Annals of Oncology Research and Therapy

: 2022  |  Volume : 2  |  Issue : 3  |  Page : 2--18

Abstracts of Evidence Based Medicine Conference in Oncology 2022 of Tata Memorial Hospital, Mumbai


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. Abstracts of Evidence Based Medicine Conference in Oncology 2022 of Tata Memorial Hospital, Mumbai. Ann Oncol Res Ther [serial online] 2022 [cited 2022 Jun 25 ];2:2-18
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 Reconstruction and cancer care – Enhancing quality living with and beyond cancer

 Free fibula flap with type 3a and 3b popliteal artery anomaly: Safety of harvest

Prince Gupta, Vineet Pilania, Ameya Bindu, Mayur Mantri

Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: The peroneal artery-based free fibula flap is an exceptional source of long vascular bone that can be readily osteotomized and permits for osteointegration. Kim et al. identified several congenital anomalies of popliteal artery branching. Type 3c anomaly [atrophied posterior tibial artery (PTA) and anterior tibial artery (ATA)] is considered an absolute contraindication for fibula flap harvest. The 3a (atrophied PTA) and 3b (atrophied ATA) anomalies, on the other hand, produce a perplexing scenario. In our study, we want to confirm the safety of harvesting free fibula flaps in 3a and 3b anomalies.

Materials and Methods: This is a retrospective study to evaluate the outcome and safety of harvest of free fibula flap in 3a and 3b anomaly. All patients with 3a and 3b anomalies undergoing successful harvest of the flap in the last five years at our center were included in the study. Patients lost to follow-up were excluded. Before surgery, patients underwent physical examination of foot pulsation, and color doppler imaging was used only in patients who had either abnormal physical examination, history of vascular disease, history of limb trauma. Intraoperatively, ATA and PTA were always objectively confirmed before ligating the distal runoff of the peroneal artery. If PTA or ATA were found hypoplastic or absent, two hemostatic clamps were applied on the proximal and distal end of the peroneal artery. Foot vascularity was assessed after deflating the tourniquet for half an hour in form of capillary refill and bleeding on pinprick. The fibula was harvested only if foot vascularity was adequate. Patient data were retrieved from electronic records and were assessed for donor site complications including wound infection, loss of skin graft, muscle necrosis requiring debridement, foot claudication, and ischemia using personal visits and telecommunication.

Results: Anomalous popliteal artery branching was seen in 55 patients out of five hundred free fibulae harvested successfully. Fibula harvest was abandoned in six patients who had type 3c anomalies. Out of 55 patients, only 25 had 3a and 3b defects, and the rest had type 2 anomalies consisting of anomalous branching of PTA and ATA. Twenty-one patients with 3a and 3b were successfully followed up. Five patients had partial graft loss requiring regrafting and one patient had muscle necrosis requiring muscle debridement and VAC therapy. Foot claudication or ischemia was not seen in any patients and all patients were able to walk comfortably.

Conclusion: Free fibula can be successfully harvested in patients with type 3a and 3b anomalies with minimal donor complication.

 Free fillet flaps: A simple and reliable option for reconstruction of large oncological resections involving limb amputation

Hetanshu Parekh, Mayur Mantri

Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Oncologic defects resulting from extremity amputations are usually quite extensive and complex. In addition to the need of large skin coverage there is also a need for substantial soft tissue for reconstruction. The 'fillet flap' or 'spare part' concept, is using part or parts of amputated or nonsalvageable traumatized limbs as a pedicled or free flap for resurfacing large defects following oncological surgery or trauma. The purpose of this study is to present our experience using free fillet flaps to reconstruct massive oncologic defects of the upper extremity.

Materials and Methods: A review of all patients, who underwent forequarter amputation, or hindquarter amputation for resection of tumour and who required any form of reconstructive surgery between 2018 to 2021 at Tata Memorial Hospital, Mumbai was performed. Patient demographics, clinical and surgical characteristics, and postoperative complications were reviewed.

Results: A total of 7 patients were identified; of them, 6 had forequarter amputation, and 1 had hindquarter amputation for locally advanced tumours. 4 were reconstructed with split thickness skin graft, 1 with pedicle fillet flap and 2 with free fillet flaps. Of the patients with free fillet flaps - mean age was 53.5 years. Mean tumour size was 25 cm, and negative tumour margins were achieved in all the patients. Mean flap size was 798 cm. The mean follow-up was 6 months. There were no partial or total flap losses in the postoperative period. One patient had developed chyle leak unrelated to reconstructive surgery which was managed conservatively. Both the patients received postoperative radiation therapy without any complications.

Conclusions: Reconstruction of extensive defects following oncological extremity amputation can often be optimally done using free tissue transfer from disease free distal amputated limb. The salvaged “spare parts” can be used as a free fillet flap, reducing the need of additional donor areas and their morbidity related problems. Also free fillet flaps are provide sturdy vascular cover for these defects which can withstand radiation and also be a good base for applying artificial limb/prosthesis.

 Free flap reconstruction in children less than 5 years with malignant tumors

Radhika Kapahtia, Mayur Mantri

Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Free tissue transfer has been widely reported as being an effective method for reconstructing surgical defects following resection of head and neck tumors in adults, but data on its application in the pediatric population are sparse. These children undergo preoperative chemo/radiation, both of which adversely affect wound healing and growth. Resection and reconstruction must take into account the anatomy and growth pattern in case of bone and soft tissue tumors and the of the anatomy of the craniofacial complex in case of head and neck reconstructions . Donor site morbidity can be substantial following the harvest of tissue in the growing limb. Other concerns - challenges of performing microsurgery in children whose blood vessel diameters are small, anatomic landmarks are inconsistent, and growth of anastomosed vessels is anticipated.

Materials and Methods: In our study the feasibility and safety of free flap reconstruction in children less than 5 years of age undergoing extensive surgical excision of malignant head and neck and extremity tumors were assessed We performed a retrospective review. Main outcome measures included the site and the extent of the resection , the flap used for reconstruction , the size of the vessels both donor and recipient, complications at the primary and donor sites, functional and aesthetic outcome, and tumor control.

Results: A total number of 21 patients aged less than 5 years of age were included in this study. All of them underwent free flap reconstruction. All tumors were malignant , both head and neck and Bone and soft tissue tumors. Transferred free flaps were 13 free antero-lateral thigh flaps (12 = Head and reconstruction , BST =1 ) and 7 were Free fibula Flaps (6 = Head and neck Reconstruction and 1 = Bone and soft tissue tumor ) . The mean follow-up was 24.5 months. The overall early and late complication rates were 25 and 20%, respectively. There were no flap losses and no donor site complications. Functional outcome, including mastication, deglutition, and speech, was satisfactory. Local tumor control rate at last follow-up was 87.5%.

Conclusion: Free flap reconstruction is an efficient and relatively safe technique for reconstructing surgical defects in children undergoing extensive surgery for malignant disease which requires extensive planning and meticulous tissue handling.

 Mucoepidermoid carcinoma of the parotid gland in a 6 year old girl

Taskeen Mannan Sikora, Vidita Powle, Amit Mulay, Nutan Jumle, Snita Sinuk

Jehangir Hospital and Research Centre, Pune, Maharashtra, India

E-mail: [email protected]

Introduction: Neoplasms of salivary glands are rare in children, representing fewer than 10% of all paediatric head and neck tumors. Approximately 80% of salivary gland tumors are considered benign, pleomorphic adenoma being the most common type. Mucoepidermoid carcinomas account for 50% of malignant salivary gland tumors in children. Mucoepidermoid carcinoma of the parotid gland is very rare in children.Because of the rarity of salivary gland malignancies in children and the array of different histopathologic types, it has been difficult to accumulate a broad experience and to establish a standard treatment strategy. Herein, we present our experience with mucoepidermoid carcinoma of the parotid gland in a 6 year old child.

Materials and Methods: A 6 year old girl presented with a 2 year history of a left hard 3x4 cm parotid swelling. CECT showed a mass involving the superficial and deep lobes of the left parotid gland extending into the sternocleidomastoid muscle and the overlying skin. CT guided biopsy showed low grade mucoepidermoid carcinoma. She underwent a total radical parotidectomy with left sided selective neck dissection and facial reanimation.The tumor was found to involve the superficial and deep lobes of the parotid and also found to encase the main trunk of the facial nerve; a decision was taken to sacrifice the facial nerve proximally in the fallopian canal, saving maximum length of the uninvolved distal branches. Reanimation was done using the masseteric nerve to reinnervate the zygomatic branch/eye branch and a few fibres of the spinal accessory nerve to reinnervate the marginal mandibular nerve.

Results: Her postoperative recovery was adequate and the re-innervated facial nerve function demonstrated good function. She was followed up every 6 monthly and at the end of 1 year her facial tone with a near total eye closure showed a House Brackmann Score II, enhanced with physiotherapy and electrical stimulation.

Conclusion: Although very rare, salivary gland neoplasms may occur in children in their first decade of life and treatment is multidisciplinary. Primary facial reinnervation must be attempted wherever possible. In the case of this 6 year old with appropriate workup and planning we were able to achieve good oncological clearance and facial reanimation with good quality of life.

 Extracorporeally irradiated femur autograft combined with vascularized fibula flap for reconstruction of femur defect in a case of osteosarcoma – Modified Hemi-Capanna technique

Dipmalya Chatterjee, Ankur Gupta

Balco Medical Centre, Naya Raipur, Chhattisgarh, India

E-mail: [email protected]

Background: Osteosarcoma of femur, requiring bony resection, needs immediate reconstruction to preserve integrity and function of lower limb. Various techniques have been described including use of megaprosthesis, bone allograft, irradiated bone autograft, free fibula flap, combined fibula flap and bone allograft (originally known as Capanna Technique). Each technique has its advantages and disadvantages. However, there is limited literature on use of irradiated resected femur bone (autograft) combined with free fibula flap to reconstruct femur defect. We present a case of Osteosarcoma of femur in a ten-year girl, treated with bony resection and reconstructed with vascularized fibula transfer along with resected femur bone used as autograft after extracorporeal irradiation.

