Corynebacterium species are increasingly recognized as opportunistic pathogens in immunocompromised hosts. We report three cases of culture-confirmed Corynebacterium infections in cancer patients undergoing radiation therapy at a tertiary care centre. Two patients developed Corynebacterium striatum skin and soft tissue infections and one had Corynebacterium matruchotii vaginal infection. All cases presented with foul-smelling discharge and delayed wound healing in previously irradiated tissues. Identification was performed using MALDI-TOF MS (Bruker Biotyper®) and standard microbiological methods. Direct Gram stain of all specimens revealed gram-positive, pleomorphic rod-shaped bacilli. Antimicrobial susceptibility testing confirmed susceptibility to linezolid in all isolates, and culture-guided therapy with linezolid resulted in rapid clinical improvement. These cases highlight the importance of recognizing Corynebacterium species as true pathogens rather than contaminants in immunocompromised cancer patients.

ABSTRACT:Pulmonary alveolar proteinosis (PAP) is a rare pulmonary pathology characterized by the accumulation of surfactant within type II alveolar epithelial cells. Whole lung lavage is the standard treatment for pulmonary alveolar proteinosis involving a large volume of fluid is infused into one lung and subsequently retrieved while the other lung is remains ventilated. Fast-tracking a patient undergoing whole lung lavage requires vigilant monitoring of arterial blood gases, fluid status, and respiratory mechanics. We report a case of a patient who underwent whole lung lavage for PAP, where early extubation was performed, avoiding the complications associated with prolonged mechanical ventilation.

Purpose: The aim of this matched-pair cohort study was to evaluate the potential of intensity-modulated proton therapy (IMPT) for sparring of the pelvic bone marrow and thus reduction of hematotoxicity compared to intensity-modulated photon radiotherapy (IMRT) in the setting of postoperative irradiation of gynaecological malignancies. Secondary endpoint was the assessment of predictive parameters for the occurrence of sacral insufficiency fractures (SIF) when applying IMPT. Materials and Methods: Two cohorts were analyzed consisting of 25 patients each. Patients were treated with IMPT compared with IMRT and had uterine cervical (n = 8) or endometrial cancer (n = 17). Dose prescription, patient age, and diagnosis were matched. Dosimetric parameters delivered to the whole pelvic skeleton and subsites (ilium, lumbosacral, sacral, and lower pelvis) and hematological toxicity were evaluated. MRI follow-up for evaluation of SIF was only available for the IMPT group. Results: In the IMPT group, integral dose to the pelvic skeleton was significantly lower (23.4GyRBE vs 34.3Gy; p < 0.001), the average V 5Gy , V 10Gy , and V 20Gy were reduced by 40%, 41%, and 28%, respectively, compared to the IMRT group ( p < 0.001). In particular, for subsites ilium and lower pelvis, the low dose volume was significantly lower. Hematotoxicity was significantly more common in the IMRT group (80% vs 32%; p = 0009), especially hematotoxicity ≥ CTCAE II (36% vs 8%; p = 0.037). No patient in the IMPT group experienced hematotoxicity > CTCAE II. In the IMPT cohort, 32% of patients experienced SIF. Overall SIF occurred more frequently with a total dose of 50.4 GyRBE (37.5%) compared to 45 GyRBE (22%). No significant predictive dose parameters regarding SIF could be detected aside from a trend regarding V50Gy to the lumbosacral subsite. Conclusion: Low-dose exposure to the pelvic skeleton and thus hematotoxicity can be significantly reduced by using IMPT compared to a matched photon cohort. Sacral insufficiency fracture rates appear similar to reported rates for IMRT in the literature.

