PURPOSEThe incidence of cancer is rising in India, and radiotherapy plays a vital role in the management of most cancers. More radiotherapy centers are being set up across the country to cater to this need. Quality assurance (QA) of radiotherapy is crucial to minimize risks and ensure best outcomes for all patients receiving radiotherapy. We outline an effort to develop a standardized radiotherapy QA program implementable across India through a consensus process among stakeholders.METHODSThe team structured a Standardised Unified Radiotherapy QA model (SURAQSA), a program of pan-India radiotherapy QA incorporating elements of radiotherapy trials QA, adapted for the Indian health care system. Engagement of a cross-section of radiation oncologists working across India to achieve consensus on the issue was essential. This paper describes the consensus development process among the diverse Indian centers/professionals in support of the SURAQSA program. The statement was introduced to clinicians through the vehicle of an abbreviated Delphi consensus process, with guidance from the Royal College of Radiologists (United Kingdom). We outline the elements of the SURAQSA program and describe the consensus adopted.RESULTSThirteen centers from across India were represented in the workshop. Three of the consensus statements on external QA of each center, prospective peer review of contours, plan quality measures, and protocol-driven management, as the basic requirements received unanimous support. Consensus was also achieved on the pilot subsite for this exercise with minor disagreement.CONCLUSIONThis report showed feasibility of a wide stakeholder engagement to deliver focused outputs and is a huge step toward formulating site-specific radiotherapy QA programs. The process allowed oncologists to highlight the need to take essential steps for radiotherapy safety across centers with varying availability of trained manpower and infrastructure.

PURPOSE:Concurrent cisplatin and radiation for high-risk laryngopharyngeal cancers have high failure rates. This Phase II randomized study compares standard radiation dosing with FDG-PET guided escalated dosing in p16-negative oropharyngeal (OP) and locally advanced laryngopharyngeal (LP) cancers. MATERIALS AND METHODS:Our randomized clinical trial included patients with locally advanced p16-negative OP and LP cancers. 18FDG PET guided escalated arm 73.5 Gy/30 fractions patients were treated with a 5 mm isotropic margin on the SUV40%max (BTV-PET) whilst the standard arm patients received 66 Gy/30 fractions to the high-risk CTV. Both arms were planned to receive concurrent cisplatin chemotherapy (40 mg/m2 weekly). The study was designed as a hybrid/seamless Phase 2 study to first exclude excess grade 4 toxicities, followed by an efficacy comparison. Efficacy outcomes included 2-year locoregional recurrence, disease-free survival (DFS), and overall survival (OS). RESULTS:From 2016 to 2021, 102 patients were treated (42 LP, 60 OP), with 51 in each treatment arm. Median age was 59, with 72.5% having T3/4 primaries and 58.8% N2-3 nodal stage. Both arms received a median of 5 cisplatin cycles. Safety assessment showed only a single patient with Grade 4 toxicity, and the trial was allowed to complete accrual. Acute grade 3 toxicities showed no significant differences between the two arms, with mucositis (35.3% in both arms), dermatitis, dysphagia, and feeding tube requirement being similar. With a median follow-up of 40 months, the 2-year locoregional control rate was 85.4%, with no significant difference between the arms (88.6% standard vs 82.2% escalated, p = 0.57). The 2-year DFS and OS rates also showed no significant differences (59.7%, 64.7%, 54.8% for DFS, 67.3%, 68.2%, 66.6% for OS, p = 0.65 and p = 0.99, respectively). CONCLUSION:While feasible, FDG-PET-based dose escalation did not improve local control, DFS, or OS in our patient population.

