic tumor models. 3D in-vitro tumor models are a compromise between 2- dimensional cultures of isolated cancer cells and complex xenografts of human cancers. Transplantable tumors in lab animals are used to establish many radiobiologic principles. Xenografts maintain chemotherapeutic response characteristics of class of tumors from which they are derived. Spheroids contain a heterogenous population of cells, much like a tumor, but are more quantitative and more economical. Spheroids from outside to center consists of –asynchronous aerated cells, non-cycling G1 like aerated cells, non- cycling G1 like hypoxic cells, necrotic cells. Spheroids are intermediate in complexity between monolayer cell cultures in-vitro and transplantable tumors in experimental animals. Organoids represent advancement over spheroids and reflect human tumor architecture in an in-vitro model system. Here, we review current strategies in the field of cancer models. Conclusions: There is a wide range of tumor models, each with distinct advantages and disadvantages. Due to the inherent differences in complexity and functionality, the choice of model is usually dependent on the application. In-vivo and in-vitro tumor models can be used for various cancer researches whereas in vitro 3D models continue to develop to be better indicators of in vivo drug efficacy.

 > Abstract: 353: Case report: A case of synchronous multiple primary malignant neoplasm Top

P. V. Arunmohan

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

Conclusion: The incidence of multiple primary malignant neoplasm ranges from 0.7% to 11.7%. The major haematological malignancies associated with solid tumours include multiple myeloma, myelodysplastic syndromes, non-hodkins lymphoma and chronic myelogenous leukemia. It's very rare to have gynaecological and haematological malignancy together. Published literature has reported that such malignancies are often located at the same organ, such as simultaneous hodkins lymphoma and adenocarcinoma in the uterine cervix, and adenocarcinoma and lymphoma in the stomach. A rebiopsy is the only way to verify the suspicion of synchronous multiple primary malignant neoplasm.We report a case of 63 year old female diagnosed to have carcinoma cervix with incidentally detected multiple myeloma. IHC of cervical growth suggested squamous cell carcinoma. Bone lesion was evaluated and diagnosed as multiple myeloma stage 1A. It's very challenging to manage synchronous multiple primary malignant neoplasms since there's no standard treatment for such rare conditions. This patient received concurrent radiotherapy (50 Gy in 25 fractions) and 4 cycles of weekly cisplatin followed by intracavitary brachytherapy (6.5 Gy in 4 fractions) for cervical malignancy. The patient also received chemotherapy (24 cycles of bortezomib and dexamethasone) for multiple myeloma. The patient is alive and is on followup. The review of medical literature will be included in the case report.

 > Abstract: 362: Comparative analysis of family caregivers' knowledge and perception of cancer pain with patients' pain assessment: A prospective clinical study Top

Divyesh Kumar, Mini Arora, Bhavana Rai, Sushmita Ghoshal

PGIMER, Chandigarh, India, E-mail: [email protected]

Purpose and Objective(s): The “management” of care has resulted in a shift toward the home environment as the primary setting of care and family caregivers' (FC's) as those responsible for the complex needs of patients at home.Since majority of the patients are dealt in outpatient setting, FC's knowledge regarding pain is of utmost importance for effective patient care at home.We in this study tried to assess and evaluate FC's knowledge and perception of cancer pain with patients' pain assessment. Materials and Methods: Patients and their FC's visiting our OPD were included in this study.Family pain Questinnaire (FPQ) and patient pain questionnaire (PPQ) were used for structured interview with both patient as well as their caregivers'.The scores for each subscales-knowledge and experience were caluclated for both the patients from questionnaire and statistically analysed.Reliability of the scales for PPQ and FPQ were assessed using Cronbach alpha's. Bland-Altman plots were plotted for differences of caregivers pain scores from patient's pain scores and overall scores to measure the disparity between PPQ and FPQ. t-test was applied to test the significance of differences (PPQ-FPQ) from zero. Results: For the current dataset the cronbach alpha's indicated that overall reliability scales for PPQ (0.759) and FPQ (0.754) were acceptable. Average scores for PPQ (FPQ) - knowledge , experience and total were reported as 35.91 (35.31) , 27.19 (26.86) and 63.12 (62.17) respectively. Median scores for PPQ (FPQ) were assessed as 37 (36), 28 (25) and 65 (62) for knowledge, experience and overall scales respectively. Average differences (d) for Knowledge – 0.602 , Experience – 0.333 and overall – 0.935 were observed and a t-test applied to test the significance of these differences from zero indicated no significant differences (p > 0.05). Lines of agreement for Bland-altman plot were also computed. Conclusion: No significant difference were observed.Further studies with larger sample size are warranted for confirmation of the findings.

 > Abstract: 363: How do they reach us? Mode of travel analysis for cancer treatment in government tertiary cancer center in Haryana Top

Yashpal Verma, Abhishek Soni, Anil Khurana, Paramjit Kaur, Ashok K. Chauhan, Vivek Kaushal

Pt B D Sharma PGIMS, Rohtak, Haryana, India, E-mail: [email protected]

Purpose and Objective(s): Cost of cancer care includes direct and indirect expenditure. Direct expenditure varies from center to center but indirect expenditure does not vary too much. Public hospitals and tertiary medical institutions provide cancer care at low costs. However, even in such 'free' hospitals, patients have to bear direct and indirect expenditure. Travel expenditure alone has been estimated to average approximately INR 4000 in a tertiary government cancer center, which accounted for nearly 27% of total cancer treatment expenditure in 2011. Objective is to analyze mode of access to radiation facility in a government tertiary cancer center with radiotherapy facility. Materials and Methods: In the month of January 2019, record of new patients registration in 2018 was studied and one-to-one interaction (personal/ telephonic) was done to know- 'Except in emergency, how do they usually access radiotherapy facility i.e. mode of travel' to the only working government Radiotherapy facility in the state of Haryana i.e. Department of Radiation Oncology, PGIMS Rohtak. Due attention was paid to privacy and purpose of survey was explained. Results: Total of 3732 new patients were registered in the Department of radiation oncology in the year 2018. Of these 494 patients could not be contacted for providing information. Of the remaining 3238 patients, 934 (28.84%) used railways and 2304 (71.16%) used road transport. Of the road travellers, 1538/2304 (66.75%) used public transport like bus etc. whereas 766/2304 (33.25%) used own vehicle. Conclusion: Majority of patients use public transport to access radiation therapy facility. Due to lack of awareness about travel concession schemes, travel expenditure is usually made out of pocket. Uniform policy should be to guide and assist the patients and caregivers, at very first interaction (registration) in availing maximum benefit of schemes. This type of data may be of use in formulating assistance programs by government/ NGO's.