Background: Stereotactic ablative body radiation (SABR) is a well-recognized treatment option for hepatocellular carcinoma (HCC). Due to the inherent motion of liver tumors, effective motion management is crucial for successful SABR. In the motion-encompassing motion management technique, all 10 respiratory phase image datasets are delineated and designated as the internal target volume (ITV). Some treatment centers use single or combination image sets to delineate the target volume. This study determines which specialty image set most closely matches an all-phase ITV contour on a synchronized contrast-enhanced 4DCT. Materials and methods: Synchronized 4DCT contrast and delayed scans were acquired for 10 patients in the study. The maximum intensity projection (MiP), average intensity projection (AvgIP), and minimum intensity projection (MinIP) images were generated. The ITV delineation was done in all 10 phases (ITV_all_phase). The ITV_2phase combines the peak inhale and exhale phase, ITV_2 M combines MiP and MinIP, and ITV_3 M combines MiP, MinIP, and AvgIP. All ITVs were compared to ITV_all_phase with Dice similarity index (DSI) and volumes. Results: Using ITV_all_phase as the reference, the DSI and the mean ITV volumes for the different ITVs were as follows: ITV_all_phase (1 and 116.69 cc), ITV_2phase (0.87 and 105.27 cc), MiP (0.76 and 98.24 cc), AvgIP (0.72 and 94.54 cc), ITV_MinIP (0.67 and 81.08 cc), ITV_2 M (0.84 and 106.26 cc), and ITV_3 M (0.86 and 112.51 cc). Conclusion: The study demonstrates that in the motion-encompassing technique of motion management, the target volume generated by delineating all phases of 4DCT provides the most accurate representation for patients with HCC. Specialty image sets and their combinations, while sometimes close, tend to result in less accurate targeting. Hence,the all-phase 4DCT method should be preferred to avoid geographical misses and ensure optimal treatment outcomes. However, our conclusion may be limited by the technique we employed.

Bronchogenic cysts (BCs) are a congenital anomaly, forming fluid-filled sacs in the bronchial tree during fetal development, and are relatively rare in adults. Patients with large BCs in the mediastinum presenting with severe tracheal compression pose a significant challenge to anesthesiologists. The confined and narrow space of the mediastinum exacerbates the compression effect on surrounding structures, leading to potential respiratory or cardiovascular collapse during anesthesia and postoperatively. Herein, we report the stepwise anesthetic management of a patient with a BC in the paratracheal region of superior mediastinum, causing near-complete tracheal compression, scheduled for right posterolateral thoracotomy and tumor excision. The patient presented with dyspnea, chest pain, cough, and severe tracheal compression necessitating meticulous airway management. Utilizing awake fiberoptic intubation with a single-lumen endotracheal tube and one-lung ventilation facilitated by an EZ bronchial blocker, we successfully secured the airway, provided ideal surgical conditions through lung deflation, and ensured perioperative safety. This case underscores the crucial role of comprehending the underlying pathophysiology, anticipating complications, and meticulously planning, preparing, and executing strategies for airway management and perioperative care in patients with mediastinal masses leading to significant tracheal compression.

Purpose: Low-dose radiation therapy (LDRT) to lungs did show encouraging results in COVID-19 patients in some clinical trials. However, there has been some concern regarding the long-term risk of radiation-induced cancer (RIC). Compared to the conventional AP-PA field technique, volumetric modulated arc therapy (VMAT) can potentially reduce the dose to the marrow and other organs at risk (OARs) and thus minimize the risk of cancer. We designed a dosimetry study to study if VMAT can reduce the exposure to the marrow and other OAR doses and curtail the estimated life-time attributable risk (LAR) of cancer. Methods and Materials: We retrieved the computed tomography scan data of 10 patients (aged 40-60 years, median 48 years) who have been already treated for any malignancy in the region of the thorax. A dose of 1.0 Gy in single fraction was prescribed to both lungs. All the organs were delineated as per the established guidelines. The dosimetry achieved by the two plans was compared to find the difference. Mean OAR doses were used to estimate the LAR for both plans and compared. Results: Planning target volume coverage parameters like conformity index and homogeneity index were significantly better with VMAT (P value < 0.05 for all). The mean dose to most OARs was significantly lower with VMAT (P value < 0.05 for all). The mean dose to the marrow was significantly lower with VMAT (59.05 vs 81.9 cGy with P value < 0.05). The overall LAR was significantly lower with VMAT as compared to the conventional plan (0.357% vs 0.398%, P value < 0.05). Conclusion: Compared to the conventional technique, VMAT provides better OAR dosimetry for lung irradiation (a prescription dose of 1.0 Gy or more) in COVID-19 pneumonia. VMAT significantly reduces the risk of RIC. We therefore suggest if lung LDRT is used for COVID-19 patients, VMAT is the preferred technique for a prescription dose of >= 1.0 Gy.

