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   Table of Contents - Current issue
Coverpage
April-June 2021
Volume 12 | Issue 2
Page Nos. 39-88

Online since Monday, June 21, 2021

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EDITORIAL  

Early indications of clinical trials direct toward need of research for successful low-dose radiation therapy for COVID-19 pneumonia p. 39
Badri Narain Pandey
DOI:10.4103/jrcr.jrcr_12_21  
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ORIGINAL ARTICLES Top

The importance of hemoglobin levels before and during chemoradiotherapy in locally advanced carcinoma cervix p. 41
Lanisha Jolitha Sequeira, Donald Fernandes, Sharaschandra Shankar, MS Athiyamaan, Sandesh B Rao, MS Vidyasagar, V Mohsina, Sheeba Santhmayer
DOI:10.4103/jrcr.jrcr_66_20  
Purpose: Carcinoma cervix forms a major burden among malignancies in women in India. Anemia is very common among Indian women and a high proportion of carcinoma cervix patients present with anemia. Previous studies show that hemoglobin level may be considered as a prognostic factor in carcinoma cervix. It has been observed that anemia is associated with diminished radiocurability in patients with carcinoma of the cervix. However, the therapeutic benefit of the measures to correct anemia remains debatable. The objective of this study was to evaluate the association of hemoglobin concentrations and its correction by blood transfusions before and during treatment and the response to chemoradiation. Materials and Methods: Fifty patients with histologically proven squamous cell carcinoma of the cervix (Stage II to IV) from December 2018 to May 2020 were taken up for this study. Patients received definitive chemoradiation of 50 Gy in 25 fractions, 2 Gy/fraction, 5 fractions per week, along with-weekly injection cisplatin/carboplatin, followed by brachytherapy. All patients had their pretreatment hemoglobin levels measured at the first consultation. The effects of hemoglobin concentrations at presentation and during therapy on the clinical response to radiotherapy were studied. Blood transfusions and the time point when transfusions were given were recorded. Results: Eighteen patients received packed red blood cell transfusion before the start of radiation therapy and 9 patients received packed cell transfusion during radiation therapy. Out of the 18 patients who received transfusion before RT, 3 patients had complete response. Out of the 9 patients who received transfusion during radiation, 4 had complete response. The presence of anemia had a significant impact on the response rate. Pretreatment anemia was associated with poor response and local control among patients who underwent chemoradiotherapy for cervical cancer. Conclusion: Pretreatment hemoglobin and hemoglobin levels during radiation therapy were prognostic factors for local control, in addition to stage and histology, which might have independently predicted the outcome.
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Diagnostic reference levels for head and abdominal computed tomography of adult patients in selected states in South-South Nigeria p. 46
Anwuli Christiana Tobi, Chukwuka Emmanuel Mokobia, Joyce Ekeme Ikubor, Akintayo Daniel Omojola, Maryann Etim Ekpo, Anita Franklin Akpolile
DOI:10.4103/jrcr.jrcr_67_20  
Context: Diagnostic reference level (DRL) is the first step in the optimization process to manage patient dose corresponding with the medical purpose. Aim: The objective of this study was to develop local DRL for computed tomography (CT) of the head and abdomen in adult patients in four CT centers in South-South Nigeria. Materials and Methods: A prospective, cross-sectional study of 546 adult patients that underwent CT examination of the head and abdomen from 2018 to 2020 using four different CT scanners. Volume CT dose index (CTDIvol) and dose length product (DLP) of contrast and non-contrast CT examinations of the head and abdomen were collated and the 50th percentile DRL was determined and compared to other published DRLs. Results: The 50th percentile CTDIvol/DLP for non-contrast head CT examination for centers A, B, C, and D was 75.3 mGy/1776.6 mGy.cm, 21.8 mGy/457 mGy.cm, 17.4 mGy/373.6 mGy.cm, and 29.6 mGy/628.5 mGy.cm, respectively. The 50th percentile CTDIvol/DLP for contrast head CT examination for centers A, B, C, and D was 150.6 mGy/3326.2 mGy.cm, 41.4 mGy/832.4 mGy.cm, 35.6 mGy/653.6 mGy.cm, and 77.9 mGy/1458.4 mGy.cm, respectively. The 50th percentile CTDIvol/DLP for non-contrast abdomen CT examination for centers A and B was 22.8 mGy/1488.5 mGy.cm and 7.9 mGy/302.3 mGy.cm, respectively. The 50th percentile CTDIvol/DLP for contrast abdomen CT examination for centers B and C was 19.6 mGy/825.7 mGy.cm and 31.5 mGy/1555.5 mGy.cm, respectively. There was correlation between contrast and non-contrast CTDI (P = 0.003) and DLP (P = 0.025) for the head. Conclusion: Wide variations CTDIvol and DLP values were observed among the centers for similar body part CT examinations.
