Kundan Singh Chufal - Academia.edu (original) (raw)

Papers by Kundan Singh Chufal

Research paper thumbnail of Time saved is time earned: Implementation of an agile workflow system in a high-volume radiation oncology centre Workflow optimization in radiation oncology

Research Square (Research Square), Mar 6, 2024

Research paper thumbnail of A practical and practicable framework for implementing cardiac-sparing radiotherapy techniques in breast cancer

Cancer research, statistics and treatment, Dec 31, 2022

Research paper thumbnail of Cardiac markers in left-sided breast cancer patients receiving adjuvant radiotherapy: a prospective study

Cardio-oncology, Apr 8, 2024

Research paper thumbnail of Palliative stereotactic radiotherapy for metastases during COVID-19: relief when cure is implausible

BMJ supportive & palliative care, Jan 19, 2021

Research paper thumbnail of A preliminary investigation on long-term consistency of MPC as a quick daily QA application

International Journal of Cancer Therapy and Oncology, Dec 10, 2017

The purpose of this study was to establish Machine performance check (MPC) application as a compr... more The purpose of this study was to establish Machine performance check (MPC) application as a comprehensive daily QA program in a clinical setting for a True Beam 2.0 system and investigate the first ten months (195 days) daily QA data generated by the MPC. Methods: An automated daily quality assurance (QA) application named machine performance check (MPC) was recently launched by Varian Medical Systems with their TrueBeam 2.0 linear accelerator (linac) system. MPC performs all the essential machine tests such as Beam Constancy Check, and Geometry Check with the use of an IsoCal phantom. There is no systematic published study on long-term consistency and validation of MPC in a clinical setup for its acceptance as an alternative QA application. In the present study, we collected data with the MPC for over ten months (195 days) on a TrueBeam 2.0 system. The data was analysed for reproducibility and also compared with the data collected with other statndard QA devices at the time of commissioning of the TrueBeam system for validation. Results: The results showed that the reproducibility of MPC was at least an order of magnitude less than the tolerance values for the respective parameters and also the average measured values for all QA parameters studied. The MPC measured isocenter accuracy, and output values were close to the Winston-Lutz test (within 0.1 mm) and the ion-chamber measurements (within 0.1%), respectively. Conclusion: With our long term result, it is evident that the MPC could be an alternative daily QA tool. A comprehensive and long-term validation of the MPC measured values with the other standard QA methods over the ten month period will be needed before accepting MPC as a reliable QA tool.

Research paper thumbnail of Hypercellular round cell liposarcoma: A comprehensive cytomorphologic study and review of 8 cases

Journal of Cytology, 2017

Myxoid and round cell liposarcomas (RCL) are low and high-grade counterparts of a common subtype ... more Myxoid and round cell liposarcomas (RCL) are low and high-grade counterparts of a common subtype of liposarcomas (LPS), representing a histologic continuum. The aim was to study the cytomorphology of hypercellular RCL and to look for features that differentiate RCL from other sarcomas displaying round cells with myxoid change. Eight cases of hypercellular RCL were identified retrospectively in which round cell component constituted greater than 75% of the area. Cytomorphological features were studied in detail. Four cases were predominantly composed of round cells, out of which 2 were entirely composed of round cells. Myxoid metachromatic stroma was absent in 2 cases, while it was present in ample amounts in the remaining 6 cases. Spindle cells were completely absent in 5 cases and lipoblasts were observed in a single case of RCL. Plexiform vascular capillaries were seen in 4 cases. Adherence of neoplastic round cells around thin capillaries (ANAC) was observed in 7 cases. Plexiform capillary plexus and ANAC should be separately evaluated. The latter feature is the most consistent one, and is an important clue to the adipocytic nature of the neoplasm when hypercellular round cell areas are aspirated. Confident diagnosis of hypercellular RCL can be made on the basis of this feature. Lipoblasts, although specific, are seen in few cases. The rest of the features are nonspecific and useful only in combination.

Research paper thumbnail of PO-1802 Deep learning using Pre-NACRT imaging can predict pathological response in esophageal cancer

Radiotherapy and Oncology, Aug 1, 2021

Research paper thumbnail of PO-1790 Alpha-Beta ratio estimation and radiotherapeutic equivalence of chemotherapy in oesophageal cancer

Radiotherapy and Oncology, Aug 1, 2021

Research paper thumbnail of EP-1094: Total tumour volume predicts response in head and neck cancer: regression tree analysis and models