Aneurysmal atrial septal defects (ASDs) represent a rare subset of congenital cardiac anomalies, characterized by bulging of the interatrial septum. This condition poses unique challenges in diagnosis, management, and outcomes due to its variable clinical presentation and associated complications. While echocardiography remains the cornerstone of diagnosis, advanced imaging modalities such as cardiac magnetic resonance imaging (MRI) and computed tomography (CT) may provide additional insights. Optimal management strategies for aneurysmal ASDs require careful consideration of patient-specific factors, including the size and location of the defect, associated cardiovascular abnormalities, and the presence of pulmonary hypertension. Surgical repair, whether through conventional open-heart techniques or transcatheter interventions, remains the primary treatment modality; however, the approach may vary based on individual patient characteristics. Anesthetic considerations, including hemodynamic monitoring and perioperative care, are crucial in optimizing outcomes and reducing the risk of complications during surgical interventions. Long-term follow-up is essential to monitor potential complications such as residual shunting, arrhythmias, and the development of pulmonary vascular disease. Collaborative efforts among cardiologists, cardiothoracic surgeons, anesthesiologists, and other multidisciplinary specialists are paramount in providing comprehensive care for patients with aneurysmal ASDs.

IntroductionThis study aims to quantitatively assess eligible patients and project the demand for particle therapy facilities in India from 2020 to 2040. In addition, an economic analysis evaluates the financial feasibility of implementing this technology. The study also examines the prospective benefits and challenges of adopting this technology in India.MethodologyCancer incidence and projected trends were analyzed for pediatric patients using the Global Childhood Cancer microsimulation model and adult patients using the Globocan data. Economic cost evaluation is performed for large-scale combined particle (carbon and proton-three room fixed-beam), large-scale proton (one gantry and two fixed-beam), and small-scale proton (one gantry) facility.ResultsBy 2040, the estimated number of eligible patients for particle therapy is projected to reach 161,000, including approximately 14,000 pediatric cases. The demand for particle therapy facilities is projected to rise from 81 to 97 in 2020 to 121 to 146 by 2040. The capital expenditure is estimated to be only 3.7 times that of a standard photon linear accelerator over a 30-year period. Notably, the treatment cost can be reduced to USD 400 to 800 per fraction, substantially lower than that in high-income countries (USD 1000 to 3000 per fraction).ConclusionThis study indicates that, in the Indian scenario, all particle therapy models are cost-beneficial and feasible, with large-scale proton therapy being the most suitable. Despite challenges such as limited resources, space, a skilled workforce, referral systems, and patient affordability, it offers substantial benefits. These include the potential to treat many patients and convenient construction and operational costs. An iterative phased implementation strategy can effectively overcome these challenges, paving the way for the successful adoption of particle therapy in India.Plain Language Summary In India, eligible patients benefiting from high-precision particle therapy technology projected to rise till 2040. Despite high upfront costs, our study finds the long-term feasibility of all particle therapy models, potentially offering a substantial reduction in treatment cost compared to high-income countries. Despite challenges, India can succeed with an iterative phased approach. The study assesses patient eligibility and demand for particle therapy in India, conducts economic analysis, and explores the technology's potential advantages and challenges in the country. image