Materials and Methods: A single case is being presented here. A ten-year girl presented with osteosarcoma of shaft of right femur with poor response to Chemotherapy. Surgical resection and reconstruction by Capanna Technique was planned. However, due to unavailability of femur allograft, the technique was modified to use the resected femur as autograft. Patient was operated in August, 2021. The resected femur measured 12cm. Bone specimen was sent for single fraction high dose (50 Gy) radiation. 19cm fibula along with a monitoring skin paddle harvested from the opposite leg was used along with irradiated femur autograft as on-lay pattern reconstruct (Modified Hemi-Capanna), fixed with locking plate. Post-operatively, isotonic exercise of hip and knee joint was initiated. Full weight bearing on donor leg was started at 15days. Radiological imaging was done at 6, 12 and 18weeks and functional outcome was assessed by Lower Extremity Function Scale (LEFS) at 18weeks.

Results: Callus formation was noted at 18weeks. Gradual weight bearing on right leg was started at 18weeks. Limb function score on LEFS at 18weeks was 44 with full active and passive range of motion at hip and knee joint.

Conclusion: Combining vascularized fibula with femur graft has higher chance of union and lesser complications compared to any of the standalone techniques as fibula provides biology and the femur graft provides immediate structural stability to the reconstruct. Irradiated femur autograft can be used in situations where allograft is not available, especially in oncologic setting.

 Selecting vessels in microvascular reconstruction for lower limb defects in cancer patients

Aditya Vora, Vineet Pilania

Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Introduction: The primary goal of lower extremity reconstruction is to recover function and maintain it, for which skeletal reconstruction with stable soft tissue coverage is essential. Proper selection of a recipient vessel is essential for success of free tissue transfer, especially when the transfer is to the lower extremity.

Materials and Methods: This was a retrospective observational study from 2016 to 2021.In these 6 years a total of 292 free flaps were done for lower extremity defects after tumor resection. Data was collected for the type of tumor, the defect size, site, flap used, vessel used for anastomosis and the type of anastomosis done. Data was also collected for the number of re-explorations done, cause of the re-explorations and secondary procedures done for the same.

Results: Among them the posterior tibial vessel was used in 162 cases, anterior tibial in 60 cases, femoral artery in 28 cases and other vessels in 42 cases. The most common flap used was the anterolateral thigh flap in 196 cases. Flap success rate was 93.44%.

Conclusions: There are multiple factors which may lead to flap failure but the most important is selecting the right vessel for anastomosis but the ultimate decision should be made on the table during surgery when the actual artery or vein is exposed and shows signs of good pulsation and flow.

 Extracorporeal sterilisation and reimplantation of tumor bone – Extracorporeal radiotherapy or cryosurgery?

Aakriti Jain, R. Arora, D. Arya, V. Verma, A. Tiwari

Department of Musculoskeletal Oncology, Max Institute of Cancer Care, New Delhi, India

E-mail: [email protected]

Introduction: Re-implantation of bone is a fair method of biological reconstruction for limb salvage surgery in diaphyseal bone tumors. Extracorporeal radiotherapy and cryosurgery with liquid nitrogen have been used for quite some time now for extra-articular bone tumors. We tried to answer a commonly asked question-What happens to this reconstruction using recycled dead bone in the short-mid-term follow up?

Materials and Methods: A total of 41 limb salvage surgeries using extracorporeal radiotherapy (n=25) and liquid nitrogen (n=16) and re-implantation were performed by two surgeons from 2010 till 2021. All patients underwent wide excision using the standard technique. After resection, specimens were subjected to 50 Gy radiation or liquid nitrogen for 20 minutes in a single sitting, and re-implanted into the defect immediately afterwards using suitable fixation.

Results: The average follow up was 4 years (Range- 1.2 year to 11 years). A total of 27 patients were disease free at last follow up, while 6 patients died of disease. All bone- graft junctions had healed (except two patients done recently with a short follow up). Secondary bone grafting/ bone marrow injection had to be done for persistent nonunion in three patients- all three for the diaphyseal sides. Out of 30 limbs that were ultimately salvaged, 20 patients who had solidly united at last follow up had been allowed uninhibited use of the limb including impact sports. Seven patients had been allowed full weight bearing but not impact sports, as they were still waiting for solid bony unions. While patients with pedicled cryotherapy treated bone had shorter rehabilitation time as compared to irradiated bone (2.75 months as compared to 12.18 months for ECRT), both the procedures had comparable functional scores on the last follow up.

Conclusions: Extracorporeal radiation and re-implantation of tumor bone is an excellent method of reconstruction with predictably good outcomes. Longer follow ups in the cryotherapy group will further reveal the longevity of these reconstructions.

 Ablative surgery for axillary oligo-recurrence – Reconstruction with forearm free flap

H. L. Deepak, K. S. Gopinath1, S. Amarendra1, K. Anand2

Department of Surgical Oncology, Sri Devaraj Urs Medical College, Kolar, 1Department of Surgical Oncology, Health Care Global Hospitals, 2Department of Plastic and Reconstructive Surgery, Sparsh Hospitals, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Axillary recurrence following a complete axillary clearance in low. However, it can present with intractable pain, paresis of the limb and lymphedema. Treatment includes Local excision to radical surgery, chemotherapy and radiotherapy.

Case Report: We report a patient with locally advanced breast carcinoma who underwent a Forequarter amputation due to an axillary recurrence which was progressive to chemotherapy and radiotherapy leading to a Non-functional limb with edema and intractable pain. The reconstruction of the chest wall following forequarter amputation was done using the flap from the amputated limb, thus avoiding donor site morbidity with long term survival.

Conclusion: Forequarter amputation may be required for a non-functional limb with pain following axillary oligo-recurrence. The important aspect of our report was that the chest wall reconstruction following the amputation was done with free flap from amputated limb avoiding donor site morbidity.

 Supraclavicular artery flap for oral oncologic defect reconstruction

Pratiksha Pawar, Sachin Verma1, Ameya Bihani

Department of Head & Neck Onco Surgery, SRJ-CBCC Cancer Hospital, 1Department of Plastic and Reconstructive Surgery, GM Medical College and MY Hospital, Indore, Madhya Pradesh, India

E-mail: [email protected]

Background: Oral oncologic reconstruction not only demands filling up of the defect but also requires proper functional and aesthetic restoration of three dimensional structures for which nowadays microvascular free flap is the ideal choice of reconstruction. But free flaps require specialised microvascular expertise, adds operating time and increase costs to patients and is also contraindicated some co-morbid patients where there are high chances of flap failure or might have a very high risk of post-operative complications. Hence the aim of this prospective study is to evaluate advantages and disadvantages of supraclavicular artery for oral oncologic reconstruction.

Materials and Methods: This is a prospective randomised study which includes 19 patients, out of which 14 were male and 5 were female and the age range was 45-60 yrs. Inclusion criteria was disease involving Buccal mucosa.

Results: Thirteen patients had no post-operative complication, 3 had partial necrosis, 2 had distal marginal necrosis with wound dehiscence, 1 had pus discharge with wound dehiscence and orocutaneous fistula. There was no significant donor site morbidity.

Conclusion: Supraclavicular atery flap provides feasible alternative for defect reconstruction in oral oncologic resections in patients with medically compromised status for longer general anaesthesia and failed free flaps, in remote areas due to lack of availability of expertise in micro vascular skills. It provides good skin colour match, minimal post-operative complications, requires short learning curve of surgical technique and low treatment cost.

 Our experience of free vascularized free fibular grafts

Firoz Borle, Saumya Mathews

Department of Plastic Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Proximal humerus is one of the anatomical sites frequently involved by bone and soft tissue malignant tumors. Surgery represents the main therapeutic option to treat and eradicate the disease. Large skeletal defects post ablative surgery of the upper extremity pose a serious clinical problem with potentially deleterious effects on both function and viability of the limb. Options of reconstruction on long bone defects include osteoarticular allograft, bone allograft, prosthesis and graft prosthesis composite. Transfer of a vascularized fibular graft is the method of choice for reconstruction of defects of long bones. The purported advantages of vascularized fibula transfer are early union, bone remodelling, shoulder stability and less infection. The aim of the present study was to analyse the operative results, complications, and post-operative function after vascularized fibula graft transfer and the indications for this procedure.

Materials and Methods: It was cross sectional descriptive study. Seven patients underwent upper limb bony reconstruction with vascularised free fibula graft during 2008 till 2021 were included in the study. Minimum follow up duration was 6 months. The postoperative course of the transferred bone was examined, and functional results were evaluated using MSTS scale.

Results: The follow up duration ranged from 6 to 256 months. All the fibular grafts survived. The median period to achieve radiographic union was 4.4 months. The median overall functional rating of the reconstructed shoulder joint was 70 percent.

Conclusion: Free fibular grafts in the treatment of malignant bony neoplasms of the upper extremity has a high rate of union and good overall outcomes.

 Musculoskeletal oncology Current practices and bridging the gaps

 Cryoablation: Minimally invasive treatment for bone tumors

Saket Patwardhan, Suyash Kulkarni, Nitin Shetty, Kunal Gala, Daksh Chandra, Sayed Faisal

Department of Radiology, Tata Memorial Centre, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Cryoablation is a novel thermal ablation technique of interventional radiology for the management of bone and soft tumors. Its principle is based on the Joule Thompson effect. The method uses cryoprobes to transfer air, argon and helium gases to the target lesion for alternate freeze-thaw cycle to cause cell death. Argon gas expands between chambers of the cryoprobes leading to immediate cooling around the tip to less than -100°C causing cell membrane disruption by the formation of ice ball, dehydration and vessel thrombosis. Complete cell death occurs 3-5 mm deep to the ice ball margin. After this, helium is transmitted, which is exothermic and permits thawing of the ice ball. Then the cryoprobes are removed. Cryoablation in bone and soft tissue tumors is an effective technique for alleviation of bone pain and local control of tumors. Cryoablation has been used at our institution in cases of fibromatosis, chondroblastoma and plasmacytoma. In the treatment of pain associated with skeletal metastasis, a reduction of 91 percent at 4 weeks and 95 percent at 12 weeks was seen in a study. An optimum control was seen in 45 of 52 musculoskeletal oligometastases of varying histologies (87 percent) in a single-center review of cryoablation. It has also been found that a combination of cryoablation and radiotherapy adds to the efficacy of management of bone metastasis. Spinal metastases can be treated with a good efficacy using cryoablation. Complications from cryoablation of bone tumors include injury to structures during applicator placement, post-procedural pain, post-ablation syndrome, nerve injury, secondary fracture, and avascular necrosis. Thus, Cryoablation is a safe and effective ablation technique that can be monitored with cross -sectional imaging, has less peri-procedural pain and can target larger tumors better and the ablation zone in the vicinity of crucial structures can be seen.