 > Abstract: 367: Audit of patients with solid tumors receiving chemotherapy in a radiation oncology daycare Top

Muthulingeshkumar Muthukarthikeyan, Noopura Ramavarman, Pragna Sagar, Gunaseelan Karunanithi, Parthasarathy Vedasoundaram, Pandjatcharam Jagadesan

JIPMER, Puducherry, India, E-mail: [email protected]

Purpose and Objective(s): Chemotherapy in solid tumors can result in variable tumor response depending on multiple disease, host and treatment-related factors. Knowledge of tumor response to various chemotherapeutic regimens will aid the oncologist in appropriate choice of anti-cancer drugs. We intended to study the various solid tumors treated with chemotherapy in a radiation oncology daycare and also the chemotherapy regimens used in our daily clinical practice. Materials and Methods: The departmental records of all patients with solid tumors (carcinoma or sarcoma) receiving neoadjuvant and/or palliative chemotherapy in our radiation oncology daycare unit between January 1st and December 31st 2018 were collected. Patients without clinically measurable tumor lesions were excluded. Also those who had received concurrent and/or adjuvant chemotherapy have been excluded. The distribution of cancers, types of chemotherapy used and response rates were studied. Results: The median age of the study participants was 55 years (11-89 years). The most common cancers seen were cervical cancer in women and oral cavity cancers in men. Cisplatin + Paclitaxel was the most common regimen used for head and neck cancers (86 patients, 41.6% of head and neck cancers), cervical cancers (30 patients, 51.7% of cervix) and for gastrointestinal cancers (13 patients, 26% of GI). 248 (75%) of the patients were given palliative therapy and 80 (24%) were given neoadjuvant therapy. The response assessment was done for cervix and head & neck cancers for whom the imaging details were available. Out of 57 patients, 8.8% had complete response, 26.3% had partial response, 22.8% had stable disease and 42.1% patients had progressive disease. Conclusion: The most common solid tumors treated with neoadjuvant or palliative chemotherapy were oral cavity cancer followed by cervix cancer. Among cancers of the uterine cervix, head and neck, single agent methotrexate had produced the highest tumor response over other chemotherapy agents used either singly or in combination and older patients were found to have better objective tumor response.

 > Abstract: 374: Dosimetric evaluation of new radio photo luminescence glass dosimiter for patient specific quality assurance of three-dimensional conformal radiotherapy, intensity modulated radiation therapy and rapidarc Top

Kesavan Govindaraj, Senthilkumar Shanmugam

Vadamalayan Integrated Cancer Center, Madurai, Tamil Nadu, India, E-mail: [email protected]

Purpose and Objective(s): The main purpose of this study was to implement the new Radio Photo Luminescence (RPL) glass dosimeter for the IMRT and VMAT patient specific Quality Assurance and dosimetry using indigenously developed multi rotational phantom and also compared with pinpoint ion Chamber measurement. Materials and Methods: The multi rotational phantom was design for thoracic region. It has multiple provisions in both the Lungs, Heart, Surface, spine and Target region. The new RPL glass dosimeter was analyzed for its dosimetrics characteristic in photon beam. To determine the accuracy of the glass dosimeter in photon dose measurements, we compared the glass dosimeter and pinpoint chamber measurements using a indigenously developed multi rotational phantom. We investigated the feasibility of the glass dosimeter for the measurement of dose distributions near the superficial region for photon IMRT and VMAT plans with a varying separation between the target volume and the surface of 10 patients. The IMRT and VMAT plan is calculated on phantom to create patient specific quality assurance verification plan. The same plans were executed by setting the phantom under linear accelerator with RPL and Semiflex. This measured data was compared with the planning system data in each case and with both detectors. The unique manual rotation system provided on the both the lungs as well in heart. The rotation almost covers the whole lung and heart which allows as to measuring point dose on various positions. The rotation was accurately moved manual with the help of labeling on the surface for rotation position. Separate holder for RPL and semi flex chamber detector has been provided which allow as accurately position the detector. The phantom consists of 35 slices of PMMA material in an axial direction. Each slice has a dimension of 1 cm thickness, 35 cm length, and 20 cm height. And total thickness of the phantom is about 35 cm. Radio-Photo-Luminescence Glass Dosimeter (RPLGD) has many advantages of high sensitivity, low energy dependence, low fading effects, excellent dose linearity, and readout repeatability in photon beams. Five patient plans of IMRT and VMAT with thoracic lesions were selected for this work. RPL and Semiflex and multi rotational phantom were used for pre treatment patient specific QA. Results: The mean variation between two detectors is 1.8 % and the maximum variation is 2.85 %. The standard deviation is 0.098. The difference between the measured values for both the two detector in TPS as well as actual phantom measurements is less than 3% in all types of comparison which is very much acceptable. Conclusion: From this dosimetric study, we conclude that, the thorax rotational phantom with RPL AND semiflex chamber are suitable for routine IMRT patient specific QA purpose.

 > Abstract: 376: Can the western data on body mass index and cancer be implied on our patients? A retrospective single institutional study Top

M. Lithika Lavanya

Mysore Medical College, Mysore, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): BMI has proven to be an important and convenient marker that can be obtained in clinical setup. High BMI's relevance is shown in many diseases like hypertension, myocardial infarction , stroke, and also in cancers like breast, colon, endometrium. In our set up, we don't come across as much obese patients as in developed countries. And there are very few studies on the correlation between abnormal BMI & cancer per say, in our population, hence the need for this study. Materials and Methods: In the present study weight & height of cancer patients who were treated with chemotherapy and / or radiotherapy as a definitive or adjuvant modality or with palliative intent in K R Hospital (Mysore Medical College And Research Institute) from July 2010 to August 2019 was collected from data base. BMI was calculated using standard formula. The BMI was retrospectively analyzed for any correlation with cancer, in our population. We have also separately analyzed the most common cancers we see, like breast and head and neck and cervix, for any significant pattern of BMI changes. Statistical Methods: Categorical data is represented in the form of frequencies and proportions. Chi-square test was used as test of significance for qualitative data. Continuous data was represented as mean, median and standard deviation. Results: Mean age 53.10 ± 12.32 years and Median age 54.00 years. In the study 28.54% were underweight, 52.46% had normal BMI, 13.86% were overweight and 5.15% were obese. In the study there was significant association between age and BMI. Highest proportion of underweight were seen in the age group 51 to 60 years (30.83%), and highest proportion of obesity were seen in the age group 41 to 50 years (35.85%). Among males, 40.68% were underweight and 7.74% were overweight and 0.82% were obese. Among females, 19.97% were underweight and 53.58% were overweight and 8.24% were obese. Majority of our breast cancer patients fell under underweight category, majority of cervix cases & head and neck cancer patients had normal BMI. Conclusion: When a simple marker like BMI shows such changes, then we do have to be cautious & shouldn't blindly imply western data & data from developed countries on our patients.

 > Abstract: 378: Correlation between biological tumour control probability modelling and positron emission tomography computed tomography based response in locally advanced laryngeal cancer treated with volumetric modulated arc therapy Top

Manu Mathew, Suvankar Das, Subhashini John, Balu Krishna, Rajesh Isiah, Rabiraja Singh, Simon Pavamani

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

Purpose and Objective(s): The goal of Radiation therapy in general, aims at the maximum Tumour control Probability (TCP) and the minimal Normal Tissue complication Probability (NTCP).In routine use most of the radiation therapy centres use physical dose based optimisation for high precision Radiation Planning. Biological optimisation and Evaluation has been upcoming as it involves a more personalized dose delivery taking into account of the biological parameters. This study looked at the utility of biological evaluation with TCP modeling in Eclipse Planning system v13.7 and its correlation with PET CT based response in laryngeal cancer patients treated with Radical Chemoradiation. Materials and Methods: Eleven patients of Locally advanced Laryngeal cancer cell carcinoma treated with intensity modulated radiation therapy using Volumetric Modulated Arc technique was considered for this retrospective analysis.