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Clinical-radiological prognostic factors in patients with brain metastasis-A retrospective study from a tertiary care centre In Easten India p. 53
Rashmi Singh, Anup Kumar, Praveer K S Munda, Rajanigandha Tudu, Payal Raina
DOI:10.4103/jrcr.jrcr_4_21  
Background: Brain metastasis (BM) is the most common (MC) intracranial tumor in adults. The outcome depends upon prognostic factors (PF) and optimal use of multimodality treatment. Objectives: We aimed to know clinicoradiological PF and their correlation in BM patients. Materials and Methods: Retrospectively, 19 BM patients treated with radiotherapy (RT) for the same between January 2018 and December 2019 were selected. Details of age, sex, Karnofsky performance status (KPS), recursive partitioning analysis (RPA), primary diagnosis, histopathology report, imaging details for BM-number, size and location, extracranial metastasis (EM), and primary tumor control (PTC) status were collected from the physical records. Descriptive statistics for the categorical variables and Bi-variate Spearman correlation were used to analyze the correlation between BM size, number, type of primary (TOP) with RPA, KPS, age, gender, PTC, and EM individually using the SPSS software version 20. Results: 84.2% of patients were <65 years age and 57.8% were males. Lung cancer was the MC primary (73.7%). The PF in majority were KPS <70 (52.6%), RPA III (52.63%), multiple BM lesions (73.7%), uncontrolled primary (78.9%), and BM size >1.5 cm (84.2%). EM was observed in 31.6% patients. 94.73% and 68.4% of patients received whole-brain RT and systemic treatment, respectively. The maximum duration of FU was 12 months and 78.9% of patients were lost to FU post-RT. Significant correlation was observed between BM size and RPA class, KPS (R = 0.456; P = 0.049), and TOP correlated with gender (P = 0.028) and PTC (P = 0.000). However, no significant correlation between the age, RT dose, EM, number of lesions and RPA, PS (P = 0.339). Conclusions: The presence of multiple poor PF in majority of our patients and their poor follow-up indicate inertness toward health issues. Furthermore, larger BM lesions correlated with higher RPA suggesting poor outcome, so treatment modality to be judicially selected. The positive correlation between gender, PTC and primary cancer, and their prognostic role in BM should be validated in the larger studies.
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Dosimetric parameters predicting radiation-induced oral mucositis in head-and-neck cancers in two intensity-modulated radiation therapy protocols: A retrospective analytical study p. 59
Paul Simon, Donald J Fernandes, Sandesh B Rao, MS Athiyamaan, MS Vidyasagar, Sharaschandra Shankar, V Muhsina, S Sheeba
DOI:10.4103/jrcr.jrcr_65_20  
Background: In locally advanced head-and-neck cancers (HNCs), definitive chemoradiation therapy has emerged as the treatment of choice due to the benefit of organ preservation. Radiation therapy is known to cause significant acute and late toxicities when it is used at radical doses. Studies have shown that more severe toxicities such as mucositis were observed in patients who received radiation therapy with concurrent chemotherapy. Incidental radiation exposure to buccal mucosa during radiation therapy for HNCs contributed to acute radiation-induced oral mucositis (RIOM). Objective: The objective of the study was to dosimetrically evaluate the dose received by buccal mucosa in patients with HNC patients undergoing sequential intensity-modulated radiotherapy technique (SEQ-IMRT) and simultaneous integrated boost intensity-modulated radiotherapy technique (SIB-IMRT). Materials and Methods: Forty patients with histologically proven squamous cell carcinoma of head and neck excluding nasopharyngeal and oral cavity cancers, who received radical chemoradiation therapy by SEQ-IMRT or SIB-IMRT were retrospectively analyzed. The total prescribed dose to the planning target volume was 70 Gy delivered in 2 Gy daily fractions in SEQ-IMRT and 66 Gy in 30 fractions in SIB-IMRT. All patients received concurrent weekly injection cisplatin (35 mg/m2). Dosimetric parameters of right and left buccal mucosa (V 15 Gy, V 30 Gy, and V 45 Gy) were recorded and correlated with grades of RIOM and weight loss as per CTCAE v5.0. Results: Mucositis and weight loss were accessed from week 1 to 7 in the SEQ-IMRT arm and week 1–6 for SIB-IMRT arm. Grade 3 mucositis was observed among 2 patients (10%) and 3 (15%) patients in the SIB-IMRT and none in SEQ-IMRT arm. Grade 2 Weight loss was observed among 35% of patients in SIB-IMRT arm and 5% patients in SEQ-IMRT arm. Conclusion: This study assessed the occurrence of several RIOM as predictive factor with respect to dose received to buccal mucosa in HNC patients, except nasopharyngeal and oral cavity cancer. Our data demonstrated relationship between V30 Gy of buccal mucosa and oral mucosal toxicity with associated weight loss in patients with HNCs undergoing radical chemoradiation therapy.
