In the last few decades, there have been major improvements in diagnosis, staging, and management of cancer which has translated into better disease outcomes and longer survival rates and with better quality of life. This improvement in the quality of life is by better normal tissue sparing caused by the increasing use of newer techniques and technologies, especially in surgery and radiotherapy. Along with higher survival, there is now greater acknowledgment of the need to treat local recurrences and hence the increased use of re-irradiation. Better technology such as intensity modulated radiotherapy translates into better sparing of normal tissue, but at the same time, late toxicity is still of concern. Factors such as residual late damage, total dose, fraction size, technique, type of tissue, and time interval to re-irradiation still guide prescription of the re-irradiation dose. Knowledge of long-term recovery of organ at risk is hence of importance in re-irradiation. This review article has emphasized on the recovery and tolerance of organs at risk such as Spinal cord, Brainstem, and Brain. This is important in prescribing doses for the target volume for re-irradiation and in setting constraints for surrounding critical organs during the planning process.

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Introduction: In craniospinal irradiation (CSI), prone position has been commonly used but, in some patients, especially pediatric cases where anesthesia is needed prone position may not help. In planning CSI by supine technique, beam geometry and field matching have to be considered, and immobilization is essential to ensure reproducibility of treatment. Materials and Methods: Data of four patients (3 with medulloblastoma and 1 with lymphoma) treated between March 2012 and October 2013 were included in this retrospective dosimetric study and analyzed. Patients were evaluated for dose coverage, organs at risks (OARs) sparing, number of monitor units, and daily table position shifts. Results: All patients underwent CSI by volumetric-modulated arc therapy (VMAT) technique in supine position. All four cases developed Grade 1 skin changes, and only one case developed a Grade 2 change at the end of radiotherapy; also both pediatric cases developed Grades 2 and 3 anemia and leukopenia toward their 4^th week of treatment onward. The Rapid Arc®-CSI plans were able to generate dose distributions with high planning target volume (PTV) conformity and homogeneity and with sparing of OAR. The cumulative conformity index for all patients was 0.986, and homogeneity index was 0.1007. The mean PTV doses were within 108% with V110% of <12%, and V107% was 20%. On the evaluation of patient setup errors, a maximal shift of 3 mm in longitudinal direction was noted. At 3 years, all medulloblastoma cases except 1 were in remission. One adult patient with medulloblastoma had multiple spinal metastases at 1 year. Conclusions: Treatment of patients in supine position is reproducible and easily maintained with minimal acute reactions. VMAT technique helps avoid junctions, field-matching, and benefits with image guidance for precise dose delivery, conformity, and OAR sparing.

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Aim: To compare the analgesic efficacy of epidural ropivacaine–fentanyl with bupivacaine–fentanyl combination administered by patient-controlled epidural analgesia (PCEA) technique for postoperative pain relief after major abdominal oncosurgery. Materials and Methods: A prospective, randomized, interventional, parallel group, active control study was conducted on 60 patients with American Society of Anesthesiologists physical status I–III. Random allocation was carried out into two groups of 30 patients each. Intraoperatively, after administering a loading dose (10mL of 0.5% bupivacaine) in both the groups, continuous infusions of 0.1% bupivacaine plus fentanyl (2 µg/mL) (Group BF) or 0.1% ropivacaine plus fentanyl (2 µg/mL) (Group RF) were started at the rate of 5mL/h. Postoperatively, same drug concentrations were administered via PCEA pump at 4mL/h as a baseline infusion (bolus dose, 3mL; lockout interval, 15min). Visual analog scale (VAS) score at rest and on coughing was recorded at specific time points. Rescue analgesia was administered as per protocol. Results: VAS scores at rest and on coughing were higher in Group BF as compared to Group RF. Group RF had less drug consumption, required fewer PCEA boluses, and had minimal motor blockade as compared to Group BF. Conclusion: Good analgesic efficacy with lower drug consumption makes Group RF well suited for postoperative PCEA with hemodynamic stability and minimal motor blockade.