Inclusion Criteria:

  1. Patients with Locally advanced laryngeal cancer treated with Radical Radiotherapy/ Chemoradiotherapy with VMAT
  2. Patients should be having baseline PET CT scan prior to treatment and having a response PET CT done around 10-12 weeks post treatment.

Demographic data was collected from the medical Records incuding Age, Sex, Diagnosis, Stage of the disease, EBRT dose, Clinical Response, Baseline and Response PET CT SUV (Standardised Uptake) values.Retrospective evaluation on the treated CT data sets was done. Biological evaluation developed by the Ray Search Laboratories (Stockholm, Sweden) which has been incorporated in the Eclipse Treatment Planning System version 13.7 (Varian Medical Systems, Inc., USA) was used for the present study. TCP-poisson LQ function was selected for the target tissues. Radiobiological parameters (D50, Gamma Value) was incorporated as per the tissue and stage of the disease. To reduce the uncertainty the Repair and Repopulation parameters was not incorporated for the evaluation. TCP (Tumour Control Probability) was reported as per Robertson Model which was present in the Model library. TCP values was plotted for different patients. Response PETCT done for all patients done after 3 months of completion of treatment was used for response assessment. Response was evaluated according to percentage change in SUV (Standardised Uptake Value). Correlation of TCP values with percentage SUV values was analysed using descriptive statistics. Results: All eleven patients had T3/T4 laryngeal cancers and and had recieved radical chemoradiation. All patients recieved 7000 cGy to high risk PTV. As per Robertsonian model D50 for these cases was 6500 cGy and Gamma value was of 1.8. Pretreatment PET CT mean SUV max was 14.99 and Post treatment mean SUVmax was 4.84. Among the eleven patients, nine patients (81.8%) had Complete/Partial response to PET CT and while two patients had progressive disease (18.1%). Average TCP values generated amount to 65.8%. Patients who had Progresssive disease on TCP modelling showed a value of 68.97 % and 67.73 % respectively which was above the average value. Conclusion: This study did not showed any correlation between TCP values (using biological evaluation tools) and PET CT based response. The drawback of this study includes the small sample size and lack of assessment of other confounding factors.This study does help in designing further studies using biological evaluation as a tool.

 > Abstract: 382: A rare case of primary orbital lymphoma in early age group Top

Prabhakar Gupta, Jyoti Dane

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

Background: Lymphoma of orbit are rare tumor comprising only 1% of all Non - Hodgkin's lymphoma. The majority of non-hodgkin's lymphomas of orbit are extra nodal marginal - zone B- cell lymphomas of mucosa associated lymphoid tissue (MALT) type lymphoma. Primary orbital lymphoma usually presents as a painless periorbital swelling with low grade proptosis and diplopia. Purpose: To present a rare case of primary orbital lymphoma. Methodology- A patient 17 yr old male came with complain of protrusion of left eye since 1 month patient was apparently alright 1 month back then patient complain of headache aggrevated at night and painless progressive proptosis of left eye. Incision biopsy was done. HPR suggestive of Non -hodgkin's lymphoma and IHC show CD- 20 Negative. We give 40Gy radiation in 20 fractions in 4 week and chemotherapy with CHOP regimen (cyclophosphamide, adriamycin, vincristin , prednisolone) 6 cycle. At completion of treatment patient are remain tumor free and patient kept on follow up. Discussion: Primary orbital lymphoma is an extremely rare condition and usually presents as a painless periorbital swelling with low grade proptosis and diplopia in a patient in his 6th or 7th decades. Conclusion: Primary orbital lymphoma is a rare tumor good response with chemotherapy (CHOP regimen) and radiation.

 > Abstract: 403: Comparative dose study with and without compensator using dosimetry by ion chamber in head and neck cancer Top

Tejaswita Singh, Anuj Tyagi, Ashok Kumar Arya

Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, E-mail: [email protected]

Background: In Head and Neck cancer cases the heterogeneity is the issue and need to be corrected. The dosimetric evaluation of the heterogeneity correction is important to evaluate dose coverage of superficial target volumes. The aim of this study is to compare the doses with and without compensators using ion chamber in treating head and neck cancer patients on a cobalt teletherapy unit. Materials and Methods: The present study was carried in Department of Radiation Oncology, SNMC, Agra. The duration of the study was two years. Six gel cubes (each of size 5 cm*5 cm*1 cm ) were fabricated using gelatin, distilled water and N -acrylamide, N,N'-methylene bis acrylamide, THPC) and thereafter were irradiated first for known dose of different doses viz 25 cGy, 50 cGy , 100 cGy, 200 cGy, 300 cGy, 400 cGy and CT scan (using factors 140 kV, 160 mA and slice thickness 5 mm) of the phantom was taken and optical densities were measured to get a calibration factor and estimate the linear dose range of the gel dosimetry. A wax phantom of these patients was prepared and between its two halves, three strips of wal (two of size 14 cm*2 cm*0.5 cm and one of 8 cm*2 cm*0.5 cm) were kept and irradiated with and without compensator. Thereafter dosimetry was done using ion chamber. Results and Discussion: The average Standard Deviation in the with and without compensator reading was 2.7 and 4.2. The result suggest that the gel dosimetry can be used with sufficient accuracy for clinical use. Compensators were found effective but not up to the mark, although further study need to be done with other dosimeters.

 > Abstract: 415: Cost analysis and overview of single versus multiple fraction palliative radiotherapy for painful bone metastasis Top

Vinodh Kumar Selvaraj, Deleep Kumar Gudipudi

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

Purpose and Objective(s): Bone is the third most common organ affected by metastases, after the lung and liver. Bone metastases represent a prominent source of morbidity in cancer patients. Radiotherapy offers effective pain palliation in such patients. Both single and multi-fraction radiotherapy treatment schedules have comparable pain control. However, other factors like re-irradiation rate, cost involved, opioid usage and radiotherapy machine load differ between the two schedules. Here, we have done a retrospective review of patients who received palliative radiotherapy in our institute. Materials and Methods: Case records, radiotherapy treatment plans and charts of patients who received palliative radiotherapy for painful bone metastasis in our institute between June 2017 to May 2018 were reviewed. The demographic features, sites of primary, metastatic bone sites, fractionation schedule used, re-irradiation rates and cost analysis were studied. Results: The study included 60 patients. Median age was 54 years (25-78). Male to female ratio was 1.1:1. Most common site of primary was lung (40%), followed by breast (21.66%) and site of bone metastasis was vertebra (51.8%), followed by pelvis (16.4%) and long bones (31.8%). Two-third of patients had metastasis to multiple bones. Multifraction radiotherapy was more preferred than single fraction (33.3%). Out of 60 patients, 4 were irradiated for second time and 7 underwent re-irradiation subsequently. Among single fraction RT, only 2 patients required reirradiation. Average cost for single fraction RT is Rs.13500. Whereas for multi-fraction schedules, the treatment cost ranges from Rs.20000 to 30000 and an additional cost for hospital stay, food and transportation ranges from Rs.10000 to Rs. 65000 based fractionation size, type of radiation, in patient ward charges. Conclusion: In a high volume cancer centers, single fraction palliative radiotherapy can be a cost effective alternative for pain palliation in bone metastasis patients with reduced re-irradiation rate and radiotherapy machine load.