Radiotherapy and Oncology, Apr 1, 2016

Material and Methods: Retrospective review of all patients with T4 HNSCC treated with IMRT at our... more Material and Methods: Retrospective review of all patients with T4 HNSCC treated with IMRT at our centre, between December 2010 and February 2013. Overall, relapse free and local relapse-free survival were calculated from date of biopsy to date of death, relapse or last follow up. Results: Of the 69 patients with T4 tumours, 73.9% were male and median age was 69 (41-84). 50.7% were oropharyngeal tumours and 73.9% were node positive. Primary resection was performed in 18 patients. Eighteen patients underwent radiotherapy alone and 51 received concurrent chemotherapy (45 cisplatin, 6 cetuximab). Median follow up was 3.0 years (range = 3 months to 3.9 years). 28 patients died; 22 related to HNSCC, 6 from other causes. Overall survival at 3 years was 58.0% (95% CI: 44.6 to 69.1). 28 patients (40.6%), relapsed with median time to relapse of 8 months. 20 patients (29.0%) relapsed locoregionally and 11 patients (15.9%) developed distant metastatic disease. For 8 patients, distant metastases were the only site of relapse. Surgical salvage was performed in 6 patients with locoregional relapse only, 2 of whom have since died from causes related to HNSCC. Relapse free survival at 3 years was 54.0% (95% CI: 40.5 to 65.8) and loco-regional relapse free survival at 3 years was 65.5% (95% CI: 51.2 to 76.5). Nineteen patients (27.5%) had residual disease on PET scan 12 weeks post treatment. These patients were at greater risk of relapse and death with 3 year overall survival of 37.0% (95% CI 15.4 to 59.0) and 3 year relapse free survival of 40.5% compared to 3 year overall survival of 85.7% (53.9 to 96.2) and 3 year relapse free survival of 79.0% (47.9 to 92.7) in patients with normal PET scans. Conclusion: There is a significant risk of relapse and death in T4 HNSCC tumours, particularly in those with residual disease following radiotherapy. However, IMRT, either alone or in combination with chemotherapy or surgery, achieved 3 year locoregional control of 65.5% (95% CI 51.2%-76.5%). This is a meaningful local control rate for locally advanced disease in which local relapse confers significant morbidity.

Research paper thumbnail of Nodal Volume as a Prognostic Factor in Locally Advanced Head and Neck Cancer Treated With Concurrent Chemoradiaton With IGRT: An Updated Analysis From an Indian Institution

International Journal of Radiation Oncology Biology Physics, Mar 1, 2016

Results: For the entire series, ART plans had significantly better planning target volume (PTV) c... more Results: For the entire series, ART plans had significantly better planning target volume (PTV) coverage. The mean percentage dose covering 95% of PTV (D 95) was 96.44% for ART versus 95.58% for NART (PZ.0003) for PTV70, and 94.63% for ART versus 93.94% for NART (PZ.0009) for PTV60. Using our treatment setup, only MPS was able to define 2 risk groups for plan deterioration. The high-risk group (HRG) comprises 27 patients with MPS>1 mm and the low-risk group (LRG) comprises 13 patients with MPS1 mm. The mean PTV70 (D 95) for ART versus N-ART for the HRG and LRG were 96.44% versus 95.36% (PZ.0001), and 96.15% versus 96.02% (PZ.686). The same was true for PTV60 with 94.93% versus 93.36% (PZ.0033), and 94.62% versus 94.00% (PZ.104). When compared to ART, 6 out of 40 NART plans had a PTV70 and/or PTV60 (D 95) drop exceeding 3% (PZ.0255), 5 of them in the HRG. The ART plans achieved a significantly lower spinal cord dose maximum (SCMD) of 42.64 Gy versus 44.47 Gy (PZ.0001). Only 1 patient in this group had SCMD exceeding 46 Gy as compared to 13 in NART plans (PZ.0012). The improvement in the mean parotid dose with ART in this series did not reach statistical significance (33.35 Gy versus 34.20 Gy, PZ.063). Conclusion: ART plans resulted in improved tumor coverage and better spinal cord sparing compared to the corresponding NART plans in the present NPC patient series. Further evaluation of the value of the predictive factors will be carried out in a larger sample of patients.

Research paper thumbnail of Artificial Intelligence Enabled Prognostic Modelling For Thymomas

International Journal of Radiation Oncology Biology Physics, Nov 1, 2020

Research paper thumbnail of Treating patients with brain metastases has evolved: scalp-sparing, hippocampal avoidance whole brain radiotherapy with simultaneous integrated boost

Case Reports, Dec 7, 2017

Research paper thumbnail of EP-1091: Stratifying patients of head and neck cancer into risk groups for local control: predictive models

Radiotherapy and Oncology, Apr 1, 2016

________________________________________________________________________________ patients were ex... more ________________________________________________________________________________ patients were excluded because didn't receive CT (T1N0). From the remaining 100, 95 received concomitant plus adjuvant CT and 5 concurrent CT. We found a median OTT of 49 days (range: 11-83 days). 39 patients completed CCRT in more than 7 weeks (50-83 days) from which 31 (79%) in 8 weeks and the remaining 8 (21%) in more than 8 weeks. Interruption causes were by medical indication in 6 (15%), and non-clinical reasons in 33 (85%-patient no show, machine breakdown, and mis-coordination between departments). Compensations were performed at the discretion of the treating physician in the 8 patients with OTT longer than 8 weeks. No difference in local control (LC, p= 0.766), overall survival (OS, p= 0.855) or metastases free survival (p= 0.131). Cox regression confirmed age, N stage, local control and distant metastases status as prognostic factors however no impact was found for OTT (p = 0.890 for < 7 weeks; p = 0.959 for < 8 weeks; and p = 0.960 for > 8 weeks). Conclusion: In our study, we found no differences in LC and OS regardless OTT. These data must be interpreted with caution due to the high number of patients receiving CT that may compensate the unplanned interruptions in such a sensitive entity. Further studies with longer follow up are necessary to recommend or not withholding compensations in this setting. EP-1091 Stratifying patients of head and neck cancer into risk groups for local control: predictive models