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Context: Treatment decisions in early-stage hormone receptor-positive breast cancer patients are dependent on the potential risk of cancer recurrence. Multiple expensive gene expression based or cost-effective methods are used to assess the risk in conjunction with traditional prognostic determinants – age, tumor parameters – size, node, grade, and gold standard biomarkers-estrogen receptor, progesterone receptor (PR), and Human epidermal growth factor receptor 2. Aim: The aim of this study is to compare the performance of multiple economic methods, namely, (1) Ki67; (2) immunohistochemistry 4 (IHC4)-multi-biomarker test; (3) Luminal A/B subtyping (4) PREDICT-an online tool. Settings and Design: IHC was performed as per standard protocol on a retrospective cohort of 401 patients. The Kaplan–Meier analysis and Cox proportional-hazards model were used. Results: The results confirmed that lymph node status is the most useful prognostic indicator among the traditional clinicopathological parameters. IHC4 had a hazard ratio (HR) of 2.847 and separated the low-, intermediate- and high-risk groups significantly (P = 0.0248). Luminal subtyping (HR = 2.530) also stratified the two risk groups significantly (P = 0.0321), but had HR lesser than IHC4. Ki67 and PREDICT could not separate the cohort into low- and high-risk groups with statistical significance. All tools compared separated the low-, intermediate- and high-risk groups with a maximum of 7% difference in metastasis-free survival significantly less compared to Oncotype Dx, which separates with 28% difference in survival. Conclusions: IHC4 is a significant predictor of prognosis among the four tools tested. However, multiple limitations of IHC4 tool about validation and lack of standardized protocols for IHC create a need for a robust, accurate, and cost-effective risk assessment tool.

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The treatment options for recurrent tumors are limited. Re irradiation is being increasingly considered as an option, in view of the advances in treatment techniques, particularly the ability to document doses, overlay plans, intensity modulation, and image guidance. preclinical and clinical studies has been to estimate the total cumulative doses (EQD2) also termed as normalized total dose (NTD) that can be delivered to various tissues. In this review article reirradiation radiobiology of different tissues and dose fractionation have been discussed.

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Radiotherapy (RT) in relapsed brain tumors has been used sparingly because of the risk of toxicity, particularly white matter necrosis. However, evidence from preclinical animal models and increasing data from clinical series show that brain and spinal cord have marked repair potential, and re irradiation should be considered a valid option in selected patients. The choice of technique and dose fractionation for re irradiation depends on tumor characteristics (volume and location), previous RT dose and volume, and patient characteristics (age and performance status). For small volume tumors in noneloquent areas, single fraction SRS and brachytherapy may be good options. For small and intermediate volume tumors in eloquent areas, FSRT or hypofractionated RT may be used. For large volume recurrences, requiring partial brain irradiation, conventional fractionation is safer and offers palliation with minimal risk of radiation induced toxicitie.

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Reirradiation, in combination with systemic therapy or biologicals, in recent years, has become a popular option for locally recurrent cancers and for infield second malignancies in cases where surgical salvage is not feasible. However before embarking onto such a course of second radiation a systematic approach is needed to avoid undesirable consequences and to gain meaningful advantage in terms of survival and local control. An decision making approach for common cancers where re-irradiation is commonly used like the head and neck cancers, the gliomas and in cases of gynecological cancers has been discussed. Proper selection of the cases and the choosing the intention for re-irradiation is probably most important initial step. Care of the details of the initials course of radiation like the dose fractionation schedule, volume irradiated, dose to the Organs at risk along with patient's present general condition is of utmost importance. Issues like dose memory, threshold time interval, maximum effective cumulative dose etc are still areas of research and their importance in each individual site needs to ascertain in future. Finally, the aim is to have a perceived benefit over the potential of harm in a successful course re-irradiation.