 > Abstract: 421: Case Report Top

Amol Pawar

Government Medical College and Hospital, Nagpur, Maharashtra, India, E-mail: [email protected]

Plasmablastic malignant round cell tumor in HIV negative (immunocompetant) patient is an extremely rare disease. We present rare case of rapidly progressive, metastatic plasmablastic malignant round cell tumour in a immunocompetant female. A 40 years old female presented with bilateral lower limb weakness and a paravertebral mass since 1 month. Magnetic resonance imaging done at private hospital revealed that it was lobulated heterogeneously enhancing mass lesion involving multiple thoracic vertebral bodies and adjacent ribs with intracanalicular component compressing spinal cord, which on near total excision (done at private hospital) developed recurrence at same site within 2 months along with subsequent development of rapidly growing multiple similar soft tissue lesions in the body (anterior mediastinum, abdomen, bilateral breasts, with adjacent bone destruction). Histopathology and Immunohistochemistry of excised mass was suggestive of plasmablastic malignant round cell tumor (positive for CD 138 , MUM-1, CD 38, CD 30 and negative for CD 20, PAX 5 , ALK -1, Cycling D1). FNAC and Flow cytometry done from other lesions also confirmed the diagnosis of plasma cell neoplasm. Bone marrow examination was within normal limit. further evaluation was also done and Multiple Myeloma had been ruled out. Patient now has been started on CHOP regimen based chemotherapy.

 > Abstract: 423: Blockchain and Oncology Top

Nikhil Dhull, Joseph Varghese, Anil Kumar Dhull1

Christ, Deemed to be University, Bengaluru, Karnataka, 1Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Background: Till now many people think blockchain as the technology behind bitcoin and as a supporting framework for financial records, although it is somewhat true because bitcoin introduced blockchain in the market and not the other way around but what they don't know is that it is capable enough to do much more than this. Methodology and Results: Blockchain is simply a small part of an entire package, a distributed ledger technology that can be programmed to record and track anything of value no matter if it is a financial transaction, medical record, land title or some other uses. The major question is, we already had so many different processes to track and store all this information, then why Blockchain? The reason being:

  1. Ways to track and store data
  2. Creates trust in data
  3. No more intermediaries

In short, blockchain is a ledger of facts, replicated across several computers assembled in a peer-to-peer network. Facts can be anything from monetary transactions to content signature. Members of the network are anonymous individuals called nodes. All communication inside the network takes advantage of cryptography to securely identify the sender and the receiver. When a node wants to add a fact to the ledger, a consensus forms in the network to determine where this fact should appear in the ledger; this consensus is called a block and thus the name, “block-chain”. Now, you might be wondering what is the need of this technology in Oncology or medical field as such, the answer is that the current methods for diagnosis as well as treatment of various stages of cancer as well as the new methods that are currently worked upon generates an enormous amount of useful data that can be used to tackle the same scenario with better precision the next time it arises, but in reality, most of it gets wasted. Even though, at some places, using current technology, people are trying to make a ledger of as much data as possible but at each stage as the vital information is being passed on from patient to the doctor, then to treatment center and finally to pharmaceutical company. Manual documentation workflows increase the risks that important data will fall through the cracks, which could be catastrophic for the patient as well as to research. This data requires a safe and seamless interaction of multiple stakeholders in the overall process and that is why it can heavily benefit from the blockchain technology by utilizing the shared, secured and safe ledger that it provides. Conclusions: Thus, data collection and study using this automated ledger system provides a vast spectrum of diagnosis, treatment and research opportunities. Not only this, soon when blockchain technology develops, using AI and machine learning, we can co-relate the data of previously affected patients and deduce a simple and direct strategy to tackle various stages as well as causative agents of cancer in a better manner.

 > Abstract: 428: To evaluate the response rates of stereotactic body radiotherapy in extracranial oligometastasis Top

Mansi Sandip Shah, Geeta Narayanan

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

Aim and Objective of the Study: To evaluate response rates of SBRT in patients treated with extracranial oligometastasis. To assess the toxicity of the procedure. Materials and Methods: The patients with oligometastasis presented to the Department of radiation oncology Vydehi Institute of Medical Sciences and Research Centre were included in the study from Jan 2017 to June 2018 with sample size of 30. This is a hospital based, single arm, nonrandomised, prospective, interventional study. Site of the metastasis should be less than 3 and number of lesions should not exceeding 5. The total or maximum diameter of the lesion should not exceeding 7 cm were considered. The dose received varied according to site of metastasis. For Spinal metastasis a dose of 25 Gy in 5 fractions, for liver 45 Gy in 3 Fractions, for lung and scalp 24 Gy in 6 fractions and for lymph node 30 Gy in 5 fractions were given. All patients underwent PET CT before the treatment. Response evaluation was done according to RECIST CRITERIA 1.1 by either PET CT or CT scan after 3 months. Results: Thirty patients with extracranial oligometastasis who came to the department of radiation oncology in Vydehi hospital from the year January 2017 to June 2018 were treated with SBRT to the site of oligometastasis. In our study, a total of 30 patients were studied out of which 17 (56.7%) were female and 13 (43.3%) were male. we had varied primary site majority number of patients were primary breast cancer. Nineteen (63.3%) had skeletal metastasis and only 11 (36.7%) had organ metastasis three had Liver, four had Lung, two had scalp and two had node metastasis. Out of the 30 patients studied 13 (43.3%) of patients had stable disease, 9 (30%) had Progressive disease, 6 (20%) had partial response and only 2 (6.7%) had a Complete response according to RECIST CRITERIA 1.1. Twenty five (83.3%) patients were alive in the end of the study and five (16.7%) died during the study. Conclusion: SBRT can achieve good response without major morbidities. Long term follow up is required to evaluate survival benefit.