Research paper thumbnail of Brachytherapy for Treatment of Refractory Plasma Cell Cheilitis

Dermatologic Surgery, Aug 18, 2021

Research paper thumbnail of Image-guided volumetric modulated arc therapy for breast cancer: a feasibility study and plan comparison with three-dimensional conformal and intensity-modulated radiotherapy

The British Journal of Radiology, 2013

To test the feasibility of volumetric modulated arc therapy (VMAT) in breast cancer and to compar... more To test the feasibility of volumetric modulated arc therapy (VMAT) in breast cancer and to compare it with three-dimensional conformal radiotherapy (3D-CRT) as conventional tangential field radiotheraphy (con TFRT). Methods: 12 patients (Stage I, 8: 6 left breast cancer and 2 right breast cancer; Stage II, 4: 2 on each side). Three plans were calculated for each case after breast-conserving surgery. Breast was treated with 50 Gy in four patients with supraclavicular lymph node inclusion, and in eight patients without the node inclusion. Multiple indices and dose parameters were measured. Results: V95% was not achieved by any modality. Heterogeneity index: 0.16 (VMAT), 0.13 [intensity-modulated radiotherapy (IMRT)] and 0.14 (con TFRT). Conformity index: 1.06 (VMAT), 1.15 (IMRT) and 1.69 (con TFRT). For both indices, IMRT was more effective than VMAT (p50.009, p50.002). D mean and V20 for ipsilateral lung were lower for IMRT than VMAT (p50.0001, p50.003). D mean , V2 and V5 of contralateral lung were lower for IMRT than VMAT (p.0.0001, p50.005). Mean dose and V5 to the heart were lower for IMRT than for VMAT (p50.015, p50.002). Conclusion: The hypothesis of equivalence of VMAT to IMRT was not confirmed for planning target volume parameter or dose distribution to organs at risk. VMAT was inferior to IMRT and 3D-CRT with regard to dose distribution to organs at risk, especially at the low dose level.

Research paper thumbnail of Clinical Outcomes Of Patients With Pathologic Residual Nodal Disease After Neo-Adjuvant Chemoradiation For Esophageal Carcinoma

International Journal of Radiation Oncology Biology Physics, Nov 1, 2020

363 Hospital. 50% isodose curve covered more than 95% target. The physical total dose of 3900 cGy... more 363 Hospital. 50% isodose curve covered more than 95% target. The physical total dose of 3900 cGy w4900 cGy (prescribed dose of 280 cGy w350 cGy/F) were delivered over 10w14 fractions, 5 consecutive fractions per week. Primary outcome was objective response (OR) using response evaluation criteria in solid tumors (RECIST). Other outcomes included local control (LC), progression-free survival (PFS) and overall survival (OS) We also reported treatment toxicities using RTOG criteria and CTCAE 5.0. In addition, Log-rank test and COX proportional hazards model were used to analyze the influencing factors for survival.

Research paper thumbnail of Can the Choice of Radiotherapy Delivery Technique Influence Which Target Delineation Protocol to Use? A Plan-Quality-Based Analysis in Left Breast Cancer

Introduction This study investigates the optimal target delineation protocol stratified by treatm... more Introduction This study investigates the optimal target delineation protocol stratified by treatment planning technique in patients undergoing whole breast radiotherapy after breast conservation surgery. Materials and Methods Target delineation using Tangent (RTOG 0413 Whole Breast Irradiation Protocol), European SocieTy for Radiotherapy and Oncology (ESTRO), and Radiation Therapy & Oncology Group (RTOG) guidelines was performed on 10 randomly selected treatment planning computed tomography datasets of patients with leftsided breast cancer. An objective plan quality metric (PQM) scoring schema was defined and communicated to the medical physicist prior to commencement of treatment planning. Treatment planning was performed using field-in-field (FiF) intensity modulated radiotherapy technique (IMRT), inverse IMRT, and volumetric modulated arc therapy (VMAT), for each type of target. Two-way repeated measures, analysis of variance was utilized to compare the total PQM scores and dosimetric variables, stratified by treatment planning method. Results Total PQM score of plans for FiF, IMRT, and VMAT revealed that Tangent and ESTRO delineations were equivalent regardless of planning technique (Tangent vs. ESTRO for FiF, p = 0.099; Tangent vs. ESTRO for IMRT, p = 0.029; Tangent vs. ESTRO for VMAT, p = 0.438). Both delineation protocols were significantly superior to RTOG for all treatment planning techniques. Conclusion For all treatment planning techniques, ESTRO and Tangent delineation were equivalent and both achieved significantly higher scores than RTOG delineation.