Learning Objectives:

To understand the principle and technique of cryoablation, its various applications in bone and soft tissue tumors and the complications of the procedureTo create awareness of the future applications of this novel technique.

Conclusion: Cryoablation is a promising and novel minimally invasive method in the management of bone and soft tissue tumors. The musculoskeletal clinicians and radiologists must know the technique, advantages and disadvantages of this novel intervention for better management of musculoskeletal tumors, better care and improvement of quality of life of the patient.

 Clinicopathological features of four ultra rare cases of BCOR-CCNB3-positive sarcomas

Bharat Rekhi, Vaibhavi Vengurlekar, Omshree Shetty, Ajay Puri

Department of Pathology, Tata Memorial Hospital, Homi Bhaba National Institute University, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Sarcomas with BCOR genetic alterations are included in the recent WHO classification of soft tissue and bone tumors. Currently, there is a single reported study from our country on BCOR-CCNB3-positive sarcomas. We present clinicopathological features of 4 additional such cases.

Materials and Methods: Nine cases of undifferentiated round to spindle sarcomas were tested for BCOR-CCNB3 and CIC-DUX4 (type I and II) fusions by reverse transcriptase-polymerase chain reaction. All these tumors were negative for EWSR1 gene rearrangement and a single case, also for SS18 rearrangement, by fluorescence in-situ hybridization. The integrity of RNA was assessed by performing PCR for ß-actin (ACTNB) housekeeping gene 208 and 432 bp. Samples analyzed on 10% PAGE and interpreted using gel documentation system. Certain fusion-positive cases were sequenced using capillary electrophoresis.

Results: Four tumors occurred in 3 males (13-year-old, 17-year-old, and 16-year-old) and a single female (37-year-old), in tibia, femur, temporal region, and thigh, respectively. Histopathologically, tumors were composed of round (n=4), polygonal (n=3), to spindly cells (n=2) in a myxoid matrix (n=3) with interspersed thin-walled vessels (n=4) and focal necrosis (n=2). A single tumor,post-chemotherapy revealed bone formation (case 1), while another revealed chondromyxoid stroma (case 2). Immunohistochemically, tumor cells displayed dot-like reactivity for MIC2/CD99 (4/4), positivity for SATB2 (4/4), BCOR (3/3), focal positivity for EMA (1/4), and negativity for desmin (0/4), S100P (0/4) and WT1 (0/3). Therapeutically, 2 patients underwent neoadjuvant chemotherapy (73% response and 78% response), followed by surgical resection. Two patients were offered palliative radiotherapy and palliative chemotherapy, in view of metastasis at presentation and unresectability. Three patients developed lung metastasis and 2 patients developed local recurrences. Finally, there patients were alive with disease and a single patient was lost to follow-up.

Conclusions: Certain morphological features, such as spindle and polygonal cells, in addition to round cells, along with myxoid stroma, intervening vessels; dot-like immunoreactivity for MIC2, lack of EWSR1 rearrangement, and intraosseous location constitute as diagnostic clues for BCOR-CCNB3-positive sarcomas. SATB2 and BCOR are useful immunostains for triaging such cases for BCOR-CCNB3-fusion testing, which constitute essential criteria for diagnosing these ultra-rare tumors.

 Results of single incision technique for acetabular resection

Vishnu Ramanujan, Suman Byregowda1

Apollo Proton Cancer Center, Chennai, Tamil Nadu, 1Department of Orthopedic Oncology, Narayana Hospitals, Bengaluru, Karnataka, India

E-mail: [email protected]

Background: Utilitarian incision is work horse incision for pelviacetabular resections and includes the iliac, ilioinguinal, inguinoperineal and illiotrochanteric limbs. The use of the illio trochanteric portion results in the formation of a tripointer with increased incidence of wound problems seen in 20-40% of patients. These problems are further compounded as acetabular resections require reconstructions. We aim to evaluate the results of acetabular resections and reconstruction in patients through single incision where the illiotrochanteric incision was avoided.

Materials and Methods: Retrospective review of patients between Jan 2017 and June 2021. 16 consecutive patients with malignant tumors involving acetabulum underwent resections and reconstructions through single incision technique. Incision begins at pubic symphysis, along inguinal ligament, and runs posteriorly along iliac crest to end at sacroiliac joint. In patients requiring pubic bone resections additional inguino perineal incision was used. The outer table dissection was carried out without using the ilio trochanteric limb to access the hip joint and to identify the sciatic nerve. Intra operative details and post-operative complications were collected and analysed.

Results: Nine males and 7 females with a mean age of 24 years (1-60 years) were included. Median follow-up was 13 months. 8 patients were diagnosed with Ewings sarcoma, 4 with chondrosarcoma and 1 each with osteosarcoma, synovial-sarcoma, clear-cell sarcoma and metastatic thyroid cancer. 5 patients had open biopsies. 9 patients had 1+2, 3patients had 2+3 and 4underwent 1+2+3 resections. 4patients underwent reconstruction with ECRT and reimplantation while remaining 12 had mesh pseudoarthrosis. 9 patients received NACT and 11 received adjuvant chemotherapy. 7 patients received PORT. All patients underwent R0 resections. Mean duration of surgery was 300 min and mean blood loss was 1300 ml. 11 patients had tumor size >8cms. 3 patients had early post-operative wound problems 1of which healed by secondary intention and remaining 2requiring re surgery with debridement and VAC closure in 1 and flap cover in 1. 1 patient had inadvertent bowel injury and succumbed 30 days post-surgery. 2/3 patients with wound problems had open biopsy. No patients had late wound problems (>45 days). The use of NACT, PORT, age, type of reconstruction and type of resection had no influence on the post-operative wound morbidity.

Conclusion: With an overall wound complication rate of 18%, use of single incision acetabular resection is oncologically safe, allows for adequate exposure for both resection and reconstruction and has wound complication rates lesser than that for use of T incision.

 Clinico-pathological spectrum of series of alveolar soft part sarcoma from a tertiary care cancer referral centre in India

Kanwalpreet Kaur, Amisha Gami, Priti Trivedi

Department of Onco-Pathology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

E-mail: [email protected]

Background: Alveolar soft part sarcoma (ASPS) are rare soft tissue tumours characterized by distinctive histomorphology of variably discohesive epithelioid cells arranged in nests and translocation of t(x;17) (p11.2;q25) resulting in ASPSCR1-TFE3 fusion. The aim of present study is to review the clinical, histopathological and immunohistochemical profile of ASPS.

Design: Present study is retrospective and descriptive. All cases with histological diagnosis of ASPS were retrieved from archives of oncopathology. Clinical and radiology details were taken from the case records.

Results: 19 patients of ASPS were identified from 2012 to 2021. Age range was 2- 47 years and M:F ratio was 0.9:1. Most common site was lower extremity followed by upper extremity, retroperitoneum, head and neck, chest wall and lung. Size range was 3-22 cm. Nearly 57.9% cases presented with AJCC stage IV at the time of diagnosis having synchronous metastasis with lung as the most common site (90.9%). Metastasis preceded detection of primary tumour in two cases. One case of posterior fossa mass and other of pathological fracture in right femur were diagnosed as ASPS on biopsy. Subsequently, PET revealed a primary mass in left iliac region and right thigh respectively. All cases showed similar histopathologic features comprising of monomorphic epithelioid cells arranged in nests encircled by sinusoidal capillary vasculature. Cells had abundant granular eosinophilic cytoplasm and vesicular nuclei with prominent eosinophilic macronucleoli. In all cases, significant proportion of nuclei showed wrinkling and concave nuclear contour described as apple bite nuclei. Other features noted were occasional mitosis (~3/10 hpf) including atypical mitosis and necrosis in 9 cases, lymphovascular emboli (n=6), focal solid areas (n=2), infiltration of single tumour cells in the septa (n=3), nuclear pleomorphism (n=2), bi and multinucleated cells (n=4). None of the cases showed intratumoral lymphocytes.

All cases showed diffuse nuclear positivity for TFE3 and consistent negativity for AE1/AE3, EMA, HMB45, PAX8, MyoD1, SMA, synaptophysin and chromogranin. Only two cases showed focal S100 positivity while one showed focal desmin positivity. All cases underwent resection followed by doxorubicin-based chemotherapy. Radiotherapy was also given in 6 cases.

Conclusion: Diffuse strong nuclear TFE3 positivity is sensitive for ASPS but can be seen in subset of PEComa and renal cell carcinoma hence should be evaluated in conjunction with other IHC markers.

 Role of diffusion-weighted MR imaging in the characterization of soft tissue tumors

S. S. K. Venkatesh, Ekta Dhamija, Adarsh Barwad, Rambha Pandey, Sandeep Boriwal, Sameer Rastogi, Mukesh Kumar

Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India

E-mail: [email protected]

Background: Magnetic resonance imaging (MRI) is the imaging investigation of choice in patients with soft tissue mass. In addition to confirming the presence of mass and assessing the presurgical extent, it can also be used to differentiate benign and malignant soft tissue tumors (STT). Diffusion-weighted imaging (DWI) is a form of molecular and functional imaging which can predict the tumor cellularity and hence its behavior. Tumors with high cellularity due to the presence of cell membranes, show restricted diffusion and hence low ADC (apparent diffusion coefficient) whereas tumors that are less cellular show high ADC values. This study has been planned with the aim of ascertaining the role of Diffusion-weighted imaging (DWI) and calculating the ADC cut-off in differentiating benign and malignant tumors.

Materials and Methods: This prospective study was conducted after obtaining clearance from the institute ethics committee. Diffusion-weighted images of 26 patients with suspected STT were obtained at three different b-values (0,500,1000) and pixel-wise ADC maps were generated. The average of ADCmin, ADCmean and ADCmax (x10-3mm2/s) were calculated by drawing circular/elliptical region of interest (ROI) including most of the tumor and excluding necrotic areas. Histopathological assessment was taken as the gold standard and univariate analysis was performed using the t-test followed by Receiver operator characteristics (ROC) analysis of statistically significant parameters (p-value<0.05).

Results: Out of the 26 patients, 15 were benign and 11 were malignant. The male-female ratio was 2.8:1 and lower limbs were the commonest involved sites. The average of ADCmin was 1.23±0.46 for benign tumors and 0.81±0.21 for malignant tumors; average of ADCmeanwas 1.83±0.7 and 1.31±0.36; average of ADCmax was 2.4±0.42 and 1.9±0.44 for benign tumors and malignant tumors; respectively. Significant difference was observed in ADCmin (p= 0.038) and ADCmax (p=0.04) with a cut-off value of 0.86 for ADC min showing sensitivity and specificity of 72.73% and 73.33% respectively, and a cut-off value of 2.19 for ADC max showing sensitivity and specificity of 72.73% and 73.33% respectively; in differentiating the STT.