ABSTRACT Purpose: Low-dose radiation therapy (LDRT) to lungs did show encouraging results in COVID-19 patients in some clinical trials. However, there has been some concern regarding the long-term risk of radiation-induced cancer (RIC). Compared to the conventional AP-PA field technique, volumetric modulated arc therapy (VMAT) can potentially reduce the dose to the marrow and other organs at risk (OARs) and thus minimize the risk of cancer. We designed a dosimetry study to study if VMAT can reduce the exposure to the marrow and other OAR doses and curtail the estimated life-time attributable risk (LAR) of cancer. Methods and Materials: We retrieved the computed tomography scan data of 10 patients (aged 40–60 years, median 48 years) who have been already treated for any malignancy in the region of the thorax. A dose of 1.0 Gy in single fraction was prescribed to both lungs. All the organs were delineated as per the established guidelines. The dosimetry achieved by the two plans was compared to find the difference. Mean OAR doses were used to estimate the LAR for both plans and compared. Results: Planning target volume coverage parameters like conformity index and homogeneity index were significantly better with VMAT ( P value < 0.05 for all). The mean dose to most OARs was significantly lower with VMAT ( P value < 0.05 for all). The mean dose to the marrow was significantly lower with VMAT (59.05 vs 81.9 cGy with P value < 0.05). The overall LAR was significantly lower with VMAT as compared to the conventional plan (0.357% vs 0.398%, P value < 0.05). Conclusion: Compared to the conventional technique, VMAT provides better OAR dosimetry for lung irradiation (a prescription dose of 1.0 Gy or more) in COVID-19 pneumonia. VMAT significantly reduces the risk of RIC. We therefore suggest if lung LDRT is used for COVID-19 patients, VMAT is the preferred technique for a prescription dose of ≥1.0 Gy.

Introduction: Paratesticular sarcoma are extremely rare malignant tumours. Unlike other sites, they tend to be lower grade and have higher propensity of lymphatic spread. They tend to fail locally and occasionally in the regional lymph nodes. In the absence of target volume delineation guidelines and technical illustration of conformal planning, we have made an attempt to illustrate conformal planning methodology and define target volume based on current evidence in a case of paratesticular sarcoma. Methods: We are presenting a case of 62-year-old male who presented with 15-cm scrotal swelling and underwent high inguinal orchidectomy with ligation of spermatic cord. Histopathology presented a well-differentiated leiomyosarcoma of epididymis. Post-operative radiotherapy target volume included the tumour bed, ipsilateral inguinal nodes and lower pelvic nodes as the clinical target volume. Conclusion: Adjuvant radiotherapy using advanced delivery technique such as volumetric arc technique can provide good dose distribution with good sparing of organs at risk. The downside of conformal radiation delivery is that it is a resource-intensive and has no established target volume delineation guidelines.

AbstractIntroduction:Giant cell tumour of the tendon sheath (GCTTS) is the second most common tumour of the hand. Despite surgery, local recurrence after excision has been reported in up to 45% of cases. Post-operative radiotherapy (PORT) has been found to be promising in preventing these recurrences in high-risk group. One of the reservations of PORT is secondary effects of radiation which may cause a decreased range of motion of the affected joint, sensory changes and nail changes. Surface mould brachytherapy can provide a high dose to target volume with a rapid fall of dose to surrounding structures. Despite this, it is less used, the possible reason can be less technical proficiency.Methods:We have technically illustrated surface mould brachytherapy in a case of GCTTS of the left index finger, and compared dosimetrically with more widely used conventional photon and electron external beam radiotherapy.Conclusion:The 6-MV photon treatment plan with a bolus plan provided the least dose to skin (106%) and phalanges (103%). It has a Homogeneity index (1·06) closest to 1, whereas the Conformity index of all plans was similar. The dose coverage was adequate in all plans. The second-best plan dosimetrically was the surface mould brachytherapy.