Research paper thumbnail of Simultaneous integrated boost by Intensity Modulated Radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery – A clinical and dosimetric perspective

Journal of the Egyptian National Cancer Institute, Dec 1, 2018

Aim: To study feasibility of simultaneous integrated boost by intensity modulated radiotherapy (S... more Aim: To study feasibility of simultaneous integrated boost by intensity modulated radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery and its impact on cosmesis and dosimetry. Patients and methods: Between January 2014 and June 2017, all breast cancer patients fulfilling inclusion and exclusion criteria were enrolled in a prospective study conducted at a tertiary cancer centre in North India. All patients received adjuvant radiotherapy by simultaneous integrated boost technique following breast conserving surgery. Clinical information including patient and pathological characteristics, observed acute and chronic toxicities along with cosmesis using Harvard score were recorded and analysed. Univariate analysis and multivariate logistic regression analysis were performed for those variables which were found to be significant (p < 0.050) to study the influence of clinicopathological and dosimetric factors on toxicity and cosmetic outcome. Results: Maximum acute skin toxicity during treatment was Grade 0-1 in 68.2% and Grade 2-3 in 31.8% of cases, respectively. Fibrosis was the commonest late toxicity with Grade II fibrosis being noted in 16.3% of cases. Assessment of global cosmesis at 12 months follow-up showed good/excellent cosmesis in 88.4% of cases. Mean age, tumor size and homogeneity index (HI) were the significant factors associated with fair or poor cosmetic outcome and Grade 2 fibrosis on multivariate analysis. Telengectasia and breast edema were more frequent in patients with larger tumor size/GTV volume. There were 5 recurrences including 1 ipsilateral local breast tumor recurrence. Conclusion: SIB-IMRT is a dosimetrically feasible option in patients undergoing breast conserving surgery and provides good/excellent cosmetic outcome.

Research paper thumbnail of Immunotherapy in advanced non-small-cell lung cancer (NSCLC) after progression on chemotherapy: real-world results from a prospective institutional cohort

Immunotherapy, Aug 1, 2022

New ways of exploiting the immune system for cancer treatment have been tested for decades with m... more New ways of exploiting the immune system for cancer treatment have been tested for decades with moderate outcomes. Based on previous immunotherapy knowledge, agents targeting immune checkpoints seem to be remarkably effective in a wide range of tumors. Immune checkpoint inhibitors in metastatic non-small cell lung cancer (NSCLC) provide longlasting responses in specific patients. Nevertheless, with overall response rates ≤ 20%, combinational protocols for various patient subgroups are needed. A good partner treatment to immunotherapy could be chemotherapy, as it successfully modulates the immune response either by controlling or enhancing the antitumor immune activity. Primary research provides promising results in metastatic NSCLC patients using this approach, but further largescale trials are needed. The implementation of immunotherapy in nonmetastatic cases is also appealing. We review the potential clinical benefits of immunotherapy alone or in concert with chemotherapy in NSCLC.

Research paper thumbnail of Role of benzydamine hydrochloride in the prevention of oral mucositis in head and neck cancer patients treated with radiotherapy (>50 Gy) with or without chemotherapy

Supportive Care in Cancer, Dec 16, 2016

Purpose Benzydamine is recommended for prophylaxis of oral mucositis (OM) in head and neck cancer... more Purpose Benzydamine is recommended for prophylaxis of oral mucositis (OM) in head and neck cancer (HNC) patients for radiation doses (<50 Gy). This study evaluates role of benzydamine for higher radiation doses (>50 Gy) with or without chemotherapy. Methods One hundred twenty patients of HNC with planned radiation doses of ≥60 Gy were randomized to group A (control radiotherapy alone), group B (study radiotherapy alone), group C (control chemoradiotherapy), or to group D (study chemoradiotherapy). Groups A and C were advised saline mouth rinses, and in groups B and D, additional benzydamine rinses (0.15%) were advised. Mucositis grading was done with both WHO (WHO-M) and CTCAE (CTC-M) version 4.0 (common terminology criteria for adverse events) weekly. Results Patient characteristics are presented in the table. Patients in group B had lesser grade 3 WHOM and CTC-M as compared to group A, 62.1 vs. 36.4% (p = 0.038) and 51.7 vs. 27.3% (p = 0.043), respectively. The rates of Ryle's tube feeding (RTF), intravenous fluid supplementation (IVF), and hospitalization were also lesser in group B as compared to A, 34.5 vs. 21.2% (p = 0.18), 27.6 vs. 9.1% (p = 0.06), and 6.9 vs. 0% (p = 0.21), respectively. WHOM and CTC-M in groups C and D were not statistically different, 64.3 vs. 43.3% (p = 0.091) and 53.6% vs. 43.3% (p = 0.30), respectively. The rates of RTF, IVF, and hospitalization were all lesser but p > 0.05. Conclusion Benzydamine significantly reduces OM even at doses >50 Gy in HNC patients. Its role in patients receiving concurrent chemotherapy further needs to be evaluated.