 > Abstract: 429: High dose image guided intensity modulated proton therapy for sacral chordomas: Early experience Top

Nagarjuna Burela, Srinivas Chilikuri, Sapna Nangia, Dayananda Sharma, Kartikeswar Patro, M. P. Noufal, Manoj G. Wakade

Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India, E-mail: [email protected]

Purpose and Objective(s): Proton therapy is considered standard of care for the treatment of spinal chordomas. Current study was undertaken to study the early experience of treating Sacral Chordoma with Intensity Modulated Proton Therapy (IMPT). The patient data of all chordomas treated at our centre are being captured prospectively under the purview of a chordoma registry trial. Current abstract reports dosimetric as well as early toxicity outcomes. Materials and Methods: Of the 6 patients treated so far, four had history of previous surgery, two had received prior radiation and one patient had both. All plans were generated using 3-4 field multi field optimization technique on Raystation Citrix version 7 and dose was calculated using Monte Carlo algorithm 4.1. Dose prescribed was 70.4 CGE (EQD2-74Gy) in 32 fractions to gross disease and 60-64CGE/32 fractions to the intermediate risk CTV (IRCTV). All patients underwent daily image guidance with KV imaging and CBCT. Surface guidance was used to monitor intra-fraction motion. Patients received treatment in prone position with empty bladder and optimal bowel preparation. Results: The median age was 56 years (35 to 64). The mean volume of GTV and IR CTV is 887cc (470-1345cc) and 2397cc (1338-3558cc) respectively. All patients completed the planned treatment without any interruptions. All accepted plans were robustly optimized to account for range uncertainty and setup errors upto 3 mm. Dose volumetric parameters achieved for target and OAR's were as per the clinical goals. Rectal mean V70, V65 and Dmax were 1.8%, 6% and 65.7 CGE respectively. The mean volume of sigmoid receiving 70Gy and 65Gy was 0cc and 0.13cc respectively. The mean of Dmax to sigmoid was 57.7CGE. The max doses to urinary bladder (15.5CGE) and bowel bag (V45 was 12cc) were clinically insignificant. The mean cauda equina dose max achieved was 56.37CGE. None of the patients had RTOG grade 3 bowel or bladder toxicity, two patients had grade 2 bowel toxicity, one had grade 2 bladder toxicity and two patients had grade 3 dermatitis. Conclusion: Delivery of image guided high dose IMPT is feasible in patients of sacral chordomas and early experience shows it is associated with minimal toxicities.

 > Abstract: 437: Short course radiation therapy and chemotherapy followed by delayed surgery in locally advanced rectal adenocarcinoma: Initial results of prospective study from a tertiary care centre Top

Sumeet Aggarwal, Swarupa Mitra, Abhinav Dewan, Inderjeet Kaur, Soumitra Barik, Abhiramasundari Vivekanandan, Kiran Dobriyal, Jwala Mukhee

Rajiv Gandhi Cancer Hospital, New Delhi, India, E-mail: [email protected]

Introduction: Short Course RT (scRT) and chemotherapy followed by delayed surgery and adjuvant chemotherapy was hypothesized to increase the pathological complete response (pCR), decrease distant failures and improves survival in locally advanced rectal cancer patients. Methods: Patients who underwent neoadjuvant short course radiation therapy, chemotherapy and underwent surgery were included in the present analysis. All scRT patients were planned by IMRT technique and given as continuous daily single fraction to the dose of 25Gy/5fractions/5 days. These patients then received FOLFOX based chemotherapy for 4-6 cycles, surgery and adjuvant chemotherapy. T3/T4 including synchronous liver metastasis patients was included in the study. Radiological evaluation was done by PET MRI at baseline and after completion of chemotherapy prior to surgery. Pathological response and toxicity evaluation was noted and analyzed in current study. Results: Twenty-three patients were analyzed in an intention to treat analysis enrolled between November 2018 and April 2019. All patients completed scRT. Metastatic (Liver) vs Non metastatic: 6/23 vs 17/23. Local surgery was done in 16 patients: 2/6 in metastatic group (post resection of metastatic disease) and 14/17 in non metastatic group till date. In metastatic cohort, 2 patients had progressive disease and 2 patients were lost to follow up. In non metastatic cohort, 1 patient refused for surgery and 2 patients were lost to follow up. Surgery was done in 16 patients: 10/16 had APR, 5/16 had LAR and 1/16 had total proctocolectomy (due to underlying ulcerative colitis). All patients achieved negative resection margins. AJCC pathological tumour regression grade (pTRG) was assessed: 5/16 (31%) has TRG 0 (Complete response), 7/16 (44%) patients had TRG 1 (Moderate/significant response), 4/16 (25%) had TRG 2 (Minimal response), No patient (0%) had TRG3 (Poor response). Four patients had node positivity and tumour deposits in surgical specimen in which 75% had a minimal response (TRG2). PNI positivity was found in 1/16 patients and it had a minimal response (TRG2). No patient had any break or required admission during radiotherapy. While on chemotherapy, >50% patients had grade 2 or more hematological toxicity. GI toxicity was assessed in terms of diarrhea, pain abdomen (colitis), need of supportive care and admission. No patient had grade 4 GI toxicity. Two patients had subacute intestinal obstruction which was successfully managed conservatively. Conclusion: Short course radiation therapy followed by adjuvant chemotherapy and delayed surgery is a well tolerated regimen with encouraging results and good pathological response rates. Long term results related to late effects and survival analysis are awaited.

 > Abstract: 443: Adaptive intensity modulated proton therapy planning – Indications, frequency, dos and don'ts, Apollo Proton Cancer Centre experience Top

Utpal Gaikwad, Srinivas Chilukuri, Sapna Nangia, Dayananda Sharma, C. H. Kartikeshwar Patro, M. P. Naufal, Rakesh Jalali, Manoj Wakde, Rajesh Thiyagarajan

Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India, E-mail: [email protected]

Introduction: This is a retrospective audit of treatment plans of all consecutive patients who were treated at our centre, over the last nine months specifically to address the need for treatment re-planning during a course of pencil beam scanning proton beam therapy (PBT). Patients and Methods: All 68 consecutive patients who were treated with PBT with pencil beam scanning technique from 2nd January till 30th September 2019 were included in this study. All plans using either single field optimization or multi field optimization or hybrid of both were generated on Raystation Citrix version 7 and dose calculated using Monte Carlo algorithm 4.1. All patients underwent daily image guidance with KV imaging and/or CBCT. Most patients underwent repeat CT (QACT) imaging every week of the treatment or as determined by CBCT. Paediatric patients underwent MR imaging and CT was only performed if the likelihood of need for adaptive re-planning was high. We noted deformations in target, OARs or patient anatomy and there by assessed the need for adaptive re-planning. IMPT plan was overlaid over QACT images to assess dose perturbations to target and OAR or to assess uncertainties and re-planning was performed based on the necessity. Results: Of the treated 68 patients 15 (22.1%) were chordomas, 13 (19.1%) were gliomas, 12 (17.6 %) head neck cancers, 6 (8.8 %) cranio-spinal irradiation, 5 (7.4 %) thoracic and 5 (7.4 %) prostate malignancies and 13 (19.1 %) were other subsites. 18 (26.5%) patients were of paediatric age (<18 years). Average 3 QA images (CT and or MR) acquired for each patients, and 208 QA CT images were analysed by treating physician and physicist for dose perturbations. Re-planning was done if any significant dose perturbations was noticed. 30 patients (54.4%) underwent Re-planning, of them 12 were HN cases, 11 were skull base and brain cases, 2 were pelvic, 5 were other subsites. Of the reasons of Re-planning most common was deformation in skin subcutaneous tissue 15 (50%), followed by deformation in target volume 9 (30%), deformation in organs at risk 3 (10%), deformation in structures in beam path such as sinuses 3 (10%). Conclusion: With robust IMPT planning, it is important to meticulously assess all patients during plan implementation with regular scheduled monitoring using appropriate clinico-radiological assessment for even minor deformation of target, organs at risk, and structures in beam path with multidisciplinary approach. Dose perturbations due to any such deformations stated above should be diagnosed earliest and corrected proactively so as to constantly achieve optimal planned target and OAR doses. This will translate precise benefits of modern proton therapy, limiting toxicities both acute and late and will help improve therapeutic ratio further.