Conclusion: DWI can be used to differentiate benign and malignant STT. Malignant tumors show diffusion restriction and lower ADC values particularly ADC min (<0.86) and ADC max (<2.19) compared to benign tumors.

 Role of diffusion weighted imaging in differentiate malignant and benign musculoskeletal neoplasms

Sannidhi Dewan, Jay Thakkar, Nirad Mehta, Manish Agarwal

Department of Radiodiagnosis, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Purpose of the study is to evaluate the added value of Diffusion Weighted Imaging (DWI) for evaluation of musculoskeletal tumors and to derive an optimal cut-off ADC value to differentiate malignant and benign musculoskeletal neoplasms.

Materials and Methods: This is a retrospective study of 85 patients with histopathologically proven bones (n = 61, 47 malignant, 14 benign) and soft tissue (n = 24, 21 malignant, 3 benign) neoplasms. Conventional features like size, margins, T1/T2 signal intensity, cortical breach/bone expansion/medullary involvement, neurovascular bundle involvement were assessed. DWI analysis was done by a blinded radiologist having MRI reporting experience of 3 years by placing three ROIs on solid (non-necrotic) component and Mean ADC value were derived for each neoplasm which were confirmed by another senior radiologist with an overall MR experience of more than 15 years. Discrepancies were resolved by consensus. Histopathological diagnosis was considered as gold standard. Mean ADC values of benign and malignant groups were compared statistically. Sensitivity and specificity were obtained. A cut-off ADC value was derived from ROC curves with optimal sensitivity and specificity using the Youden Index.

Results: True visual diffusion restriction was confirmed among 34/47 malignant bone tumors on b-800 DW images, while 10/14 benign bone tumors showed facilitated diffusion. Similarly, visual restriction was seen among 20/21 malignant soft tumors, while 2 out of 3 benign soft tissue tumors showed visual facilitated diffusion. Statistically significant difference was noted between the mean ADC value of malignant (1.20±0.68 x 10-3mm2/s) and benign bone tumors (1.57±0.69 x 10-3mm2/s) (p=.04). 11/19 chondrosarcomas showed facilitated diffusion with a high mean ADC value of the chondrosarcoma group (n = 19) 1.73 x 10-3 mm2/s. Also, the difference of mean ADC value of the benign (1.33±0.20 x 10-3mm2/s) and malignant (0.85±0.26 x 10-3mm2/s) soft tissue tumors was found to be statistically significant (p=0.006). For bone neoplasms, cut-off mean ADC value of 1.1x10-3 mm2/s was derived with sensitivity, specificity, PPV and NPV of 72.34%, 71.43%, 89.5%, 43.5%, respectively. Similarly, for soft tissues, a cut-off mean ADC value of 1.0 x 10-3 mm2/s was achieved with sensitivity, specificity, PPV and NPV of 100%, 85.71%, 50% and 100%, respectively.

Conclusion: In addition to conventional MR, DWI with ADC analysis is a powerful tool in musculoskeletal tumors evaluation and a cut-off value may help differentiating benign from malignant neoplasms. In chondroid malignancies, contrary to expectations, high ADC values are seen owing to matrix free fluid.

 Lymphoma presenting with dominant bony involvement: Clinicopathological characteristics

Manasi C. Mundada, Faiq Ahmed, K. Suseela, Veerendra Patil, M. V. T. Krishna Mohan, Senthil J. Rajappa, T. Subramanyeshwar Rao

Department of Pathology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

E-mail: [email protected]

Background: Primary lymphoma of bone (PBL) is rare entity, comprising of 7% of bone tumours and <1% of Non-Hodgkin lymphoma. The most common site involved is femur and Diffuse large B cell Lymphoma (DLBCL) is the most common histological subtype.

Materials and Methods: Retrospective study from Jan 2020 to Dec 2021. Lymphoma presenting as single/ multiple bony lesion without significant regional lymph node involvement were included in the study. The demographic, clinicopathological, Radiological parameters were noted and treatment details with follow up was retrieved where available.

Results: The frequency of PBL reported was 2%, M: F ratio was 1:1, median age at presentation 58 years (range 11 to 76 Years). Sr no Age/Gender Clinical features Radiology HPE diagnosis with IHC Treatment Follow up.

11/M Swelling below knee with pain over 1 month Lytic lesion with periosteal thickening and cortical break s/o Brodie's abcess.(5.3 x3.4x3 cm) ALCL,ALK + ALCL-99 protocol followed by 3000 cGy in 15 fractions, using 6 MV photons and 2 fields (AP/PA) PET-CT at the end of four months showed good response50/M Right hip pain Lytic lesion with cortical break and ST extension (8.7x5.8cm) DLBCL (Non GCB) R-CHOP Finished two cycles of chemotherapy22/M Pain in hip and knee (R) Increased activity on PET in (R) hemi pelvis, femur ALCL,ALK+ CHOEP Finished 5 cycles of chemotherapy on follow up and reassessment66/F Fracture shaft femur – DLBCL (Non GCB)76/F Pain Large lytic lesion in pubic rami with extensive soft tissue involvement in pelvis. DLBCL (GCB)69/F Back pain since 4 months Single Lytic lesion in L3, L4 with paravertebral soft tissue extension Hodgkin lymphoma ABVD Finished two cycles of chemotherapy.

Conclusion: Rarity of these lesions makes diagnosis a challenge. Most commonly they are misdiagnosed as benign process especially in children (abscess/osteomyelitis) or as metastasis or myeloma in elderly age group. DLBCL remains the most common subtype; however anaplastic large cell lymphoma is common in pediatric age group. High index of clinical suspicion with robust diagnostic workup (histopathology with immunohistochemistry) can guide faster diagnosis.

 Intramedullary melanocytic schwannoma of conus medullaris: Case report

Syeda Hana Hussain, I. Monica, Syed Fayaz Ahmed, M. A. R. Basalathullah

Department of Radiation Oncology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India

E-mail: [email protected]

Background: Schwannomas are benign slow growing tumours arising from nerve sheath schwann cells commonly from posterior spinal nerve roots. A rare variant is melanocytic schwannoma which occurs <1% of nerve sheath tumours. Here we describe a case of 30 years old female patient with intramedullary melanocytic schwannoma of conus medullaris treated with surgical excision & adjuvant radiotherapy.

Case Report: A 30 year old female patient presented with complaints of low backache radiating to right lower limb of 6 months duration, gradually progressive over 1 year duration, associated with paraesthesia in right lower limb. MRI dorsal-lumbar spine revealed focal intramedullary lesion in conus medullaris extending from D11-L1levels. The mass was mixed signal intensity onT1, T2 confluent hyperintense lesion with hypointense rim, mixed signal intensity on STIR and heterogeneously enhancing. During surgery, well encapsulated greyish lesion was identified and was removed completely with D12-L1 laminectomy. Immunohistochemical stains for S-100, Human Melanoma Black-45 (HMB-45), SOX-10 were positive suggestive of melanocytic schwannoma. Postoperatively patient developed right lower limb weakness with power 0/5. After 3 weeks of surgery, PETCT scan revealed diffuse FDG uptake at surgical site extending from D10-L1with no metabolically active distant metastases. At postoperative 6 weeks, MRI lumbar spine was suggestive of focal T2 hyperintensity in lower end of spinal cord at level D12-L1 with no enhancement postcontrast. Patient received adjuvant radiotherapy after6 weeks, 3Gy per fraction for 12 fractions to total dose of 36Gy by conformal technique to D11-L1spine. At 2 months follow up, patient was able to walk with support with power 3/5 in right lower limb associated with paraesthesia. After follow up of 8 months, patient is able to walk without support with power of 5/5 and has occasional residual paraesthesia in right lower limb with no evidence of local recurrence or distant metastases.

Conclusion: Schwannomas are most commonly intradural and extramedullary in location; <1% is intramedullary. They are typically found in the cervical (58%), thoracic (32%) and lumbar regions (10%). Till date only 14 cases of intramedullary melanotic schwannoma have been reported in literature. We described here a rare variant of schwannoma, treated with adjuvant radiotherapy.

 Clear but not so clear. Primary clear cell sarcoma of bone – A rare case report

Mohan Krishna Pasam, Suseela Kodandapani, Lakshmi Manasa, Srinath Gupta1, T. Subramanyeshwara Rao24

Departments of Pathology, 1Orthopaedic Oncology and 2Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

E-mail: [email protected]

Background: Clear cell sarcoma of soft tissue is a rare sarcoma with morphologic similarities to malignant melanoma but has a distinct chromosomal translocation, t (12; 22) (q13; q12) with a resultant EWSR1-ATF1 fusion gene. These tumors are known to involve tendons and aponeuroses of extremities and less commonly trunk. Morphologically these tumors show epitheloid spindle cells with clear to eosinophilic cytoplasm and a phenotype similar to Melanoma. We report a case of clear cell sarcoma in a young adult arising from scapula.

Case Report: A 22 year old male came with complaints of pain and swelling in the left shoulder. He had a past history of dislocation in right shoulder 1 year ago. On MRI, a well-defined lytic lobulated heterogeneously enhancing lesion of 8.8 cm in right scapula involving spine and blade with infiltration and displacement of adjacent rotator cuff muscles was identified. Few enlarged supraclavicular lymph nodes largest measuring 2.9 cm were seen. On PET CT a hyper metabolic lesion was found in the right scapula confirming the primary lesion with uptake in the right supraclavicular node suggestive of metastasis. Biopsy showed sheets of round to oval cells with pleomorphic vesicular nuclei with prominent nucleoli and clear to eosinophilic cytoplasm. Areas of necrosis were seen. A panel of IHC was done which showed positivity for Vimentin, SOX10, and S100 & HMB45. Focal positivity was found in tumor cells in NKX2.2 and SATB2. The tumor cells were negative for PCK, SALL4, Desmin & CD99. A final diagnosis of Primary Clear cell sarcoma of bone was rendered.

Discussion: Clear cell sarcomas are rare malignant tumors of tendons and fascia of extremities and trunk. However rare primary sites like penis, retro peritoneum, lung and abdomen were reported in the literature. Only a few cases of primary clear cell sarcoma of bone were reported in the published literature. These tumors are different from other undifferentiated sarcomas owing to high recurrence rate, propensity for lymph node metastasis and unresponsiveness to chemotherapy or immunotherapy. Poor prognostic factors include large size, lymph node metastasis and presence of necrosis.