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Objective: Cancer is a leading health problem of today’s world and radiotherapy (RT) is an integral modality to treat cancers. Unfortunately, RT remains an underutilized specialty worldwide because of the lack of knowledge and wrong perceptions among referring physicians toward this specialty. These concerns and fear may discourage physicians from referring patients for RT. This study was conducted to explore the knowledge, attitude, and perception of non-radiation oncology physicians toward this specialty. Materials and Methods: This was a questionnaire-based study including 63 participants conducted at a tertiary care hospital in New Delhi, India. Results: Although the survey completion rate of 95% was encouraging, our study revealed deficiencies in training and knowledge about cancer, principles of RT, and its beneficial effects. Although most of the participants appreciated the role of RT as a core specialty, many underscored its true potential and cost-effectiveness in cancer care. There were significant concerns regarding its side effects (most important reason for non-referral) and lack of familiarity with this specialty. Conclusion: Fortunately, in spite of knowledge gaps, there was a positive attitude toward learning in future among participants.

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Acinic cell carcinoma (ACC) of the salivary glands is a low grade malignancy which can present with late recurrences and distant metastasis. Being relatively resistant to chemotherapy, managing metastatic ACC is a clinical challenge, especially considering the long duration of survival of these patients. A 33-year-old female presented with recurrent ACC of the left parotid, eighteen years after initial presentation; with incidentally detected asymptomatic lung metastases. She remained stable after six cycles of triple agent chemotherapy and continues to be clinically asymptomatic at nine months post chemotherapy. We hereby, report this case to highlight the late recurrence and metastatic pattern of ACC and the benefit of achieving stable disease with triple agent chemotherapy. Further clinical studies on other anticancer agents are required to achieve better treatment outcomes.

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Survival of patients with multiple myeloma has increased significantly during the past two decades. This has been attributed to a better understanding of biology, the introduction of novel agents (immunomodulators, proteasome inhibitors), autologous stem cell transplantation, and maintenance therapy. Supportive care is an important component of overall care for these patients. Most patients have a high burden of symptoms at initial presentation in form of bone pains, fatigue, anemia, renal impairment, and infections, etc. Almost 10–20% of patients may have serious complications in the first 4–6 weeks. A high index of suspicion and timely intervention is important to reduce morbidity and mortality. Therapy-related complications, e.g., neuropathy, thromboembolism, cytopenias, GI symptoms (constipation/diarrhea), and relapse of disease, pose therapeutic challenges. Protocol-based approach, systematic assessment with respect to the quality of life and functioning and coordination with a palliative care team from the beginning may improve overall functioning and outcome.

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Pseudoangiomatous stromal hyperplasia (PASH) is an occasional histological finding in the breast tissue, which rarely presents as a clinical mass. We here report a case of progressively increasing breast lump that had radiological ambiguous findings but on excision proved to be PASH on histology and immunohistochemistry (IHC). On microscopy, PASH has to be distinguished from low-grade vascular tumors as stromal spaces in it mimic the endothelium-lined vascular spaces. In view of nonspecific radiological picture, histopathological confirmation by core needle or excision is mandatory. It may coexist with in situ or invasive breast malignancies also. IHC with stromal and vascular markers is the key to diagnosis of PASH; also these tumors show positivity with progesterone markers pointing to endocrine stimulation as a possible etiology. In asymptomatic PASH, expectant management is indicated; however, in symptomatic and enlarging masses, surgical treatment should be preferred.

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With the emergence of fast modes of communication such as Twitter, Blogs, Instagram, and others, the world is writing and sharing as never before. But what distinguishes an academic publication from all other write-ups is the credibility and future utility of the message conveyed. A stringent peer review mechanism is the guarantee to trustworthiness and usability of the publication for future scientific discourse and research. Circumventing or weakening the peer review process for ulterior considerations marks a predatory journal. These journals may end up circulating scientifically questionable information that may lead astray the scientific community. It is important that a researcher is not duped by predatory calls and he makes an informed decision for his submission. This article attempts to explain in a concise manner the key attributes and modus operandi of predatory journals, the consequence of predatory publishing, and the measures that can be adopted to curb such practices.