 > Abstract: 445: Primary lymphoma femur: A rare case report Top

Blossom Chacko, Mahadevan Rajagopal, Harish Sugathan, R. K. Anand

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

Background: Primary bone lymphoma (PBL) is a rare presentation of non-Hodgkin's lymphoma. The most common histology being diffuse large B cell lymphoma, constituting for 80% of PBL. According to the WHO classification, primary bone lymphoma (PBL) is defined as a monostotic disease involving single skeletal site with or without involvement of the regional lymph nodes, or as a polyostotic disease affecting multiple skeletal sites without visceral or lymph node involvement. Here, we report a rare case of primary bone DLBCL involving proximal femur (left). A literature review of primary bone lymphomas is also discussed. Purpose and Methodology: To review the cited literature about primary bone lymphomas in the background of our case report Diffuse large B cell lymphoma proximal femur and to discuss the findings, treatment options and the outcome. Case Report and Review of Literature: A 61 year old woman was hospitalized with a history of fall followed by complaints of pain and restricted mobility of left thigh. Evaluation showed fracture of neck of femur and hence underwent hemiarthroplasty with modular bipolar prosthesis. Biopsy from femur showed dense lymphoid infiltrates with atypical lymphocytes. After 2 months she presented with swelling left thigh and on evaluation imaging showed bone destruction with swelling of 10x14 cm. Ultrasound guided biopsy revealed Diffuse Large B Cell Lymphoma NOS CD20+ CD5+ BCL6+ Ki67 50%. Staging evaluation with CT imaging of neck chest abdomen and pelvis was normal. Bone marrow aspiration and biopsy was normal. Serum LDH was also normal. She was diagnosed as DLBCL bone Ann Arbor stage 1AE (Bone), International Prognostic Index (IPI) score 1. She was treated with four cycles of chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) followed by involved field radiotherapy 30Gy in 15 fractions (2Gy/fraction). Post treatment evaluation was normal. PBL is defined as a single skeletal lymphoma with or without regional lymph node involvement, and multiple bone lesions without visceral or lymph node involvement. Its underlying causes are still largely unknown. PBL patients generally are characterized by localized bone pain, soft tissue swelling, and possibly a palpable lump in the lesion site. It commonly develops in patients aged between 20 and 50 years and has a male preponderance. The predilection site of PBL is the femur, accounting for 29% of cases, and others include the pelvis, humerus, skull and neck, and the tibia. Radiotherapy has been used alone or in combination with chemotherapy in primary bone lymphoma. Abbreviated chemotherapy with RCHOP along with involved field radiotherapy is a curative treatment for primary lymphomas of the bone. Conclusion: Although primary lymphoma of the bone is a rare entity, it must be considered in the differential diagnosis of the evaluation of bone lesion especially when accompanied by extraosseous soft tissue component.

 > Abstract: 446: Emerging role of stereotactic body radiation therapy in oligometastatic cancer: A hope in the horizon Top

Kiran Dobriyal, Maithili Sharma, M. Jwala, Swarupa Mitra, Abiramasundari Vivekanand, Abhinav Dewan, Inder Jeet Kaur Wahi, Sumeet Aggarwal, Soumitra Barik Ranjan

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

Purpose and Objective(s): The incidence of diagnosing metastasic disease has increased with the advanced diagnostic capabilities and have given a concept of Oligometastatic disease.So the question remains should oligometastatic disease be treated aggressively than its metastatic counterpart. Hellman first proposed the theory of oligometastases as a sequel to the spectrum theory of cancer metastasis.The ramification of a diagnosis of oligometastasis is a change in treatment paradigm, i.e. if the primary cancer site is controlled and the metastatic sites are ablated, a prolonged disease-free interval, and perhaps even cure, may be achieved. Oligometastatic disease is defined as a state between purely localised disease and widespread metastasis in which there are 5 or lesser clinically detectable metastatic lesion.Initially, metastatic disease was considered as an end stage disease with no curative treatment option.But now SBRT has emerged as a treatment of choice for oligometastatic disease. Historically Palliative therapy and best supportive care were the only treatments that were offered for metastatic disease irrespective of number of metastasis. Currently SBRT is one of the most recommended local therapy which is a highly conformal, non invasive form of ablative therapy in which high dose of radiation is given to metastatic lesions as a curative intent. In SBRT there is a steep dose gradient between the tumor and the surrounding normal tissue hence we can spare the Organ at risk in spite of giving high dose to tumor volume. Materials and Methods: From 2012 to 2018, 47 patients with 1-5 metastatic cancer sites were treated with escalating doses of SBRT (from 12Gy to 50 Gy, median dose -36Gy) dose to all known metastatic sites. Patients were followed with either PET CT, CT scan or MRI every 3 monthly. Results: A total of 47 patients were registered at our institute with mean age of patients were 55 years (Range 28-81), Patient cohort comprised of oligo-metastatic disease from different primary sites. 10 patients had metastatic site in liver, 6 had in brain, 7 in lung, 2 in adrenal and others miscellaneous sites were included. SBRT was delivered to a dose of 12-50Gy (mean dose 36 Gy) in 4 to 10 fractions every alternate day by either IGRT technique or respiratory gating techniques.Median Follow up was 5 months.Out of 47 patients 21 (44%) showed partial response, 10 (4.7%) showed progressive disease, 2 had stable disease after treatment with SBRT. overall Median PFS was 6.5 months. Median PFS for Lung was 7 months, Median PFS for Liver was 2 months, Median PFS for brain was 3 months. Conclusion: SBRT remains a viable treatment option for patients with limited metastatic disease with high rates of local control and minimal toxicity.

 > Abstract: 458: Multiple myeloma with central nervous system infiltration Top

Nikhil Bathija, U. Suryanarayan, Maitrik Mehta, Pooja Patel, Sonal Patel, Jyoti Poddar

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

Introduction: Multiple Myeloma presenting with central nervous system (CNS) Infiltration is Rare. Therefore it poses Diagnostic and Treatment Challenges. The Prognosis remains Poor. Case: A 55 year old female, presented to our institute with Chief complaints of Backpain, Vomiting and generalized Bodyache. On Clinical examination and thorough investigations it was diagnosed to be a case of Multiple Myeloma. The patient was on Bortezomib and Zolendronic acid. After 9 cycles patient developed Headache, Vomiting and ptosis of Right eye. MRI of Brain showed Hyperintensity in Brain parenchyma and CSF Cytology involved by Multiple Myeloma. Patient was started on triple agent Intrathecal Chemotherapy with Whole Brain Radiotherapy (WBRT) with parallel opposed fields at 3 Gy/# 5 days a week for total 10# on linear acclerator. The treatment was uneventful. After the completion of treatment CSF Cytology was negative. The patient is symptomatically better and is currently on tablet Thalidomide. Conclusion: CSF positive Multiple Myeloma is rare entity with grave prognosis. Although there are no defined treatment guidelines, Whole brain RT amd triple Intrathecal Chemotherapy may improve.