Conclusion: We report this case in view of its rarity and peculiar site of involvement. A combination of morphology, immunohistochemistry and molecular diagnostics is essential in diagnosing these rare but aggressive tumors.

 Wnt/?-catenin activated Ewing sarcoma with metastasis to pancreas: A rare case report

Shilpa Kapoor, Trupti Patel, Priti Trivedi, Ashini Shah

Department of Pathology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

E-mail: [email protected]

Introduction: Ewing sarcoma family of tumors comprises of 5 to 10% of all primary bone tumors. Nearly 30% of the patients present with metastasis at the time of diagnosis and have poor prognosis despite aggressive treatment. Common sites of metastasis include lungs and bones but cases with metastasis to stomach, bowel, ovary and brain have also been reported. Ewing sarcoma (ES) metastasis to pancreas is extremely rare with only 4 cases reported in literature till date. Herein we are enriching the literature with another case of metastasis of ES to pancreas in a 21-year-old male highlighting the role of ß– catenin signaling pathway.

Case Report: A 21-year-old male with primary ES of right iliac bone and concurrent lung metastasis was diagnosed 3 years back. He was treated with chemotherapy (Vincristine, doxorubicin, ifofosmamide) and radiotherapy. Residual mass was followed thereafter with radiology, but he never achieved complete remission though lung metastasis responded completely. Now after 3 years on routine follow up, CT scan revealed a 55 x 50 mm heterogeneously enhancing mass in distal body and tail of pancreas with residual disease in iliac bone. Biopsy from the mass showed fragmented cores of tumor composed of small round cells arranged in sheets. Cells had high nucleocytoplasmic ratio, round nuclei, finely dispersed chromatin, inconspicuous nucleoli and scant cytoplasm. This was similar to the morphology seen on iliac bone biopsy. A fragment of normal pancreatic tissue was also identified. Keeping in mind history of the patient, metastatic ES was strongly favored with consideration to other differentials such as desmoplastic small round cell tumor, small cell neuroendocrine tumor and solid pseudopapillary neoplasm. IHC thus performed showed positivity for vimentin, CD99, FLI-1, nuclear positivity for ß – catenin while being negative for synaptophysin. Considering history, histomorphology and IHC results, final diagnosis of ES metastasis to pancreas was rendered. Strong nuclear positivity for ß-catenin indicated role of WNT/ß catenin signaling pathway as one of the several potential mediators for tumor relapse and progression.

Conclusion: Here we present a rare case of Ewing sarcoma metastasis to pancreas with only 4 other cases reported in literature so far. We also demonstrated expression of WNT/ß catenin signaling pathway via IHC which can help us to predict tumor behavior in advance.

 Bizarre parosteal osteochondromatous proliferation: A rare mimic of malignancy

Saket Patwardhan, Manoj Ambhure, Amit Janu

Department of Radiology, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Bizarre parosteal osteochondromatous proliferation is a condition characterized by benign osteochondromatous proliferation of the bone cortex seen typically in the small joints of the hands and feet. This condition is usually seen in young adults in the 2nd and 3rd decades with no sex predilection. These lesions are also called “Nora lesions” after the scientist Dr Frederick Nora. They are benign with no malignant potential and no risk of metastasis. However, they have a tendency of local invasion and may also recur post excision. BPOP is an important differential of osteochondroma; which can mimic parosteal or periosteal osteosarcoma. Rarely can it also mimic parosteal chondrosarcoma. Thus, it becomes crucial to know this rare condition. It should be kept in the differential diagnosis in cases of osteosarcoma, especially in small joint involvement. Pathologically, Nora lesions are a rare form of myositis ossificans. Typically, there is proliferation of chondrocytes with irregular morphology (bizarre cells). They have similarities with Dupuytren's exostosis. 3/4th cases usually involve small bones of hands and feet. Long bones are affected less commonly. Radiographically, Nora lesion is a well-defined cortical growth. It does not have the characteristic orientation distal from the physis as in cases of osteochondromas. There may or not be a periosteal reaction or lysis. Absent medullary involvement is seen. But radiographic features alone cannot diagnose the lesion. On MRI, the lesion is T1 hypointense and hyperintense on T2 weighted and STIR sequences. The medullary cavity and adjacent soft tissues are uninvolved.

Learning Objectives:

To understand the pathophysiology and radiological features of Nora lesionsTo differentiate between Nora lesions and other benign and malignant bone lesionsTo increase awareness regarding Nora lesions for better patient care.

Conclusion: Bizarre parosteal osteochondromatous proliferation is a rare benign condition of the bone affecting the cortex and causing local invasion. It has certain radiographic and cross-sectional imaging features. It mimics other conditions like osteochondroma, parosteal osteosarcoma, periosteal osteosarcoma. It needs to be differentiated from these conditions. Treatment for Nora lesions is simple excision, whereas for malignant conditions may be amputation. The lesion also may recur post-surgery and cause local tissue invasion. Hence it becomes necessary for the musculoskeletal clinicians and radiologists to be aware of the typical and atypical radiological and pathological features of this condition for optimum patient management.

 De-differentiated liposarcoma – A rare case study with rare presentation

Disha Hassani, Neha Sethi, Abha Mathur, Maneesh Kumar

Department of Oncopathology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India

E-mail: [email protected]

Background: Liposarcomas (LS) are soft tissue sarcomas, comprising approximately 20% of all malignant mesenchymal neoplasms. Dedifferentiated liposarcoma (DDL) is a subgroup of LS. DDL is characterized as typically non-lipogenic sarcoma that is juxtaposed to WDL or occurs as a recurrence of WDL (10%), or which arises primarily (90%). Histologically, DDL typically appears as undifferentiated pleomorphic sarcoma or spindle cell sarcoma (NOS) frequently seen in retroperitoneum.

Materials and Methods: A 67 years old female presented with complaints of abdominal pain and swelling for 5months associated with a large abdominal lump, reduced appetite and constipation. On CECT whole abdomen, heterogeneously enhancing soft tissue density mass approximately 25 x 22 x 14 cm noted in left perinephric region completely adherent to spleen and kidney along with simple hepatic and renal medullary cyst. Excision of retroperitoneal tumor with enbloc removal of spleen and left kidney was performed. Specimen was sent to surgical pathology department and was further analysed.

Results: Grossly large multinodular tumor, seen covered with fascia and fat and adherent to spleen and kidney. Cut section showed myxoid and grey white fleshy necrotic areas. Histomorphology revealed Dedifferentiated liposarcoma consisting of high grade myxofibrosarcoma (MFS) along with WDL. Kidney and spleen were not involved by tumor. Pathological grade T4Nx. IHC examination showed S-100 and MDM-2 positivity in lipoblasts while DDL component showed only SMA positivity.

Conclusion: The present case is very rare as dedifferentiation occurs in up to 10% of WDL. Very rarely enbloc excision of spleen and kidney is required as seen in present case. Also it is very rare to identify MFS as the dedifferentiated component. DDL accounts for approximately 18% of all liposarcomas. About 5% DDL may show heterologous differentiation towards other mesenchymal lineages particularly osteoid, chondroid or myoid. Well and dedifferentiated liposarcomas represent a spectrum of a single disease entity, characterized by abnormalities involving chromosome 12q13-15, particularly high-level amplifications of MDM2 and CDK4 oncogenes. Poor prognosis seen in higher FNCLCC grade and myogenic differentiation, myxofibrosarcoma-like features. Both WDL and DDL can show local recurrence, being site-related commonly within the retroperitoneum, and DDL can show aggressive behaviour once metastatic. Five year overall survival rates for grade 3 DDL reported as 21% and 42% with myogenic differentiation. The mainstay of therapy for these tumors remains as surgical resection, with limited conventional medical treatment options for patients with locally recurrent or metastatic disease.

 Contemporary management of lung cancer: Hope to reality

 Role of tobacco quit line in tobacco control

Suvarna Gore, Priyal Chakravarti, Dinesh Musale, Deepa Kadam, Kalpita Lanjekar, Premdeep Gaikwad, Rahul Sonwane, Atul Budukh, Pankaj Chaturvedi, Rajesh Dikshit

Centre for Cancer Epidemiology, Advanced Centre for Treatment, Research and Education in Cancer, Navi Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Tobacco users are at high risk of developing various chronic diseases including cancer. As per Global Tobacco Adult Survey (GATS) (2016-2017), 266.8 million of all adults including 42.4% of men and 14.2% of women use tobacco in either smoked or smokeless form. As per GATS (2016-2017), 55.4% of current smokers and 49.6% of smokeless tobacco users are planning or thinking of quitting tobacco. Specific efforts and counseling are inevitable factors to support each individual that hopes to quit tobacco as it contains highly addictive substance nicotine. With this objective, 'Tobacco Quit Line' service has been initiated at Centre for Cancer Epidemiology (CCE), Tata Memorial Centre-Mumbai, India in collaboration with tobacco control division of the Ministry of Health and Family Welfare (MoHFW), Government of India (GOI). Currently, 85% of the world's population does not have adequate access to the treatment including toll-free quitlines. The World Health Organization (WHO) has recognized Quitline as one of the most effective modes of treatment.

Objective: To study the role of Tobacco Quitline (TQL) service in tobacco control.

Materials and Methods: The tobacco users desirous of quitting call on a toll-free number '1800-11-2356'. The trained counselors provide counselling on quitting tobacco habit. The counselors call back tobacco users periodically to monitor their tobacco use and support them through counseling throughout the process so that users can quit the tobacco. All calls are recorded in the software. We have received maximum calls from the Maharashtra, Gujarat, Rajasthan and Uttar Pradesh states.

Results: In the year 2020, a total of 155,652 calls were hit to the TQL system. After excluding inquiry calls and not attended calls; we have registered 42,053 (27%) calls. Out of 42,053 registered calls, 12,276 (30%) individuals agreed to attend the regular counselling by telephone. For these individuals, the quit date was set. The counselors made a total of 84,487 follow-up calls and out of which 48,561 (57.4%) calls were attended by the clients. Total quitters are 3373 (27.5%). Out of total quitters, 85.4% consume smokeless tobacco.

Conclusion: As per TQL data, one out of four people quit tobacco because of counseling. TQL services are essential in tobacco control program and can play an important role in controlling non-communicable diseases. It is recommended that developing nations should adopt this comprehensive tobacco quitline centre and should give priority while policy-making procedures to control the tobacco habits.