Research paper thumbnail of Time saved is time earned: Implementation of an agile workflow system in a high-volume radiation oncology centre Workflow optimization in radiation oncology

Research Square (Research Square), Mar 6, 2024

Research paper thumbnail of A practical and practicable framework for implementing cardiac-sparing radiotherapy techniques in breast cancer

Cancer research, statistics and treatment, Dec 31, 2022

Research paper thumbnail of Cardiac markers in left-sided breast cancer patients receiving adjuvant radiotherapy: a prospective study

Cardio-oncology, Apr 8, 2024

Research paper thumbnail of Palliative stereotactic radiotherapy for metastases during COVID-19: relief when cure is implausible

BMJ supportive & palliative care, Jan 19, 2021

Research paper thumbnail of A preliminary investigation on long-term consistency of MPC as a quick daily QA application

International Journal of Cancer Therapy and Oncology, Dec 10, 2017

The purpose of this study was to establish Machine performance check (MPC) application as a compr... more The purpose of this study was to establish Machine performance check (MPC) application as a comprehensive daily QA program in a clinical setting for a True Beam 2.0 system and investigate the first ten months (195 days) daily QA data generated by the MPC. Methods: An automated daily quality assurance (QA) application named machine performance check (MPC) was recently launched by Varian Medical Systems with their TrueBeam 2.0 linear accelerator (linac) system. MPC performs all the essential machine tests such as Beam Constancy Check, and Geometry Check with the use of an IsoCal phantom. There is no systematic published study on long-term consistency and validation of MPC in a clinical setup for its acceptance as an alternative QA application. In the present study, we collected data with the MPC for over ten months (195 days) on a TrueBeam 2.0 system. The data was analysed for reproducibility and also compared with the data collected with other statndard QA devices at the time of commissioning of the TrueBeam system for validation. Results: The results showed that the reproducibility of MPC was at least an order of magnitude less than the tolerance values for the respective parameters and also the average measured values for all QA parameters studied. The MPC measured isocenter accuracy, and output values were close to the Winston-Lutz test (within 0.1 mm) and the ion-chamber measurements (within 0.1%), respectively. Conclusion: With our long term result, it is evident that the MPC could be an alternative daily QA tool. A comprehensive and long-term validation of the MPC measured values with the other standard QA methods over the ten month period will be needed before accepting MPC as a reliable QA tool.

Research paper thumbnail of Hypercellular round cell liposarcoma: A comprehensive cytomorphologic study and review of 8 cases

Journal of Cytology, 2017

Myxoid and round cell liposarcomas (RCL) are low and high-grade counterparts of a common subtype ... more Myxoid and round cell liposarcomas (RCL) are low and high-grade counterparts of a common subtype of liposarcomas (LPS), representing a histologic continuum. The aim was to study the cytomorphology of hypercellular RCL and to look for features that differentiate RCL from other sarcomas displaying round cells with myxoid change. Eight cases of hypercellular RCL were identified retrospectively in which round cell component constituted greater than 75% of the area. Cytomorphological features were studied in detail. Four cases were predominantly composed of round cells, out of which 2 were entirely composed of round cells. Myxoid metachromatic stroma was absent in 2 cases, while it was present in ample amounts in the remaining 6 cases. Spindle cells were completely absent in 5 cases and lipoblasts were observed in a single case of RCL. Plexiform vascular capillaries were seen in 4 cases. Adherence of neoplastic round cells around thin capillaries (ANAC) was observed in 7 cases. Plexiform capillary plexus and ANAC should be separately evaluated. The latter feature is the most consistent one, and is an important clue to the adipocytic nature of the neoplasm when hypercellular round cell areas are aspirated. Confident diagnosis of hypercellular RCL can be made on the basis of this feature. Lipoblasts, although specific, are seen in few cases. The rest of the features are nonspecific and useful only in combination.

Research paper thumbnail of PO-1802 Deep learning using Pre-NACRT imaging can predict pathological response in esophageal cancer

Radiotherapy and Oncology, Aug 1, 2021

Research paper thumbnail of PO-1790 Alpha-Beta ratio estimation and radiotherapeutic equivalence of chemotherapy in oesophageal cancer

Radiotherapy and Oncology, Aug 1, 2021

Research paper thumbnail of EP-1094: Total tumour volume predicts response in head and neck cancer: regression tree analysis and models