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Ipsilateral breast or chest wall recurrence remains one the most common site of disease recurrence and significantly increases the morbidity and mortality. The current standard of care for ipsilateral breast tumour recurrence has been mastectomy. However, various recent studies showed that there is feasibility of repeat breast conservation surgery with reirradiation. Reirradiation in breast cancer is complicated approach. Many physicians are reluctant to reirradiate breast with restricted data available. This paper will review the current literature on reirradiation for locally recurrent breast cancer

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Most common site for small-cell neuroendocrine carcinoma (SNEC) is lung. Incidence of extrapulmonary small-cell carcinoma (SCC) is infrequent and very few cases of primary SNEC of head and neck have been reported in the literature. Nasal cavity as a primary site for SCC is extremely rare and thus we report a case of primary SCC of nasal cavity and paranasal sinuses who presented to our institute and approach to its management.

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Carcinoma of prostate rarely metastasizes to the testis. It is the most common primary cancers among all the solid malignancies contributing the majority of testicular metastases. Here, we report such type of rare case in a 64-year-old man who presented with a history of severe lower urinary tract symptoms and progressively increasing swelling of the right testis. The case was subsequently diagnosed as a prostate cancer with testicular metastasis.

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Radiation therapy (RT) represents a important modality for treatment of malignancies in patients of xeroderma pigmentosa (XP). There are only few reports of radiation being primary treatment and thus we report a case of twelve year old female with XP presented with squamous cell carcinoma of tongue and lower lip treated with radiation at our institute. DNA damage by radiation is repaired by base excision repair, non homologous end joining and homologous combination in contrast to XP in which defect lies with nucleotide excision repair genes and therefore clinical and cellular response to RT is similar in XP as seen with other patients.

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Context and Aim: Several studies have shown that during gutkha chewing, many harmful chemicals and metals are leached-out into the saliva altering salivary parameters including the flow rate and pH, whereas the normal range of salivary pH is recorded to be within 5.5–7.9 with the flow rate in a range of 0.33–1.42 mL/min. Due to a scarcity of literature on this aspect of the disease process of patients with oral submucous fibrosis (OSMF), this study intended to assess and compare the pH of saliva among gutkha chewers with and without OSMF and healthy subjects. Materials and Methods: This study was designed as a prospective case-control study comprising 90 individuals within an age range of 15–50 years who were divided into three groups with Group A consisting of 30 patients who were gutkha chewers with OSMF, Group B consisting of 30 individuals who were gutkha chewers but without OSMF, and Group C consisting of 30 healthy subjects who were included as normal controls. Salivary pH was measured using the pH indicator strips (INDIKROM PAPERS, pH: 3.5–6 and pH: 6.5–9). Statistical Analysis Used: The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 16.0 (SPSS, Chicago, Illinois). Comparison of the said parameters was done using chi-square test, analysis of variance (ANOVA), and Tukey’s post hoc test. A value of P < 0.05 was considered statistically significant. Results: The results were not found to be statistically significant when the pH among OSMF (Group A) and individuals with habit but without OSMF (Group B) was compared, though, significant between Groups A and C. Conclusion: From the findings of this study, it could be concluded that “reduced salivary pH could be a significant initial subjective sign of OSMF.” An early diagnosis and management of these changes, thus, can not only help such patients to improve their quality of life (QoL) significantly but also can decrease the chances of the ongoing malignant transformation.