 Does volumetric modulated arc therapy thoracic radiotherapy lead to early pneumonitis changes as a result of large volume low dose spread?

Neethu Jose, Joseph Chacko Paul, Aparna Irodi, T. Hannah Mary Thomas, K. Reka, Manu Mathew, I. Rajesh, Subhashini John, Simon P. Pavamani, Balu Krishna Sasidharan

Department of Radiation Oncology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

E-mail: [email protected]

Background: Radiation pneumonitis (RP) is a common side effect in thoracic radiotherapy. Newer techniques like Volumetric Modulated Arc Therapy (VMAT) have provided more conformal target coverage with lower doses to organs at risk (OAR). However, some studies have shown higher incidence of RP in low dose region in patients treated with VMAT/Tomotherapy. The purpose of study was to correlate the incidence and pattern of RP in V5/V10 region in thoracic radiotherapy with VMAT.

Materials and Methods: All patients who underwent VMAT to thoracic malignancy had planning CT and the imaging findings during the study period were documented and evaluated. Study looked for radiological changes in lung parenchyma suggestive of pneumonitis from start of radiotherapy till 12 weeks from end of RT. This constitutes an early onset pneumonitis change. Planning CT images were compared with weekly KV-CBCT images during the treatment duration and radiological changes were documented. In a prospective subset additional HRCT LUNG at the end of RT and 1st follow up between 6 weeks to 12 weeks post RT were acquired. All patients were assessed for radiological features of RP after informed consent.

Result: Seventy two patients were included in study group. RP (Radiologically detected) occurred in 31.9 % patients. Mean age of patients with RP were 59.5 ± 9.5 years. Men had higher preponderance than women. Lung primary had the higher incidence of RP. Chemotherapy was a risk factor for increased incidence of radiation induced lung changes but showed no significance. Pre-existing lung comorbidities and surgery had no correlation with incidence of RP. Increased tumour dose was a significant risk factor. 10 /23 had early pneumonitis changes with 3 of them having centrifugal distribution. V5 > 42% and V10 >33% showed increased incidence of RP in these low dose regions but was not statistically significant. On the other hand, V20 >28% was a significant predictor for RP. It was also found to be more evident in patients receiving Mean Lung Dose of 14.7 Gy.

Conclusion: Newer techniques of radiation therapy like VMAT results in heterogeneous dose distribution for the planned target volume with increase in the area for low-dose irradiation leading to centrifugal pattern of RP. Increase tumour dose and V20 parameter was shown as significant predictors for incidence of early RP.

 Delta radiomics feature selection workflow for longitudinal cone-beam CT to predict normal lung toxicity

T. Hannah Mary Thomas, Neethu Jose, Amal Joseph Varghese, Aparna Irodi, Joseph Chacko Paul, Manu Mathew, Rajesh Isiah, Subhashini John, Henry Finlay Godson, Timothy B. Peace, Simon Pavamani, D. Devakumar, S. Balu Krishna

Department of Radiation Oncology, Christian Medical College, Vellore, Tamil Nadu, India

E-mail: [email protected]

Background: Cone beam CT (CBCT) is used to image patients routinely during radiation therapy (RT), primarily for positioning verification. However, these images can provide more quantitative information (radiomics) that may be valuable to stratify patients early and accurately based on their own risk of toxicity, which can be essential to personalize their treatment. We want to explore image descriptors that may be potential predictors to find the patients who have a high-risk for pneumonitis early in their treatment. The aim of this study is to (1) describe a workflow for performing feature selection in a longitudinal radiomics study.

Materials and Methods: Seventy-two patients were selected who underwent thoracic radiation with volume-modulated-adaptive-therapy. All patients had at least 3 (CBCTfirst, CBCTmid and CBCTend) scans and a follow-up CT end-of-RT. Lung structures were defined on the planning CT in Eclipse treatment planning system 1) Lung (right + left combined) and 2) volume of lung receiving 5, 10, 20 Gray (V5, V10, V20) respectively. The planning CT was registered to the weekly CBCTs using rigid registration and the structures transferred to the CBCTs. The CBCTs, planning CT and lung structures were transferred from Eclipse to 3D Slicer. The CTs were resampled to isotropic voxel sizes of 2 mm3. Radiomic features (shape, size, intensity, and texture) were extracted from planning CT and 3 CBCT scans using radiomics feature extraction module made available in 3D Slicer with fixed bin width discretization. In 12 patients the CBCTs from first two consecutive fractions were considered as 'test-retest scans to help determine the minimum detectable change(C?=?1.96*Standard Deviation). For a delta feature to be considered as relevant, it should change more than 'C' in the selected subset of patients. Overlap between features in CBCTs and planning CT were found using Spearman correlation coefficient.

Results: More than 80 features from three CBCTs were found to be overlapping with features calculated on the planning CT. Less than 10 delta features had minimum detectable change in the 12 patients selected.

Conclusions: This study describes a reproducible workflow for feature selection for longitudinal radiomics in normal lung and has potential for stratifying patients early based on their risk for radiation induced pneumonitis. The selected delta radiomic features needs to be investigated and there is a need for data from other centers in India to confirm the results.

 SBRT of ultra-central lung tumors during COVID pandemic

Aman Sharma, Shipra Gupta, Abirama R. Sundari, Rampukar Bharat, Karun Kamboj, Praveen, Gopikrishna Shyam, Jyoti Yadav1, Shreejesh Mullassery1, Raaj Kishor Bisht1, Preeti Patil, Supriya Mallick, D. N. Sharma

Departments of Radiation Oncology and 1Radiation Physics, National Cancer Institute, Jajjhar, Haryana, India

E-mail: [email protected]

Background: Patients with ultra-central tumors are at higher risk of serious toxicities.

Materials and Methods: During the COVID pandemic 10 ultra-central lung tumors (PTV overlapping trachea, proximal tracheo-bronchial tree, oesophagus, great vessels or pericardium) were treated. Three patients had limited NSCLC (two T3N0 and one T4N0), 03 patients had primary NSCLC with N2 mediastinal nodes and 04 patients had oligometastatic NSCLC. SBRT dose was prescribed at 80% isodose line.

Results: Median primary tumor size was 5.5 cms (1.5 -7 cms), median lymph node size was 1.6 cms (range 9 mm-4.4 cm). Dose to primary tumor ranged from 65-56 Gy in 8 or10 fractions. All patients with mediastinal nodes were prescribed 56 Gy- 60 Gy in 8 fractions except one patient (3Gy * 12). Median PTV coverage with 100% prescription dose was 80%, median PTV coverage with 95% prescription dose was 97%. Median heart Dmean doses was 2.5 Gy (0.57 -7.5 Gy). Cardiac substructure doses were as follows right atrium Dmean 1.5 Gy (0.11 Gy-7.5 Gy), left atrium Dmean 2.2 Gy (0.3 Gy-17.5 Gy), right ventricle Dmean 0.8 Gy (0.1 Gy-4.5 Gy), left ventricle Dmean 0.8 Gy (0.1 Gy-6.7 Gy). Median PTB Dmax was 50.8 Gy (28 Gy-67 Gy), esophagus Dmax was 33 Gy (9.5 Gy-47 Gy), bilateral lung -PTV Dmean was 8 Gy (3.5 Gy-10 Gy). As regards to great vessel, median pulmonary artery. Dmax was 30.2 Gy (1.4 Gy-64.5 Gy). Pulmonary vein Dmax was 33 Gy (0.4 Gy-52 Gy). SVC median Dmean was10 Gy (3.5 Gy-26.5 Gy). Median Dmax of aorta was 44 Gy (10 Gy-58 Gy). At time of analysis 7 patients were alive at a median follow up period of 5 months (range 2.5 months – 11 months). One patient died after 6 months after developing progressive disease. One developed fatal COVID pneumonia and other fatal massive hemoptysis while on treatment. One patient developed adjacent asymptomatic pneumonitis and fibrosis. Remaining patients did not patient developed acute/subacute toxicity. All 7 patients remain disease free after receiving chemotherapy.

Conclusion: SBRT was feasible for ultracentral tumors in the COVID pandemic. One patient died due to fatal COVID pneumonia. Eight to fractions of SBRT can be delivered in NSCLC for ultracentral tumors. Long term follow-up and larger numbers of patients are required to confirm our findings.

 Comparison of afatinib versus gefitinib in metastatic adeno carcinoma lung – A retrospective single institute study

Chandralekha Krishnan, S. G. D. Gangadharan, E. Senthil Kumar, K Sivasubramaniam

Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India

E-mail: [email protected]

Introduction: There has been established role for the tyrosine kinase inhibitors (TKIs) in first line for EGFR positive metastatic non-small cell adeno carcinoma lung. LUX 7 trial compared the safety and efficacy of afatinib and gefitinib. We retrospectively analysed the tolerance and progression free survival in patients receiving geftinib and afatinib between 2019 to 2020.

Materials and Methods: Treatment naïvï e patients who had common EGFR mutation who had received tyrosine kinase inhibitors were collected from the medical records. Most of the patients were started on first line TKI, due the prevalence of COVID-19 outbreak in the particular period of time. There were 60 patients who had been started on TKIs, of which 35 had received gefitinib 250 mg once daily and 25 had received afatinib 40 mg once daily. These medical records were analysed for documenting the tolerance and these patients were contacted and reviewed in the out-patient department. PFS was calculated by Kaplan meir method.

Results: There were 24 female and 36 were male of which 12 were non-smokers. Out of the 60 patients, 12 had brain metastasis, 28 had contralateral lung metastases, 9 had bone only metastases and 11 patients had multiple metastases at presentation. The PFS was 11.5 months versus 9 month for afatinib and gefitinib repectively. Afatinib dose reduction was done due to grade 3 diarrhoea in 8 patients. Two patients were switched over to gefitinib due to poor tolerance to afatinib. Skin toxicity was present in both the groups which were tolerated without interruption. Grade 3 to 4 toxicity with afatinib was mostly seen in patients of age more than 50 years and female while young male tolerated it with the dose of 40 mg. There was no break in treatment with gefitinib.

Conclusion: Though it has been proved that, afatinib is better in terms of efficacy with good side effect profile, we noted that our patients had moderate to poor tolerance to afatinib in terms of gastrointestinal side effects and it was minimized with dose reduction.