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Dosimetric evaluation of dorsal vagal complex and vestibular apparatus in head-and-neck cancer patients treated with intensity-modulated radiotherapy p. 65
Tauseef Ali, Anuradha Singh, Anand Parab
DOI:10.4103/jrcr.jrcr_6_21  
Purpose: The purpose of this study was to dosimetrically evaluate the dose received by dorsal vagal complex (DVC) and vestibular apparatus in patients with head-and-neck cancer treated with intensity-modulated radiotherapy (IMRT). Materials and Methods: Twenty histopathologically confirmed head-and-neck cancer patients, preferably oropharynx and nasopharynx that were treated with IMRT from a period of 2018–2020, were retrospectively analyzed in this study. DVC and vestibular apparatus were contoured, and the doses received by them were noted. Results: The average minimum dose to the entire DVC and vestibular apparatus was 25.134 Gy (range, 8.77–37.49 Gy) and 12.812 Gy (range, 1.07–28.57 Gy); the average maximum point dose to the DVC and vestibular apparatus was 35.896 Gy (range, 24.29–45.53 Gy) and 33.266 Gy (range, 3.19–60.72 Gy); and the average mean dose to the entire DVC and vestibular apparatus volume was 30.151 Gy (range, 16.48–40.83 Gy) and 21.484 Gy (range, 2.99–39.42 Gy), respectively; the average volume of DVC and vestibular apparatus was 0.52 cm3 (range, 0.3–0.8 cm3) and 0.36 (range, 0.2–0.6 cm3), respectively. Conclusions: Considering the DVC and vestibular apparatus as an organ for conformal avoidance, there can be a possibility in the reduction of nausea and vomiting while treating patients of head-and-neck cancer with radiation.
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Dosimetric analysis and acute toxicity comparison of bone marrow sparing intensity-modulated radiation therapy versus three-dimensional conformal therapy with concurrent chemotherapy for the treatment of cervical carcinoma: A prospective single institutional study p. 70
Ghritashee Bora, Apurba Kumar Kalita, Mouchumee Bhattacharyya, Moirangthem Nara Singh, Partha Pratim Medhi, Shashi Bhushan Sharma, Shashank Bansal, Moumita Paul
DOI:10.4103/jrcr.jrcr_53_20  
Background: The aim of the study was to compare the dosimetry and acute toxicities of bone marrow sparing intensity-modulated radiation therapy (BMS-IMRT) and three-dimensional conformal radiation techniques (3DCRT) in locally advanced cervical cancer. Materials and Methods: This is a hospital-based prospective randomized study and histologically proven locally advanced cervical carcinoma patients were selected for the analysis. A total of thirty patients were equally allocated in the two treatment arms: BMS-IMRT and 3DCRT. External beam radiation therapy was delivered to a dose of 50 Gy/25# followed by high dose rate brachytherapy along with concurrent chemotherapy. The target volumes and the organs at risks were delineated. The BM comprised pelvic BM (PBM); lumbosacral BM (LSBM); ilium BM (IBM) and Ischium, Pubis and Pelvic femora together constituting lower PBM (LPBM). Results: BMS-IMRT was superior to the 3DCRT arm in reducing the dose to the PBM, small bowel, rectum, and bladder. On comparison of the BM dose volume histogram, the P value was significant (BMS IMRT vs. 3DCRT) in the higher dose range (30 and 40 Gy) for the IBM, LPBM, and whole pelvis BM. However, the difference in the low-dose irradiation (10 and 20 Gy) region was not significant. Furthermore, in the LSBM region, BMS IMRT was superior at all dose levels with no significant P value. Acute toxicities were higher in the 3DCRT arm. Conclusion: Thus, BMS-IMRT resulted in significant reduction of dose to the PBM. This can help in reducing the hematologic toxicities associated with pelvic radiation.