Introduction: Oesophageal carcinoma is one of the fatal cancers mainly because of its rapid spread and poor prognosis. Treatment modalities involves a multimodality approach, including surgery, radiation therapy and chemotherapy. Radiation therapy includes brachytherapy in the form of intraluminal radiation therapy. Brachytherapy permits delivery of high tumouricidal doses to superficial cancerous growth of the oesophagus while delivering much lower doses to the surrounding tissue. It is mostly given in combination with external beam radiation in patients with poor performance scores not likely to tolerate an aggressive chemoradiation regimen or as a boost to concurrent chemoradiotherapy. It is very effective in terms of local tumour control as well as in relieving symptoms in advanced/recurrent disease. Intraoperative brachytherapy and seed brachytherapy have also been tried to address the nodal disease. Methods: We undertook a review of the available literature and techniques developed in the past three decades to emphasise the role of brachytherapy in curative or palliative settings in the treatment of oesophageal carcinoma. Conclusion: Oesophageal brachytherapy will remain a tangible treatment of oesophageal cancer, although it is less commonly used due to high expertise requirement, lack of established evidence, risk of life-threatening complications and lack of interest in brachytherapy. It offers quick and useful palliation for a prolonged period, along with good quality of life and superior dosimetry. Use of novel applicators may allow dose escalation and lower toxicity. Seed brachytherapy is also emerging as a promising option in nodal recurrences.

The world is fighting the onslaught of COVID 19 for the last 10 months, ever since the first case was reported in December 2019 in Wuhan, China. Now, it has spread to over 200 countries. COVID 19-associated respiratory syndrome is causing a lot of mortality and morbidity. There are reports suggesting that the complications and ARDS associated with COVID 19 is an immune response reaction. The cytokine storm associated with severe cases of COVID 19 acts as a cause of death in many sick patients. It has been shown that COVID 19 is associated with a peculiar immune profile: Decrease in CD3, CD4, CD8, natural killer cell and B-cells; Rise in interleukin (IL)-4, IL-6 and tumor necrosis factor (TNF) alpha; Decrease in IL-10; Decrease in interferon-gamma. Low-dose radiotherapy (LDRT) immunosuppressive features resulting from M2 macrophage phenotype activation, increase in IL-10, transforming growth factor beta, a decrease in IL-6, TNF alpha and an increase in CD3, CD4, and CD8 T cell counts may negate the harmful effects of cytokine release syndrome. Literature review shows that radiation was previously used to treat viral pneumonia with a good success rate. This practice was discontinued in view of the availability of effective antibiotics and antivirals. As there are no scientifically proven treatment for severe COVID 19-associated respiratory distress today, it is prudent that we understand the benefits of LDRT at this critical juncture and take rational decisions to treat the same. This article provides an radioimmunological rationale for the treatment of immune crisis mediated complications in severe cases of COVID 19.

Abstract Mycetoma is a localized chronic subcutaneous infection caused by fungi. It is clinically characterized by a triad of tumefaction, sinuses, and discharge containing typical grains. Eumycetoma, a subtype, is characterized by a low cure rate. Long‐term medication and surgical excision are required to treat the infection. Radiotherapy, a less used modality of treatment, may provide a good salvage option for refractory eumycetoma. Herein, we present a case and a review of the literature of refractory eumycetoma of the foot where radiotherapy was used as a salvage treatment. In the present case, a dose of 17.5 Gy in five fractions was delivered, and the response was assessed as per the Response Evaluation Criteria in Solid Tumors 1.1, discharging grains status, and Dermatology Life Quality Index. The literature on the use of radiotherapy for mycetoma was found to be scanty. In the present case with radiotherapy, there was a partial radiological response, resolution of discharging grains, and improvement in the Dermatology Life Quality Index score. However, the benefit was short‐lived, but re‐irradiation and low‐dose radiotherapy resulted in sustained benefits until 15 months of follow up. The antiproliferative and anti‐inflammatory actions of radiotherapy can be exploited in the treatment of rare, medically difficult to treat mycetoma. This case report may serve as a basis for further evaluation.