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Background: Control of chemotherapy-induced nausea and vomiting is a crucial factor in ensuring patient’s compliance and adherence to cancer chemotherapy cycle. Fosaprepitant is a water-soluble N-phosphoryl derivative of aprepitant, which is often administered along with 5-hydroxytryptamine 3 antagonist and a steroid in patients with highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Materials and Methods: A single-centric, retrospective cohort study was conducted in HCG Cancer Centre in South India, where patients who were prescribed fosaprepitant as a part of standard therapy were enrolled. Results: Among the 290 patients who were included in the analysis, 41.72% were male, 58.27% were female, and 36.20% belonged to 51–60 years of age. Advanced breast carcinoma was the most common diagnosis in 38.96% patients. HEC was prescribed in 222 patients; moderate emetogenic drugs and regimen were prescribed in 62 patients. Among patients who were prescribed HEC and MEC drugs and regimen, fosaprepitant, palonosetron, and dexamethasone were prescribed on day 1 followed by dexamethasone on days 2, 3, and 4. No infusion site reaction, hiccups, or any other adverse reactions were noted. Complete response was noted in all patients (100%) with HEC and MEC regimen cases. The formulation was well tolerated with none reporting any persistent or delayed or breakthrough emesis. Conclusion: Single-dose fosaprepitant used in combination with palonosetron and dexamethasone was well tolerated and effective in preventing chemotherapy-induced vomiting in patients receiving highly and moderately emetogenic drugs and regimen.

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Borderline resectable pancreatic cancer (BRPC) is a clinically distinguished malignancy. With limited role of aggressive surgical intervention, neoadjuvant treatment is warranted. Various studies and their meta-analysis addressing this issue have shown limited benefit. However, recently two prospective multiple randomized trials have evaluated benefit of neoadjuvant chemoradiotherapy in BRPC with a positive clinical response. This article gives a brief insight into these studies and discusses future prospects for role of radiation in neoadjuvant setting in pancreatic cancer.

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A 75-year-old male with metastatic adenocarcinoma of the lung that harbored an epidermal growth factor receptor (EGFR) mutation had disease control for 16 months with EGF816, an investigational, third-generation EGFR tyrosine kinase inhibitor (TKI), in a phase I clinical trial. On disease progression, his treatment was switched to an earlier third-generation EGFR TKI, osimertinib. A rapid response occurred but was short-lived for only 10 weeks, before a rapid progression ensued. The mechanism of sequential resistance to EGF816, and subsequently, osimertinib in this male was indeterminant because of the absence of baseline genomic profiling of the tumor. Repeated molecular profiling demonstrated persistent EGFR mutations and a possibly emergent TP53 G266E mutation. This case highlighted the importance of serial biopsies for genomic analysis to understand emergent TKI resistance. As non-cross resistance may be present among the various EGFR TKI, the potential in the sequential approach in targeted therapy should be explored.

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Primary Ewing’s sarcoma (ES) of clavicle is rare; moreover, an adult patient diagnosed with clavicular ES is extremely rare. We report a case of adult-onset clavicular ES under our tracking and review of the related literature on the management of this rare tumor. A 24-year-old adult presented with an incidentally detected clavicle mass. A biopsy from the clavicle was diagnosed as ES. Whole body positron emission technique scan was suggestive of nonmetastatic presentation. The patient received both neoadjuvant and adjuvant chemotherapy. Medial clavicle resection was performed and adjuvant XRT was started. At follow-up, the patient had good range of painless shoulder movement. In conclusion, it was observed that ES of clavicle is a very rare tumor and poses a diagnostic challenge. Clavicular tumors rarely need reconstruction after resection.

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Since the identification of HER2 in breast cancer pathogenesis and the introduction of the first drugs targeting this receptor, the humanized monoclonal antibody trastuzumab and the tyrosine kinase inhibitor lapatinib, many advances have been made in the treatment of HER2-positive breast cancer that have led to a progressive improvement in the outcome of patients with early and advanced breast cancer. One of the major achievements is the development of dual HER2 blockade strategies. Evidence from the neoadjuvant and metastatic setting suggests that by combining trastuzumab with other anti-HER2 drugs such as lapatinib or the humanized monoclonal antibody pertuzumab, the efficacy of treatment may be further improved.

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