 Evaluating the performance of Droplet digital-PCR platform for the detection of resistant EGFR T790M mutation in NSCLC patients

Pradnya Joshi, N. Pawar, D. Dhanavade, O. Shetty, M. Gurav, P. Bapat, T. Pai, R. Kumar, S. Desai

Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Introduction: Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) have been successful in clinical treatment of patients with non-small cell lung cancer (NSCLC) harboring activating EGFR mutations. The T790M mutation is the frequent alteration leading to acquired resistance that occurs in ~50% to 60% of patients undergoing treatment with EGFR-TKIs. Threonine-to-methionine amino acid change at position 790 of EGFR tyrosine kinase domain causes steric hindrance and interferes with binding of TKIs. Additionally, de novo T790M mutation is also an important mechanism of primary resistance to EGFR-TKIs. The detection of the EGFR T790M is challenging, especially in liquid biopsies due low mutant copies of DNA. This study demonstrates the role of Droplet digital PCR (ddPCR) based T790M assay in providing sensitive and reliable results in biopsy and cf-DNA samples.

Materials and Methods: T790M assay using DDPCR was standardized and performance characteristics like assay sensitivity, specificity was compared to the two ancillary techniques viz; Next Generation Sequencing (NGS) and real time PCR for detecting the EGFR mutation. Detection of T790M mutation was performed on 25 FFPE samples and 35 cfDNA samples which had been tested for EGFR mutation as part of routine diagnostic procedure. Assay results of ddPCR were compared with previous results of conventional ARMS-RTPCR.

Results: ddPCR assay sensitivity was compared with NGS and Real Time PCR assay. ddPCR could detect the variant allelic frequency (VAF) as low as 0.775% reported by NGS platform on spiking mutant DNA with wild type EGFR DNA based on the NGS results. The results obtained on the dd-PCR platform in comparison with the RT-PCR platform are summarized.

 Symptom clusters among advanced lung cancer patients attending palliative care department: An observational study

Chaitanya Patil, Prasad Tanawade, Nilesh Dhamne, Yogesh Anap

Department of Radiotherapy, Kolhapur Cancer Center, Kolhapur, Maharashtra, India

E-mail: [email protected]

Introduction: Majority of the lung cancers are present in the advanced stage. The highest symptom burden is reported among lung cancer patients compared to other cancer sites. Multiple co-occurring symptoms which are interrelated occur in patients with advanced lung cancer. Such symptom clusters independently predict the patient''s function, treatment failure, and therapeutic outcomes. In total, they affect the quality of life of the patients. Therefore, identifying such clusters will help us in the comprehensive management of the patient. With this background, we conducted this study to find the symptom clusters among advanced lung cancer patients attending the palliative care department.

Materials and Methods: A prospective observational study was conducted on lung cancer patients. The study duration was one and a half years [January 2020 to June 2021]. The study was conducted in the palliative care department of Kolhapur cancer center. We have included 63 patients with histologically confirmed lung cancer. All the cases whose diagnosis was uncertain, who were on treatment for psychiatric disorders, and had poor performance status were excluded from the study. Edmonton symptom scale (ESAS-r) for assessing various symptoms of the patients. Principal component analysis with Varimax and Kaiser Rotation has been used to find the different symptom clusters in the present study.

Results: The mean age of the cases was 61.12 ± 12.23 years with male preponderance. Non-small cell carcinoma was the most frequent histological type. We found four symptom clusters after the analysis. Cluster 1- Pain, fatigue, depression, cough; Cluster 2- Anxiety and breathlessness; Cluster 3- Anorexia and weight loss; Cluster 4- nausea, vomiting, and hemoptysis.

Conclusions: We found four significant symptom clusters among advanced lung cancer patients. Palliative care physicians need to tailor the management of the patients based on these symptoms clusters. Further longitudinal studies are warranted to understand the stability of these clusters over a period of time. Underlying mechanisms for the various clusters need to be determined and addressed carefully.

 Investigation of dosimetric characteristics of lung stereotactic body radiation therapy using flattening filter-free and FF beams

Aditya K. Singla, Divya Khosla, Gaganpreet Singh, Rakesh Kapoor, Arun S. Oinam, Navneet Singh1, Shikha Goyal, Renu Madan, Narendra Kumar

Departments of Radiotherapy and Oncology and 1Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

E-mail: [email protected]

Objective: In ablation therapy, the predominant advantages of flattening filter-free (FFF) beams over the FF beams plans are (i) sharp dose fall outside the target volume, (ii) high dose rate delivery that reduces the intra-fraction errors, and (iii) more patient comfort. This study aimed to investigate and compare the dosimetric characteristics of lung stereotactic body radiation therapy (SBRT) treatment plans made with FFF and FF beams.

Materials and Methods: Ten patients treated with lung SBRT were planned with FFF and FF beams with a prescription dose of 48 Gy in 4 fractions on Monaco treatment planning system (TPS) version 5.11. All plans consisted of four partial arcs having an arc length of 210 degrees. All plans were evaluated as per RTOG 0915 protocol and compared in terms of Planning Target Volumes (PTV) Coverage, doses to organs at risk (OAR), conformity index (CI), homogeneity index (HI), and Monitor Units (MU). The maximum dose rate was 1400 MU/min for 6 MV FFF and 600 MU/min for 6 MV FF beams.

Results: The mean PTV was 83.4 cm3. Target volume was adequately covered in both the plans. PTV covered by 95% of the prescription isodose was comparable between two plans. Doses to OAR were also comparable between two plans except D15 cm3 of heart (mean 11.72 Gy in FFF and 15.41 Gy in FF, p=0.012). Conformity and homogeneity indices were also similar. Monitor units were higher with FF plans but it did not reach statistical significance (mean 3645 in FFF and 4141 in FF, p=0.263, respectively).

Conclusion: The present study demonstrates that both FFF and FF plans were comparable in terms of target coverage and doses to OAR. The monitor units were comparatively lesser with FFF leading to shorter treatment times and therefore more patient comfort and lesser chances of intrafraction errors.

 Unraveling the superior vena cava syndrome conundrum in lung cancer patients – A multivariate analysis of a tertiary care centre experience

Arjuhn R, T. N. Vijayasree, S. Jeeva, R. Giridharan,

B. Antoinette Mary Nithiya

Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India

E-mail: [email protected]

Background: Almost 50% Superior vena cava Syndrome (SVCS) was historically attributed to Infective etiology. But with Advent of newer medical technology, it was found that around 80% of SVCS is caused by Malignant etiologies especially lung cancer contributing upto 75%. In this study SVCS due to malignancy are discussed, as SVCS is a medical emergency if not promptly treated.

Aim: The purpose of this study is to analyze Treatment Characteristics (Radiation dose, duration and completion of radiotherapy) and its association with symptom reduction and mean overall survival in SVCS of lung cancer patients.

Materials and Methods: This is a retrospective study involving 40 histologically confirmed lung cancer patients with SVCS treated at Radiation oncology department of MMC in the period from January 2016 to December 2020 were taken up for the study.

Study population is classified into two groups receiving two different radiation regimens Regimen 1: 300CGY/10# (n=18)

Regimen 2: 400CGY/5# ( n=22)

Results: The mean survival for patients who underwent regimen 1 is 6.6 months and that of regimen 2 is 8 months. However it is not statistically significant (p=0.587) but mean time of symptom reduction for the patients on regimen 1 is 10.1 days and that regimen 2 is 5.6 days which is statistically significant (p=0.001).

SVCS symptoms improved within a week On RT in 40% (n=16) of patients, Around 10 days After RT with 12.5% (n=5) of the patients and at around 14 days with 17.5% (n=7) patients, Unfortunately 17.5% (n=7) had no symptom improvement by RT. Overall survival in patients whose symptoms reduced on RT was 9.05 months and it comes down to 1.2 months for patients in whom symptoms were not reduced and it is statistically significant (p=0.0005).

 Application of QUARTZ trial results in clinical practice – A translational research in a tertiary cancer centre

Sandhiya, T. N. Vijayasree, S. Jeeva

Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India

E-mail: [email protected]

Background: Whole brain radiotherapy is the main stay treatment in the management of non-small cell lung carcinoma with multiple brain metastases although there have been no randomized clinical trials Proving that WBRT improves either quality of life or overall survival. QUARTZ trial used disease specific grade prognostic assessment (DsGPA) and proved the non-inferiority of observation with best supportive care compared to WBRT in poor risk groups.

Aim: Primary Aim was to analyze the Non inferiority of Best supportive Care Over WBRT in the poor risk groups with Metastatic Non-small cell lung carcinoma in Terms of Overall Survival. Secondary Aim was to identify parameters to classify Poor risk group patients.

Materials and Methods: We retrospectively analyzed 50 consecutive patients treated by WBRT for brain Metastasis from non-small cell lung carcinoma From January 2016 to December 2019. All data regarding Demographic characteristics (Age, Gender, KPS) and tumor characteristics (Histology, No of brain metastatic lesion, Extracranial Metastasis) were collected from our medical records and through telephonic conversation with patient's relatives and analysis is done in terms of survival by comparing actual survival with estimated median survival with the help of Disease specific Graded Prognostic assessment (DsGPA) as in QUARTZ trial.

Results: Mean age for the entire cohort was 55.4 Years with male preponderance of 60% with most of them (77%) Having KPS of <70 and Predominant Histology being Adenocarcinoma (95%). 75% have more than 3 Metastatic lesion in the brain followed by 12.5% with 2 Metastatic lesion, 10% with 1 and 2.5% with 3 Metastatic lesion in Brain with Mean DsGPA Being 1.5. Select Subgroup of Patients with KPS<70, with multiple Metastatic brain Lesion and with presence of Extracranial Metastasis had drastic reduction in Median Overall survival to 1.2 months with estimated survival being 3 months.

Conclusion: From this study patients with KPS<70, more than 3 brain Metastatic lesion and presence of Extracranial Metastasis can be Categorized as Poor risk group patients.

These results confirm and correlate with results from the QUARTZ trial, suggesting that BSC is a reasonable.

 Oligometastatic non-small cell lung cancer with local recurrence managed with SBRT

Sagarika Nithyanand, Ram Charith Alva

Department of Radiation Oncology, M S Ramaiah Hospital, Bengaluru, Karnataka, India

E-mail: [email protected]

Background: Oligometastases is a state where patients present with metastasis that are limited in number and organ sites. Oligometastases are prevalent in NSCLC with 15-25% of the population responding to ablative treatment to metastases leading to prolonged disease free intervals. Ablative radiation therapy is recommended for less than 5 lesions. The first line treatment for oligometastatic NSCLC at diagnosis is palliative systemic therapy +/- immunotherapy. Systemic therapy offers an advantage in the management of oligometastases by making it amenable to resection or ablative therapies. Local consolidative therapy by stereotactic body RT (SBRT) offers a better progression free survival and an overall survival benefit. SBRT is a non-invasive method to achieve tumor control or eradication by delivering high doses of radiation that are precisely targeted through image guidance while minimizing radiation to adjacent normal tissue.