Radiotherapy and Oncology, Apr 1, 2016

Material and Methods: Retrospective review of all patients with T4 HNSCC treated with IMRT at our... more Material and Methods: Retrospective review of all patients with T4 HNSCC treated with IMRT at our centre, between December 2010 and February 2013. Overall, relapse free and local relapse-free survival were calculated from date of biopsy to date of death, relapse or last follow up. Results: Of the 69 patients with T4 tumours, 73.9% were male and median age was 69 (41-84). 50.7% were oropharyngeal tumours and 73.9% were node positive. Primary resection was performed in 18 patients. Eighteen patients underwent radiotherapy alone and 51 received concurrent chemotherapy (45 cisplatin, 6 cetuximab). Median follow up was 3.0 years (range = 3 months to 3.9 years). 28 patients died; 22 related to HNSCC, 6 from other causes. Overall survival at 3 years was 58.0% (95% CI: 44.6 to 69.1). 28 patients (40.6%), relapsed with median time to relapse of 8 months. 20 patients (29.0%) relapsed locoregionally and 11 patients (15.9%) developed distant metastatic disease. For 8 patients, distant metastases were the only site of relapse. Surgical salvage was performed in 6 patients with locoregional relapse only, 2 of whom have since died from causes related to HNSCC. Relapse free survival at 3 years was 54.0% (95% CI: 40.5 to 65.8) and loco-regional relapse free survival at 3 years was 65.5% (95% CI: 51.2 to 76.5). Nineteen patients (27.5%) had residual disease on PET scan 12 weeks post treatment. These patients were at greater risk of relapse and death with 3 year overall survival of 37.0% (95% CI 15.4 to 59.0) and 3 year relapse free survival of 40.5% compared to 3 year overall survival of 85.7% (53.9 to 96.2) and 3 year relapse free survival of 79.0% (47.9 to 92.7) in patients with normal PET scans. Conclusion: There is a significant risk of relapse and death in T4 HNSCC tumours, particularly in those with residual disease following radiotherapy. However, IMRT, either alone or in combination with chemotherapy or surgery, achieved 3 year locoregional control of 65.5% (95% CI 51.2%-76.5%). This is a meaningful local control rate for locally advanced disease in which local relapse confers significant morbidity.

Research paper thumbnail of Nodal Volume as a Prognostic Factor in Locally Advanced Head and Neck Cancer Treated With Concurrent Chemoradiaton With IGRT: An Updated Analysis From an Indian Institution

International Journal of Radiation Oncology Biology Physics, Mar 1, 2016

Results: For the entire series, ART plans had significantly better planning target volume (PTV) c... more Results: For the entire series, ART plans had significantly better planning target volume (PTV) coverage. The mean percentage dose covering 95% of PTV (D 95) was 96.44% for ART versus 95.58% for NART (PZ.0003) for PTV70, and 94.63% for ART versus 93.94% for NART (PZ.0009) for PTV60. Using our treatment setup, only MPS was able to define 2 risk groups for plan deterioration. The high-risk group (HRG) comprises 27 patients with MPS>1 mm and the low-risk group (LRG) comprises 13 patients with MPS1 mm. The mean PTV70 (D 95) for ART versus N-ART for the HRG and LRG were 96.44% versus 95.36% (PZ.0001), and 96.15% versus 96.02% (PZ.686). The same was true for PTV60 with 94.93% versus 93.36% (PZ.0033), and 94.62% versus 94.00% (PZ.104). When compared to ART, 6 out of 40 NART plans had a PTV70 and/or PTV60 (D 95) drop exceeding 3% (PZ.0255), 5 of them in the HRG. The ART plans achieved a significantly lower spinal cord dose maximum (SCMD) of 42.64 Gy versus 44.47 Gy (PZ.0001). Only 1 patient in this group had SCMD exceeding 46 Gy as compared to 13 in NART plans (PZ.0012). The improvement in the mean parotid dose with ART in this series did not reach statistical significance (33.35 Gy versus 34.20 Gy, PZ.063). Conclusion: ART plans resulted in improved tumor coverage and better spinal cord sparing compared to the corresponding NART plans in the present NPC patient series. Further evaluation of the value of the predictive factors will be carried out in a larger sample of patients.

Research paper thumbnail of Artificial Intelligence Enabled Prognostic Modelling For Thymomas

International Journal of Radiation Oncology Biology Physics, Nov 1, 2020

Research paper thumbnail of Treating patients with brain metastases has evolved: scalp-sparing, hippocampal avoidance whole brain radiotherapy with simultaneous integrated boost

Case Reports, Dec 7, 2017

Research paper thumbnail of EP-1091: Stratifying patients of head and neck cancer into risk groups for local control: predictive models

Radiotherapy and Oncology, Apr 1, 2016

________________________________________________________________________________ patients were ex... more ________________________________________________________________________________ patients were excluded because didn't receive CT (T1N0). From the remaining 100, 95 received concomitant plus adjuvant CT and 5 concurrent CT. We found a median OTT of 49 days (range: 11-83 days). 39 patients completed CCRT in more than 7 weeks (50-83 days) from which 31 (79%) in 8 weeks and the remaining 8 (21%) in more than 8 weeks. Interruption causes were by medical indication in 6 (15%), and non-clinical reasons in 33 (85%-patient no show, machine breakdown, and mis-coordination between departments). Compensations were performed at the discretion of the treating physician in the 8 patients with OTT longer than 8 weeks. No difference in local control (LC, p= 0.766), overall survival (OS, p= 0.855) or metastases free survival (p= 0.131). Cox regression confirmed age, N stage, local control and distant metastases status as prognostic factors however no impact was found for OTT (p = 0.890 for < 7 weeks; p = 0.959 for < 8 weeks; and p = 0.960 for > 8 weeks). Conclusion: In our study, we found no differences in LC and OS regardless OTT. These data must be interpreted with caution due to the high number of patients receiving CT that may compensate the unplanned interruptions in such a sensitive entity. Further studies with longer follow up are necessary to recommend or not withholding compensations in this setting. EP-1091 Stratifying patients of head and neck cancer into risk groups for local control: predictive models