 > Abstract: 464: Osteosarcoma with breast metasatsis 5 cases reported worldwide Top

Dinesh Anand, Jyothi Poddar, Ankita Parikh, Maitrik Metha, U. Suryanarayana, Pooja Patel, Sonal Shah, Niketa Thakur

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

Metastasis to breast from extra-mammary malignancies is uncommon. Most metastatic breast tumors are from the contra-lateral breast. Osteosarcoma most commonly metastasizes to lungs and extra-pulmonary metastasis in osteosarcoma is extremely rare. We report a case of an 18 year old female who presented with osteosarcoma of right humerus with metastasis to right breast, owing to its rarity. Only 5 cases have been reported till date, to the best of our knowledge. Case Report: An 18 year old girl a known case of osteosarcoma of right humerus, presented with pain and ulceration if right breast. She had received three cycles of Adriamycin and Cisplatin followed by wide local excision of the tumour and right proximal humerus in February 2018. Histopathology reports showed osteosarcoma- blastic type. All margins and cut end of bones were free. Following surgery, the patient received seven cycles of Ifosfamide and Cisplatin till April 2018. CT scan of thorax, in October 2018, revealed multiple nodules in both lungs. Patient was on palliative chemotherapy. PET scan, post palliative chemotherapy in April 2019, showed a lesion of size 4.1x4.2x4.3 cm in upper outer quadrant of right breast. There were other metastatic deposits in both lungs with SUV- 4.0. Multiple nodes were found in retro-peritoneum. Biopsy from the breast lesion was consistent with metastatic osteosarcoma. In July 2019, on clinical examination, a hard fixed mass of size 10 x10 cm in upper outer quadrant, central quadrant and upper inner quadrant was palpated. It was fixed to skin and a bleeding ulcer of the size 2x2 cm with involvement of skin was seen. It was painful and tender. Palliative radiotherapy of dose 30 gray in 10 fractions was delivered on linear accelerator The patient had relief in bleeding and pain. The patient was offered mastectomy and flap reconstruction. The patient is currently on follow up and is aymptomatic. Palliative chemotherapy is planned for the retroperitoneal lymph node deposits. Discussion: Osteosarcoma, the most common bone malignancy, often metastasizes to lungs. Breast and other soft tissues per se, are very rare sites for distant metastasis. Prognosis of patients with extra-pulmonary metastasis is very poor. Although, primary osteosarcoma of breast is rare, few cases have been reported in literature. The incidence of osteosarcoma with breast metastasis is even rarer. Breast metastases from extra-mammary malignancies are uncommon, the clinically observed rates being 0.5 to 1.3%.The most common sources are lymphomas/leukemias and melanomas. The rarity of breast metastasis is due to large volume of fibrous tissue in the breast and poor blood supply. No predisposing factors have been identified for metastasis to breast. Estrogen may increase the vascularity and stroma of the breast, and may have a role as a predisposing factor in the development of a metastasis. In accordance with this hypothesis, most reported cases have occurred in younger women. Conclusion: There are no specific management guidelines for this extremely rare condition. The purpose of this case report is to draw the attention towards its rarity and management.

 > Abstract: 466: Application of molecular imaging in radiation oncology Top

Anil Kumar Dhull, Sheeba Bhardwaj, Vivek Kaushal

Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Objective: Molecular imaging (MI) is the direct or indirect noninvasive monitoring and recording of the spatial and temporal distribution of in vivo molecular, genetic and cellular processes for biochemical, biological, diagnostic, or therapeutic applications. Pathways targeted in MI are cell metabolism, cell proliferation, hypoxia, apoptosis, angiogenesis and certain receptors. The rationale behind MI is that it allows the biological processes taking place in the body to be viewed at cellular and molecular level often well before they would be seen on CT or MRI, which enables to identify the disease in its early stage. Imaging probes are required that target these specific pathways which are then detected by various molecular imaging techniques, which are Positron Emission Tomography (PET), Computed Tomography (CT), Magnetic Resonance Imaging and Spectroscopy (MRI/MRS), Contrast Enhanced Ultrasonography (CEUS) and Optical Imaging (OI). Methodology: Literature search was done on the web for the various molecular imaging techniques in oncology and their potential role in cancer management. Results and Discussion: MI is useful in diagnosis and staging, target definition and response assessment (early and late). For diagnosis and staging FDG PET-CT Scan is used most commonly in diagnosis of primary and metastatic lung cancer, solitary lung nodule, staging of node positive head and neck cancer, staging of lymphoma and esophageal cancer, occult primary in head and neck cancer, metastatic disease (bone metastasis from non-small cell lung cancer, hepatic metastases from colorectal, gastric, and esophageal cancers, internal mammary chain lymph node metastases in breast cancer, metastatic melanoma), recurrent disease in ovarian, uterine, cervical and thyroid cancers. SPECT is used to detect prostate specific membrane antigen which helps in diagnosis of both skeletal and soft tissue diseases in prostate cancer. MRS is used for diagnosis of prostate cancer. Integrated PET/CT systems are used for target definition. PET-CT produces anatomic and metabolic images of the patient during a single procedure in the treatment position. PET-CT is used for target definition in esophageal, cervical, SCLC, NSCLC and pancreatic cancer. The literature indicates 84-87% specificity and 88-93% sensitivity of FDG-PET in various oncology applications. MI can also be used to assess the treatment response. Early response assessment is done during the course of radiotherapy and it serves as an early predictor of treatment outcome and potentially allows the therapy to be adapted in order to maximize its benefit known as biologically adaptive radiotherapy. Late response assessment is done after the completion of radiotherapy and it serves as a late predictor of treatment outcome. Conclusion: With the better understanding of the pathophysiology of cancer developments have been made in multimodality treatment of cancer; comprising surgery, radiotherapy and molecularly targeted anti-cancer agents. MI is emerging as a strong technique in the management of cancer and radiation treatment planning and can play an important role by early disease detection, diagnosis & staging, selecting targeted therapy, treatment planning and treatment monitoring. The ability of MI to detect abnormalities very early in the progression of disease has the potential to detect and cure disease in its most treatable phase.

 > Abstract: 469: Comparison of three palliative radiation schedules in bony metastasis Top

Rajeev Atri, Pawan Kumar, Anil Kumar Dhull, Rakesh Dhankhar, Vivek Kaushal

Pt. B.D.Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, E-mail: [email protected]

Objective: Bone metastases are a common manifestation of malignancy that can cause severe and debilitating effects including pain, spinal cord compression, hypercalcemia, and pathologic fracture. Radiation therapy (RT) provides successful palliation of painful bone metastases that is time-efficient and associated with very few side effects. The management of bone metastases includes radiotherapy, chemotherapy, hormone therapy, surgery, radionuclide and supportive therapy alone or in combination. The American Society for Radiation Oncology (ASTRO) initially published Palliative Radiotherapy for Bone Metastases. With the present study we compared three schedules of EBRT (6Gy single session, 8Gy single session and 10Gy in 2 fractions, 1 week apart) in bony metastasis. To compare pain relief and performance status before and after treatment in three groups. Methodology: The study is conducted on 30 randomly selected histopathologically proven patients of malignancy with bony metastasis from any primary site. Patients were divided into three groups with 10 patients in each group. Group-I, patients received palliative EBRT 6Gy single session to involved site. Group-II, patients received palliative EBRT 8Gy single session to involved site and Group-III, patients received palliative EBRT 10Gy in 2 fractions, 1 week apart to the involved site. Pain was assessed using Glasgow's pain scale and functional outcome was assessed using KPS and ECOG scale. Results and Discussion: The patients were assessed weekly for one month than monthly for six months for pain relief using Glasgow's pain scale and for functional outcome using KPS and ECOG scale. It was observed that pain relief was observed maximum in Group-III. The most common primary site found to be prostate carcinoma in 15-patients, lung cancer in 8-patients and breast cancer in 7-patients. Conclusions: Updated data analysis confirms that radiation therapy provides excellent palliation for painful bone metastases. It is also observed that all the three schedules of palliative RT are effective in bony metastasis with maximum effectiveness is seen in Group-III.