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Severe acute respiratory syndrome-coronavirus-2 (COVID-19) infection and its impact on cancer patients receiving radiation therapy: Prevalence, protection, and clinical effects p. 77
Kannan Venkatesan, J Anand Vivek, Deshpande Sudesh, Umbarkar Prakash, Ranjit Bajpai, Rohit Kabre, Ritika Hinduja, Priyanka Alurkar, Suresh Naidu, Kamalnayan Chauhan, Sandeep Shinde, Neeta Parmar, Ashwini Jejurkar, Prashant Kamble, Santosh Ullagaddi, Omkar Jadhav, Madhvi Tawde, Jyothy Nambiar, Ravindra Rohekar, Preeti Goraksha, Rajasi Dharia
DOI:10.4103/jrcr.jrcr_52_20  
Introduction: COVID-19 illness caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus has been declared a pandemic by the World Health Organization in March 2020. It had an overwhelming effect on health-care delivery in India. We report the 5 months, April–September 2020, experience in our radiotherapy (RT) department. Methods: Since April–September 2020, we registered 184 cancer patients with various site diseases for RT/chemoradiation treatment for curative/palliative therapy. Preregistration and weekly once during treatment period all underwent throat/nasopharynx swab testing with reverse transcription polymerase chain reaction. Dedicated infection prophylaxis was carried for patients and staff. Results: Of the 184 patients, 10.9% (20/184) swab results were positive for SARS-CoV-2. With appropriate COVID-19 care and quarantine, 18 patients completed the planned RT. Two died with COVID-19 infection illness and progressive locoregional cancer. We observed no excess acute RT/chemoradiation effects in this group due to infection. Conclusions: Our 5-month experience in this COVID-19 pandemic period reveals that RT treatment, COVID-19 care, and quarantine can be done with dedicated infection protective measures.
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CASE REPORTS Top

Unusual clinical accompaniment of inflammatory thyroiditis preceding hypothyroidism in radiotherapy of head-and-neck cancer p. 82
Vijaya Aditya Yadaraju, Aditya Narayan, Shilpa Kandipalli, Praveen Adusumalli, Sweta Sinha, Prabhakar Rao Vatturi Venkata Satya
DOI:10.4103/jrcr.jrcr_41_20  
The authors report an unusual clinical phenomenon of head-and-neck radiotherapy-induced thyroiditis presenting with clinical features of hyperthyroidism on immediate clinical follow-up with raised thyroid hormone levels. Conventional technetium thyroid scan showed a discordantly absent thyroid gland uptake instead of expected thyroid avidity in hyperthyroidism. The thyroid gland subsequently reverting to normal uptake in the postrecovery stage confirmed the thyroiditis nature, with prior radiation to the neck being the possible inciting factor.
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Management of pediatric cervicomedullary astrocytoma p. 85
Gopal Pemmaraju, Anand Parab, Anuradha Singh, Shubhangi Barsing
DOI:10.4103/jrcr.jrcr_40_20  
Cervicomedullary astrocytomas are low grade gliomas of childhood and young age which are typically centered at the junction of brainstem and cervical spine and present with a long duration of symptoms. The diagnosis of cervicomedullary astrocytomas is normally delayed as these tumours are slow growing and patients present with a long duration of symptoms. The symptoms are typical and can be correlated to the location of the tumour. Histopathology and Immunohistochemistry(IHC) guides us proving the diagnosis. Management of cervicomedullary astrocytomas includes surgery, radiotherapy and chemotherapy. A 13 years old female child presented with complaints of headache, vomiting, neck pain and progressive neck tilt. MRI of brain and cervical spine revealed moderate to significant expansile lesion in the dorsal aspect of lower medulla, cervicomedullary junction and the upper cervical cord upto C4-5 disc level.She underwent subtotal resection of the tumour. Histopathology and IHC confirmed her diagnosis as Astrocytoma WHO Grade-II. Patient underwent adjuvant radiation treatment to a radiation dose of 54 Grey in 27 fractions by Volumetric modulated arc therapy(VMAT) technique over a period of 6 weeks to the gross residual tumour and post-op tumour bed. Patient tolerated the treatment well. Patient experienced mild symptoms like nausea and vomiting during the course of treatment but well managed with supportive medications.
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