INTRODUCTION:Para testicular sarcomas are rare mesenchymal tumors that affect patients of all ages. Unlike other sites of sarcoma, they tend to be of lower grade and have a higher propensity for lymphatic spread. Management is hampered by the small number of patients who differ in terms of tumor grade and histology. Current treatment approaches are based on case reports, small case series and literature reviews, resulting in a number of unresolved issues. The consensus on the type of surgery and adjuvant treatment is yet to be determined. The local relapse rates in the scrotum and groin after orchidectomy comes out to be 25%-37%, indicating the need for either aggressive surgery or adjuvant treatment. There is a paucity of data identifying the patterns of failure and risk factors for recurrence, which will help clinicians tailor appropriate treatment. METHODS:We aim to perform a systematic review and meta-analysis of the available data in the last 50 years in a methodologically rigorous and transparent manner to identify patterns of failure and high-risk factors for recurrence. The protocol is prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA-P) 2015 guidelines. The protocol is registered in the International Prospective Register of Systematic Reviews (CRD42021237134). HIGHLIGHTS:Para testicular sarcomas are rare mesenchymal tumors that affects patients of all ages. Current treatment approaches are based on case reports, small case series and literature reviews, resulting in a number of unresolved issues. A systemic review was performed in 2013 based on survival rates, prognostic factors, and relapse sites on paratesticular sarcomas. However, it lacks a comprehensive review that can guide radiation oncologists to select in which patient's postoperative radiotherapy is warranted and define the target volume based on histopathological type, stage, and grade of the tumor. After 2013, new case series with improved methodology and sample size are published, which adds new information to the literature. In one case series, 22 patients with spermatic cord sarcoma were discussed, while in another study, long-term outcome analysis of 51 patients was discussed, and another study discussed eight patients.

Background: Horse shoe kidney is rare, rarer is urothelial carcinoma of renal pelvis in horse shoe kidney, but is more common than that in normal kidney. Radical nephroureterectomy with removal of a cuff of urinary bladder is the standard of treatment. Despite of complete surgery, there are loco-regional recurrences. Case Report: Presenting a case of 60-year male with gross hematuria of 2 months. On imaging found to have horse show kidney with right kidney upper pole mass, believing it to be renal cell carcinoma, nephrectomy was done. However, histopathology turned out to be low-grade urothelial carcinoma of pelvis. Patient had recurrence in left over ureteral stump and ureteric orifice after 10 months. Completion surgery followed by adjuvant intra-vesical bacille calmette guerin (BCG) was given and patient has no recurrence since past 2 years. Conclusion: Urothelial carcinoma of renal pelvis although rare, but it is three to four times more common than that in normal kidney due to chronic obstruction in horse shoe kidney. Due to multifocality of urothelial carcinoma of renal pelvis, gold standard treatment remains complete nephroureterectomy with removal of a cuff of urinary bladder. Post-operative locoregional recurrences are seen and judicious use of intravesical BCG, chemotherapy, and radiotherapy has shown to beneficial.

Background: With the pandemic gaining a firm foothold globally, various governments world-wide are trying hard to halt its unprecedented spread. The pandemic is challenging the healthcare professionals in unique ways and forcing the frontline fighters to come up with dynamic changes in almost all disciplines of medical science. This article is aimed at a detailed review of the exist-ing guidelines for radiotherapy practice during this pandemic from across the world. Methods: This review has been organised under specific subheadings that pertains to the functioning of a Radiation Oncology facility in South Asian countries like India. After a detailed Zoom video conference between the authors, it was decided to focus the review under the following sub-headings: staff allocation, staff education, screening of patients, patient waiting area modifica-tion, patient selection, radiotherapy planning and execution, review of patients on radiotherapy, brachytherapy, inpatient admissions, follow up, resident training and treatment of suspected or positive COVID 19 patients. Results: After discussion among the authors, a consensus working suggestion during the COVID-19 pandemic has been proposed for a radiotherapy center in a South Asian country like India. All the authors worked simultaneously on a Google doc docu-ment to develop this manuscript. Conclusions: This paper can be a reference document for the functioning of a radiotherapy facility during the COVID19 pandemic. As the infrastructure of different institutes vary and so does each patient, the importance of fine tuning and tailoring our final decisions before treating a patient in this unprecedented crisis cannot be undermined.