 > Abstract: 471: Dosimetric and early clinical experience with total marrow/lymphoid irradiation Top

Sham Sundar C, Srinivas Chilukuri, Rajesh Thiyagarajan, Mayur Sawant, Ganapathy Krishnan, Minnal Mookaiah, P. Manivasakar, Dayananda Sharma, Rakesh Jalali

Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India, E-mail: [email protected]

Background: Total marrow irradiation (TMI) / Total Marrow and Lymphoid irradiation (TMLI) is a radiotherapy treatment technique that targets bone marrow, lymphoid tissue, spleen and sanctuary sites prior to stem cell transplantation (SCT) in various hematological disorders. We hereby report our dosimetric and early clinical experience in patients treated with TMI/TMLI using Helical Tomotherapy at our center. Materials and Methods: Patients were immobilized in a thermoplastic mask from the head to shoulders and the rest of body in a whole body vacuum cushion. CT scanning and treatment were performed in two parts- Head first supine (HFS) and Feet first supine orientation (FFS) with field matching at mid thigh. Target consisted of entire skeleton, spleen, sanctuary sites (Brain, testes if applicable) for TMI and the target included major lymph node chains additionally for TMLI. Lungs, kidneys, mucosa of the aero-digestive track (MM), bowel, heart and liver were defined as organs at risk (OAR). Results: From March 2019 to September 2019 two patients diagnosed with Chronic Myeloid Leukemia (blast crisis) and 1 with Pre-B-cell acute lymphocytic leukemia underwent TMI/TMLI before SCT. Radiotherapy was delivered from day -7 to day -5, in 2 daily fractions of 2Gy each with at least 8 hours gap between each fraction. Plan setup parameters were defined to meet the clinical goal of 100% of the prescribed dose to cover 60% of the PTV and a minimum of 90% of prescribed dose to cover 95% of the PTV with pitch between 0.3 - 0.43, field width of 5 cm, modulation factor of 2.5 - 3.5 for HFS and 2.15 - 2.5 for FFS orientation respectively. Target coverage and OAR doses are described in [Table 1]. The time requirements for treatment planning were: contouring took 5–6 h, optimization and dose calculation 36–48 h and quality assurance 1–2 h. The in-room time per fraction was 2 h on day one, decreasing to around 1.5 h for the rest, including setup, positioning verification, in-vivo dosimetry and irradiation. Using cheese phantom and ionization chamber, point dose measurements were calculated at 3 positions for HFS plan and 2 positions for FFS plan. In vivo film dosimetry was carried out to verify junction dose. All patients completed their treatment with no Grade 3+toxicity. All the 3 patients successfully engrafted and are in good health at last follow-up. Conclusion: Although TMI/TMLI is time and labor intensive, we have demonstrated that plans with good PTV coverage, improved OAR sparing can be delivered safely and robustly in a clinical setting.
Table 1:

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 > Abstract: 478: Non-Hodgkins lymphoma of heart: A rare presentation Top

Amalu Augustine

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

Introduction: Non-Hodgkins lymphoma of heart is an extreme rare presentation, which constitutes about less than 0.01% of all cardiac tumors. The clinical symptoms of cardiac lymphomas are non-specific, which makes magnetic resonance imaging (MRI) and echocardiography as effective tools of investigation. Chemotherapy remains the mainstay in the treatment of cardiac lymphoma, assuring improved survival and outcome. Although cardiac lymphoma is associated with poor prognosis and life-threatening complications, timely and appropriate treatment can be beneficial. Case Report: A 63 year old male presented with chest pain and breathlessness of one month duration. On examination vitals were stable. Trans-esophageal echocardiogram revealed a large non-homogeneous right ventricular mass and left ventricular ejection fraction (LVEF) -52%. 3T-MRI- neck, thorax, abdomen and pelvis showed an irregular solid mass lesion involving right ventricle, measuring 10.6 cmX 6.8 cm X 9 cm. Endocardial component of the lesion was encasing the tricuspid valve, causing significant obstruction. Enlarged lymph node was seen in left para-aortic region measuring 4.8 cm X5.3 cm. Guided biopsy from para-aortic nodal mass showed NHL-DLBCL- LCA-diffuse positive, CD-20- positive. Staging evaluation with CECT- neck, thorax, abdomen and pelvis revealed only enlarged para-aortic lymphnodes. Bone marrow aspiration and biopsy were normal. Serum LDH was within normal limits. Hence, he was diagnosed as a case of NHL-DLBCL stage 3 (Ann Arbor staging system)- IPI score-4. He was treated with one cycle of R-COP chemotherapy following which, evaluation with a trans esophageal echocardiography showed complete disappearance of the cardiac mass and LVEF-65%. Considering the complete resolution of the cardiac mass and improvement in LVEF, fitness for anthracyclin chemotherapy was obtained from cardiology department and from second cycle onwards patient received R-CHOP chemotherapy for the remaining five cycles. Post-treatment evaluation with PET-CT showed remission of the disease. Cardiac evaluation with echocardiography showed good LVEF. Discussion: Cardiac lymphoma is a rare cardiac neoplasm with slight male predominance; median age at diagnosis is 63 years. Involvement of the right side of the heart predominates in cardiac NHL. DLBCL is the most common pathological variant of cardiac NHL. The major clinical features of cardiac lymphoma include dyspnea, precordial pain, pericardial effusion and shock due to cardiac tamponade. Diagnosis relies mainly on TEE and cardiac MR findings. TEE has a sensitivity of 97–100%. The sensitivity of cardiac MRI is superior to that of CT (90–92 vs. 71–73%). At present, no definite guidelines exist for the management of cardiac NHL. Early systemic chemotherapy appears to be the only effective therapy. The major regimen is the same as that for other types of NHL, i.e. CHOP chemotherapy and since 2001, CHOP + rituximab. Chemotherapy followed by radiotherapy for cardiac lymphoma may enhance survival, although its efficacy remains to be determined. The overall response rate to chemotherapy is 79% and the complete remission rate is 59%. Conclusion: Cardiac lymphoma is a rare cardiac neoplasm. This tumour is fatal unless diagnosed and treated in time. At the moment the most effective treatment is chemotherapy.


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