Materials and Methods: A 74 year old male, diagnosed with oligometastatic squamous cell carcinoma of the right lung lower lobe with left adrenal gland metastasis was staged as cT2aN0M1b. IHC- tumor cells positive for p40, desmoglein 3, CK 7 and negative for TTF-1, CK 20, ALK, ROS-1, PDL-1 and EGFR. 6 cycles of 3 weekly paclitaxel + carboplatin were administered as primary systemic therapy. Follow up PET-CT scans done every 6 months showed a stable disease with no disease progression. PET- CT scan done 2 years post diagnosis showed local recurrence at the site of primary lung lesion with no disease progression in distant sites. In view of indolent course of oligometastatic disease and recurrence at local site alone, SBRT 45Gy/5# were administered on alternate days at 9Gy/# followed by immunotherapy.

Results: Follow up PET-CT 6 month's post SBRT showed marked interval regression in size and metabolic activity and the patient being clinically stable and asymptomatic.

Conclusion: In upfront oligometastatic NSCLC with a prolonged disease free interval post systemic therapy and in those with recurrence in limited sites alone, ablative radiotherapy +/- immunotherapy can be considered to prolong overall survival.

 Clinicopathological factors and multimodality treatment in non-small cell carcinoma lung in a government tertiary care centre – A benchmarking approach

Shradha Parameswaran, T. N. Vijayasree, S. Jeeva, R. Giridharan, B. Antoinette Mary Nithiya

Department of Radiation Oncology, Madras Medical College, Chennai, Tamil Nadu, India

E-mail: [email protected]

Background: Lung carcinoma is the leading cause of death due to cancer worldwide. Most common histology among lung cancer is Non-small cell carcinoma lung (84%). Majority of NSCLC in India comes under stage III and stage IV at the time of presentation. Concurrent chemo radiation is the standard of care in stage III NSCLC.

Aim: To elaborate the clinic pathological factors in NSCLC patients who presented in our department without metastasis and received Radiotherapy and discuss the multimodality management received by those patients.

Materials and Methods: One hundred and twenty five histopathological proven NSCLC patients who received RT from 2016 to 2019 in our department were retrospectively analyzed. All data regarding demographic characteristics, tumor characteristics, treatment details and follow up period were collected. Patients received concurrent chemo radiation or radiotherapy followed by chemotherapy or radical radiotherapy or palliative radiotherapy according to the performance status. Majority of the patients received cisplatin etoposide doublet chemotherapy. Radiation dose ranged from 30 Gy in palliative intent to 60 Gy in curative intent with 2D technique using AP/PA portals followed by oblique with telecobalt machine.

Results: Average age of the entire study population is 58.6 years. Gender preponderance in seen in males with 87% (n=109) and association with smoking in 91% (n=100). Most patients had a performance status of 2 (58%, n=73) during presentation. In the wide spectrum of presenting symptoms cough with expectoration (50%) and breathlessness (40%) were highly accounted. In the population studied, side laterality is seen for Right sided ca lung 60% (n=75). 80% (n=64) of the diagnosed had SCC histologically with other histology being adenocarcinoma, neuroendocrine tumour and sarcomatoid ca. Stage III (72%, n=90) was the biggest stage group with stage III B most commonest among it. Most patients with performance status 1 or 2 received CCRT whereas most patients with PS >2 received palliative RT or best supportive care. 20% (n=25) patients defaulted during the treatment. A total of 50.4% (n=63) patients received CCRT. CDDP and etoposide were the used regimen for concurrent use with radiotherapy. The median follows up in the study population was 7.5 months. In patients who underwent CCRT median overall survival was 12 months and patients who underwent palliative treatment was 5 months.

Conclusion: Patients with PS of 1 and 2 has better overall survival in comparison with PS >2. Concurrent chemo radiation is the standard of care for all stage III inoperable NSCLC patients. In spite of multimodality management overall survival is poor with stage III NSCLC.

 Saving the uninterpretables: Troubleshooting the interpretable and thereby helping in the patient care management

Neelam Pawar, P. Joshi, T. Pai, M. Gurav, O. Shetty, R. Kumar Bapat

Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Introduction: Epidermal growth factor receptor (EGFR) gene mutations identify patients with non-small cell lung cancer (NSCLC) who benefit from treatment with anti-EGFR tyrosine kinase inhibitors (TKI) and thus, EGFR mutation detection is crucial diagnostic step for therapeutic decisions. In lung cancer, tissue is predominantly scanty where it is required to triage the specimen accordingly for histology and molecular analysis. The Cobas-EGFR mutation test V2 (Roche Molecular systems, Inc.) is a FDA approved real-time polymerase chain reaction (PCR) test for qualitative detection of EGFR mutation from FFPE as well as cf-DNA samples. The COBAS system generates results using AI based algorithms and has a rapid turnaround time of testing. Nevertheless some cases still have invalid results due to various technical reasons. The present study was performed on such invalid cases of COBAS system using a modified protocol and retesting on another platform.

Materials and Methods: study includes data of all the Invalid samples reported by the COBAS system followed by observing the pattern of the Error codes generated [Table 1]. Quality of DNA was assessed by separately running PCR of House-keeping gene ACTNB (HK-PCR). Changes in the DNA concentration were done as per the instructions in the manual and the samples were retested using another ARMS-PCR based Real-time PCR kit.{Table 1}

Results: Total 6 types of Invalid flags generated by the systems for total 80 samples included in the study. Flags were segregated in three different groups by the reason indicated for each error code in the manual. Out of 80 Invalid reports reported by the COBAS system we could successfully report the valid result for 49 samples (61%) of these 16 (20%) samples were reported EGFR mutant and 33 (41%) samples were reported as EGFR wild type. Valid results could not be obtained in 31 (39%) samples due to the sub-optimal quality of the DNA or the presence of potential PCR inhibitors.

Conclusion: This study demonstrates that the Invalid codes generated by the COBAS systems can be reevaluated further tweaking the Quality parameters of the DNA and repeating the assay with the required DNA and thus helping to salvage many of the uninterpretable results as interpretable and thereby helping in the patient care management.

 Imaging of benign mediastinal pathologies which mimic malignant neoplasms

Suryaveer Singh, Amit Janu, Suyash Kulkarni, Nitin Sudhakar Shetty, Nivedita Chakrabarty, Daksh Chandra, Ujjwal Agarwal, P. G. Nandakumar

Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Mediastinal masses encompass a wide spectrum of histopathological and radiological entities. The most commonly encountered lesions in the mediastinum are thymoma, neurogenic tumours and benign cysts, together representing 60% of the mediastinal masses. The mediastinum is divided into anterior, middle and posterior compartments, which have been named as prevascular, visceral, and paravertebral compartments respectively by the International Thymic Malignancy Interest Group (ITMIG). Anterior mediastinal tumours account for 50% of all mediastinal masses, including thymoma, teratoma, thyroid-origin lesions and lymphoma. Masses of the middle mediastinum are typically congenital cysts while those arising in the posterior mediastinum are mostly neurogenic tumours. There are certain infectious, inflammatory pathologies as well as non-neoplastic cysts and benign tumours which are close imaging differentials of other malignant lesions as well as of metastatic deposits in patients with a known primary. We strive to review the imaging features of the common as well as some unusual benign entities of the mediastinum, which are mimics of more sinister mediastinal pathologies.

Materials and Methods: The various common as well as unusual benign mediastinal conditions which are close mimics of aggressive malignant neoplasms were retrospectively searched in the hospital database search engine, and the patients' clinical details, imaging and histopathological findings were recorded, and the related literature was reviewed.

Results: Radiologic features of various benign pathologies which closely mimic malignant neoplasms, such as infectious & inflammatory conditions, benign hyperplastic pathologies, benign neoplasms, and cystic mediastinal lesions have been described in detail in this review.

Conclusion: It is prudent to be aware of salient imaging features of the described benign mediastinal masses which are frequently mistaken for malignancies or metastatic deposits of a known primary; their differential has to be kept in mind for appropriate subsequent management. Multi-modality i maging often highlights distinguishing features among the various mediastinal lesions, in addition to delineating disease extent, and in some cases, is sufficient for establishing the diagnosis. Histopathology may definitively differentiate between the various differentials whenever the diagnosis is uncertain on imaging.

 Imaging of thoracic emergencies in oncologic patients

Suryaveer Singh, Amit Janu, Kunal Bharat Gala, Suyash Kulkarni, Nitin Sudhakar Shetty, Nivedita Chakrabarty

Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India

E-mail: [email protected]

Background: Patients with cancer often experience emergent life-threatening complications, which may be a direct result of the underlying malignancy, or an indirect manifestation of cancer such as a generalised hypercoagulable state, treatment-related complications or immunocompromised state. Oncologic emergencies can occur at any time during the course of a malignancy, from the presenting symptom to end-stage disease. While the numerous metabolic, infectious and hematologic emergencies are mainly diagnosed with clinical findings and laboratory parameters, imaging is the mainstay for the diagnosis of the structural complications in oncologic patients. We strive to review the imaging findings of the various thoracic emergencies in oncology in which radiology has a pivotal role in patients' diagnosis and timely management, thus significantly impacting the overall prognosis.

Materials and Methods: The commonly encountered emergent structural complications in which imaging plays a crucial role, were retrospectively searched in the hospital database search engine, and the patients' clinical details, imaging findings as well as the subsequent management were recorded, and the related literature was reviewed.

Results: Radiologic features comprising various imaging modalities, clinical findings and the basics of management of various thoracic emergencies such as SVC syndrome, pericardial tamponade, massive pulmonary embolism, oesophago-respiratory fistula, central airway obstruction, massive haemoptysis, tension pneumothorax, bronchopleural fistula, aorto-oesophageal fistula have been described in this review.

Conclusion: Thoracic emergencies in oncologic patients are although not very frequent, but are important causes of mortality. Radiologists thus play a decisive role in promptly recognizing these life-threatening complications, thereby effecting early initiation of appropriate treatment strategies in an effort to minimize morbidity and mortality.