Research paper thumbnail of Brachytherapy for Treatment of Refractory Plasma Cell Cheilitis

Dermatologic Surgery, Aug 18, 2021

Research paper thumbnail of Image-guided volumetric modulated arc therapy for breast cancer: a feasibility study and plan comparison with three-dimensional conformal and intensity-modulated radiotherapy

The British Journal of Radiology, 2013

To test the feasibility of volumetric modulated arc therapy (VMAT) in breast cancer and to compar... more To test the feasibility of volumetric modulated arc therapy (VMAT) in breast cancer and to compare it with three-dimensional conformal radiotherapy (3D-CRT) as conventional tangential field radiotheraphy (con TFRT). Methods: 12 patients (Stage I, 8: 6 left breast cancer and 2 right breast cancer; Stage II, 4: 2 on each side). Three plans were calculated for each case after breast-conserving surgery. Breast was treated with 50 Gy in four patients with supraclavicular lymph node inclusion, and in eight patients without the node inclusion. Multiple indices and dose parameters were measured. Results: V95% was not achieved by any modality. Heterogeneity index: 0.16 (VMAT), 0.13 [intensity-modulated radiotherapy (IMRT)] and 0.14 (con TFRT). Conformity index: 1.06 (VMAT), 1.15 (IMRT) and 1.69 (con TFRT). For both indices, IMRT was more effective than VMAT (p50.009, p50.002). D mean and V20 for ipsilateral lung were lower for IMRT than VMAT (p50.0001, p50.003). D mean , V2 and V5 of contralateral lung were lower for IMRT than VMAT (p.0.0001, p50.005). Mean dose and V5 to the heart were lower for IMRT than for VMAT (p50.015, p50.002). Conclusion: The hypothesis of equivalence of VMAT to IMRT was not confirmed for planning target volume parameter or dose distribution to organs at risk. VMAT was inferior to IMRT and 3D-CRT with regard to dose distribution to organs at risk, especially at the low dose level.

Research paper thumbnail of Clinical Outcomes Of Patients With Pathologic Residual Nodal Disease After Neo-Adjuvant Chemoradiation For Esophageal Carcinoma

International Journal of Radiation Oncology Biology Physics, Nov 1, 2020

363 Hospital. 50% isodose curve covered more than 95% target. The physical total dose of 3900 cGy... more 363 Hospital. 50% isodose curve covered more than 95% target. The physical total dose of 3900 cGy w4900 cGy (prescribed dose of 280 cGy w350 cGy/F) were delivered over 10w14 fractions, 5 consecutive fractions per week. Primary outcome was objective response (OR) using response evaluation criteria in solid tumors (RECIST). Other outcomes included local control (LC), progression-free survival (PFS) and overall survival (OS) We also reported treatment toxicities using RTOG criteria and CTCAE 5.0. In addition, Log-rank test and COX proportional hazards model were used to analyze the influencing factors for survival.

Research paper thumbnail of Can the Choice of Radiotherapy Delivery Technique Influence Which Target Delineation Protocol to Use? A Plan-Quality-Based Analysis in Left Breast Cancer

Introduction This study investigates the optimal target delineation protocol stratified by treatm... more Introduction This study investigates the optimal target delineation protocol stratified by treatment planning technique in patients undergoing whole breast radiotherapy after breast conservation surgery. Materials and Methods Target delineation using Tangent (RTOG 0413 Whole Breast Irradiation Protocol), European SocieTy for Radiotherapy and Oncology (ESTRO), and Radiation Therapy & Oncology Group (RTOG) guidelines was performed on 10 randomly selected treatment planning computed tomography datasets of patients with leftsided breast cancer. An objective plan quality metric (PQM) scoring schema was defined and communicated to the medical physicist prior to commencement of treatment planning. Treatment planning was performed using field-in-field (FiF) intensity modulated radiotherapy technique (IMRT), inverse IMRT, and volumetric modulated arc therapy (VMAT), for each type of target. Two-way repeated measures, analysis of variance was utilized to compare the total PQM scores and dosimetric variables, stratified by treatment planning method. Results Total PQM score of plans for FiF, IMRT, and VMAT revealed that Tangent and ESTRO delineations were equivalent regardless of planning technique (Tangent vs. ESTRO for FiF, p = 0.099; Tangent vs. ESTRO for IMRT, p = 0.029; Tangent vs. ESTRO for VMAT, p = 0.438). Both delineation protocols were significantly superior to RTOG for all treatment planning techniques. Conclusion For all treatment planning techniques, ESTRO and Tangent delineation were equivalent and both achieved significantly higher scores than RTOG delineation.

