Indian Journal of Cancer Education and Research

Introduction: Ewing’s sarcoma (ES) is a rare but highly aggressive malignancy, predominantly affecting children and young adults, with a characteristic presentation of bone or soft tissue involvement. Whole lung irradiation (WLI) is used in the treatment of pulmonary metastases, especially following chemotherapy and surgical resection of the primary tumor. The purpose of this study was to assess the effectiveness of whole-lung irradiation in a young adult patient with metastatic Ewing’s sarcoma. Patient Information & Systemic Therapy: A young adult with progressively worsening tibial pain and swelling was diagnosed with Ewing’s sarcoma after imaging and biopsy confirmed the presence of the tumor. Neoadjuvant chemotherapy (VAC/IE) was administered, followed by surgical resection of the femoral tumor. Interim imaging showed significant reduction in pulmonary metastases, prompting the decision to proceed with whole lung irradiation. Material and Methods: The patient underwent whole-lung irradiation using a high-precision radiation therapy technique. A thermoplastic mask was employed for immobilization during CT scanning and radiation treatment. The radiation planning utilized Varian Somavision for tumor volume delineation, and the treatment plan was created using IMRT (Intensity-Modulated Radiation Therapy) with a Halcyon Elite 4.0 machine. The patient was treated with 18 Gy in 12 fractions. The breath-hold technique was utilized to minimize respiratory motion during radiation delivery. Cone Beam CT (CBCT) and portal dosimetry were employed to verify treatment accuracy. Results: The radiation dose was successfully delivered to the target volume (PTV), with a high degree of precision, as evidenced by dosimetric parameters. The V95% was above 95%, indicating that 95% of the target volume received the prescribed dose. The homogeneity index (P-HI) and conformity index (CI) showed favorable dose distribution, ensuring the target volume received a uniform dose while sparing surrounding healthy tissues. Critical organs such as the heart, esophagus, and liver received doses within safe limits, and no significant adverse effects were observed. Conclusion: Whole-lung irradiation using IMRT and advanced techniques like the breath-hold method and cone beam CT verification represents a promising strategy for managing pulmonary metastases in Ewing’s sarcoma. This individualized treatment plan maximized the therapeutic dose to metastatic lesions while minimizing risks to healthy organs, highlighting the potential for optimizing radiation therapy in this patient population.

Context: Triplet regimens with proteasome inhibitors, immunomodulatory drugs and steroid are common induction regimens used in Multiple Myeloma patients. Aims: We did a retrospective analysis of newly diagnosed multiple myeloma patients (NDMM) treated with VCd (Bortezomib, Cyclophosphamide, Dexamethasone) induction therapy in a resource constraint setting. Settings and Design: Electronic medical records of 26 NDMM patients attending a tertiary medical center in South India were analyzed. Methods and Material: The response rates of 26 NDMM patients treated with once weekly VCd induction and the clinically significant toxicities with this regimen were studied. Both transplant eligible and ineligible patients were included. Treatment responses after the 2nd and the 6th cycles of VCd were analyzed according to the IMWG uniform response criteria. The severity of toxicities were categorized using NCI-CTAE version 5 grading system. Statistical analysis used: IBM SPSS version 28 software was used for analyzing the results. Results: Of the 26 patients enrolled, 50% were above the age of 65 years. Median follow up was 17.5 months. In an intention to treat (ITT) analysis, the ORR was 57.7% (15/26) with VCd after 6 cycles, with CR of 34.6% (9/26), VGPR 19.2% (5/26) and PR 5.3% (1/19). The major toxicity was ≥ grade 2 peripheral neuropathy (PN). Grade 2 or more cytopenias were seen in 3 patients. 3 patients had grade 2 & 3 infections. 8% patients discontinued the treatment due to adverse events and 32% required bortezomib dose reduction. Conclusions: VCd is an effective induction regimen for NDMM patients with early deep response rates. This is especially important in LMICs like India, where the out of pocket healthcare expenditure is around 60%. VCd is a feasible regimen even for elderly NDMM patients with comorbidities

Purpose: Total Body Irradiation (TBI) is a critical component of conditioning regimens prior to hematopoietic stem cell transplantation (HSCT). This report presents the first clinical implementation of VMAT-based TBI for a 19-year-old male patient using a Halcyon™ Elite linear accelerator, with treatment planning performed in Eclipse™ Treatment Planning System (TPS) version 17.0. The prescribed dose was 12 Gy delivered in 10 fractions, consistent with a reducedintensity conditioning protocol. Methods: The patient was simulated in head-first supine (HFS) positions using vaclock immobilization and full-body support. A planning target volume (PTV) was defined by cropping 3 mm from the external contour to avoid build-up issues. MAT plans were created using 12 isocenters with 6 MV flattening-filter-free (FFF) beams. The treatment was planned using Eclipse v17.0, with emphasis on achieving uniform PTV coverage while minimizing dose to critical organs-atrisk (OARs) including lungs, kidneys, lenses, and testes. Pre-treatment quality assurance (QA) was performed with portal dosimetry. Results: The treatment plan achieved adequate PTV coverage, with D95% of 10.76 Gy, ensuring acceptable dose homogeneity (HI = 0.26). The mean doses to the left and right lungs were 11.45 Gy and 11.48 Gy, respectively. The mean kidney doses were 11.09 Gy for the left kidney and 10.98 Gy for the right kidney. The doses to the lenses (5.38 Gy) and testes (14.27 Gy) remained within institutional tolerance limits. The total monitor units (MU) delivered were 2704.9.The total beam-on time per fraction was approximately 15 minutes, with overall treatment time including setup and imaging averaging 1 hour 30 minutes. Gamma analysis using 3%/3 mm criteria demonstrated 100% passing rates (γ < 1.0) for both head-first supine (HFS) and feet-first supine (FFS) setups, exceeding the 97% institutional tolerance. Conclusion: Halcyon VMAT-based planning provided satisfactory target coverage and organ sparing within an efficient and reproducible workflow. Halcyon may be considered a suitable platform for TBI delivery in adolescent and young adult (AYA) patients undergoing transplantation.

Background: Renal cell carcinoma (RCC) is a highly aggressive cancer with a notable propensity for metastasis. The most frequently affected sites include the lungs, bones, liver, adrenal glands, lymph nodes, and brain. It is estimated that around one-third of patients with advanced RCC develop bone metastases. Acral metastases are rare, accounting for only 0.1% of all metastatic bone involvement. Case Description: A 62-year-old male presented with complaints of bleeding micturition for 1 week. Computed Tomography-Chest plus Abdomen plus Pelvis showed a lesion in lower pole parenchyma of left kidney. Patient underwent Left Radical Nephrectomy. Post operative HPR revealed Clear cell carcinoma grade 3, with Lymphovascular invasion. Patient was started with Tablet Sorafenib 200mg 2BD from June 2022 till November 2022. Patient defaulted treatment for 1.5 years then presented with complaint of swelling and pain over Right thumb. X-Ray Hand revealed completely destroyed 1st metacarpal and proximal phalanx suggestive of? Metastasis. Biopsy from lesion confirmed Atypical Renal Cell Carcinoma. Patient was treated with Injection Zoledronic Acid monthly and Tablet Sorafenib. Palliative RT was given to the right thumb for pain management.