Research paper thumbnail of Simultaneous integrated boost by Intensity Modulated Radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery – A clinical and dosimetric perspective

Journal of the Egyptian National Cancer Institute, Dec 1, 2018

Aim: To study feasibility of simultaneous integrated boost by intensity modulated radiotherapy (S... more Aim: To study feasibility of simultaneous integrated boost by intensity modulated radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery and its impact on cosmesis and dosimetry. Patients and methods: Between January 2014 and June 2017, all breast cancer patients fulfilling inclusion and exclusion criteria were enrolled in a prospective study conducted at a tertiary cancer centre in North India. All patients received adjuvant radiotherapy by simultaneous integrated boost technique following breast conserving surgery. Clinical information including patient and pathological characteristics, observed acute and chronic toxicities along with cosmesis using Harvard score were recorded and analysed. Univariate analysis and multivariate logistic regression analysis were performed for those variables which were found to be significant (p < 0.050) to study the influence of clinicopathological and dosimetric factors on toxicity and cosmetic outcome. Results: Maximum acute skin toxicity during treatment was Grade 0-1 in 68.2% and Grade 2-3 in 31.8% of cases, respectively. Fibrosis was the commonest late toxicity with Grade II fibrosis being noted in 16.3% of cases. Assessment of global cosmesis at 12 months follow-up showed good/excellent cosmesis in 88.4% of cases. Mean age, tumor size and homogeneity index (HI) were the significant factors associated with fair or poor cosmetic outcome and Grade 2 fibrosis on multivariate analysis. Telengectasia and breast edema were more frequent in patients with larger tumor size/GTV volume. There were 5 recurrences including 1 ipsilateral local breast tumor recurrence. Conclusion: SIB-IMRT is a dosimetrically feasible option in patients undergoing breast conserving surgery and provides good/excellent cosmetic outcome.

Research paper thumbnail of Immunotherapy in advanced non-small-cell lung cancer (NSCLC) after progression on chemotherapy: real-world results from a prospective institutional cohort

Immunotherapy, Aug 1, 2022

New ways of exploiting the immune system for cancer treatment have been tested for decades with m... more New ways of exploiting the immune system for cancer treatment have been tested for decades with moderate outcomes. Based on previous immunotherapy knowledge, agents targeting immune checkpoints seem to be remarkably effective in a wide range of tumors. Immune checkpoint inhibitors in metastatic non-small cell lung cancer (NSCLC) provide longlasting responses in specific patients. Nevertheless, with overall response rates ≤ 20%, combinational protocols for various patient subgroups are needed. A good partner treatment to immunotherapy could be chemotherapy, as it successfully modulates the immune response either by controlling or enhancing the antitumor immune activity. Primary research provides promising results in metastatic NSCLC patients using this approach, but further largescale trials are needed. The implementation of immunotherapy in nonmetastatic cases is also appealing. We review the potential clinical benefits of immunotherapy alone or in concert with chemotherapy in NSCLC.

Research paper thumbnail of Role of benzydamine hydrochloride in the prevention of oral mucositis in head and neck cancer patients treated with radiotherapy (>50 Gy) with or without chemotherapy

Supportive Care in Cancer, Dec 16, 2016

Purpose Benzydamine is recommended for prophylaxis of oral mucositis (OM) in head and neck cancer... more Purpose Benzydamine is recommended for prophylaxis of oral mucositis (OM) in head and neck cancer (HNC) patients for radiation doses (<50 Gy). This study evaluates role of benzydamine for higher radiation doses (>50 Gy) with or without chemotherapy. Methods One hundred twenty patients of HNC with planned radiation doses of ≥60 Gy were randomized to group A (control radiotherapy alone), group B (study radiotherapy alone), group C (control chemoradiotherapy), or to group D (study chemoradiotherapy). Groups A and C were advised saline mouth rinses, and in groups B and D, additional benzydamine rinses (0.15%) were advised. Mucositis grading was done with both WHO (WHO-M) and CTCAE (CTC-M) version 4.0 (common terminology criteria for adverse events) weekly. Results Patient characteristics are presented in the table. Patients in group B had lesser grade 3 WHOM and CTC-M as compared to group A, 62.1 vs. 36.4% (p = 0.038) and 51.7 vs. 27.3% (p = 0.043), respectively. The rates of Ryle's tube feeding (RTF), intravenous fluid supplementation (IVF), and hospitalization were also lesser in group B as compared to A, 34.5 vs. 21.2% (p = 0.18), 27.6 vs. 9.1% (p = 0.06), and 6.9 vs. 0% (p = 0.21), respectively. WHOM and CTC-M in groups C and D were not statistically different, 64.3 vs. 43.3% (p = 0.091) and 53.6% vs. 43.3% (p = 0.30), respectively. The rates of RTF, IVF, and hospitalization were all lesser but p > 0.05. Conclusion Benzydamine significantly reduces OM even at doses >50 Gy in HNC patients. Its role in patients receiving concurrent chemotherapy further needs to be evaluated.