Introduction: Automatic segmentation of target volumes and organs at risk may save time and reduce inter-observer variability. However, commercial systems are costly, difficult to customise, and often poorly represent local populations. We developed a deep learning-based automatic segmentation system (DRAW), based on a client-server architecture using a decoupled inference layer to enable on-demand use of computational resources. We report the initial deployment experience and performance across two centres.Materials and Methods: The DRAW system was deployed at two geographically distant centres. System uptime, successful segmentation rate, and segmentation time were recorded. Spatial overlap metrics, including the Dice similarity coefficient (DSC), Dice Jaccard coefficient (DJC), 95th percentile Hausdorff distance (HD95), surface Dice similarity coefficient (sDSC), and mean distance to conformity (MDC), were computed for a sampled subset where automatic segmentation and manually modified structures were available. A qualitative assessment of the extent of contour modification required was performed independently at one centre. Inter-centre differences were assessed using independent-samples t-tests.Results: Between April 2025 and April 2026, 4215 of 4303 uploaded series (98%) were successfully segmented. The API server uptime exceeded 99.5%. Median segmentation time was 20.2 minutes. Quantitative evaluation of segmented structures was performed in 380 patients. Aggregated mean DSC was 0.81 at Centre A and 0.78 at Centre B. Other spatial overlap metrics also showed a lower performance in Centre B. On qualitative review at Centre B, no modification was required for 24% of structures, while major and minor modifications were required for 33% and 31% of structures, respectively.Conclusion: The DRAW system was deployed and maintained across two centres with acceptable performance. Differences in model performance between the training and external centre indicate the need for more robust training. Open-source tools can reduce barriers to adopting automatic segmentation in resource-constrained settings.

Modern medicine, especially oncology in low-and middle-income countries (LMICs), requires clinicians to remain updated in a rapidly evolving field of medicine in the face of a high clinical load. Clinicians need to be able to critically evaluate published evidence and make informed decisions about the individual patients they treat. A clinical culture that encourages clinicians to question and think critically would produce high-quality research from parts of the world that have highest disease burden but lowest contribution to published research. A two-day research methods course was conducted jointly by the Tata Medical Center, Kolkata and the West Bengal Chapter of the Indian Psychiatric Society on 22nd-23rd August 2025. We report on our experience of organising this course and the lessons learned from interacting with the audience in an LMIC setting. Live anonymous participant responses were captured using Mentimeter software during the training, and written anonymous feedback were provided by majority of attendees. The three main barriers to conducting research that our participants reported were: 'lack of training in research', 'difficulties in writing a research paper' and the 'researcher's personal circumstances'. The participants in our course comprised both men and women clinicians, mostly in their early careers and this group of learners appreciated hands-on training on literature search, reference management and working with the SPSS statistical software to conduct standard statistical tests. To achieve this, institutions and individuals need to foster a conducive environment for research, inspiring those who will be responsible for the future health care delivery.

BACKGROUND AND OBJECTIVE:Most patients with high-risk localized prostate cancer (HRLPC) do not undergo stereotactic body radiotherapy (SBRT) in part because of the limited evidence of long-term outcomes. We report long-term efficacy and toxicity outcomes for men treated with SBRT for HRLPC. METHODS:Individual patient data from ten prospective clinical studies evaluating SBRT for HRLPC across nine institutions were pooled in the Stereotactic Body Radiotherapy for High-Risk Localized Carcinoma of the Prostate consortium. The Kaplan-Meier method was used to estimate 5-yr biochemical recurrence (BCR) and distant metastasis (DM), stratified by receipt of intensified treatment (≥12 mo of androgen deprivation therapy [ADT] with extremely dose-escalated [≥8 Gy/fraction] prostate-directed SBRT). The impact of intensified treatment on BCR-free survival and DM-free survival was evaluated using multivariable Cox proportional hazards models. Late Common Terminology Criteria for Adverse Events grade ≥2 gastrointestinal (GI) and genitourinary (GU) toxicity was analyzed using time-to-event models. KEY FINDINGS AND LIMITATIONS:In 440 patients with a median follow-up time of 60.4 mo, 5-yr BCR and DM rates were 22% (95% confidence interval [CI] = 17-26%] and 9.2% (95% CI = 6.2-12%), respectively. In the 93 patients (21%) who received intensified treatment, 5-yr BCR and DM rates were 7.4% (95% CI = 1.7-13%) and 3.7% (95% CI = 0-7.9%), respectively. Receipt of intensified therapy was associated with a significant reduction in both BCR (hazard ratio [HR] = 0.38 [95% CI = 0.20-0.74], p = 0.005) and DM (HR = 0.43 [95% CI = 0.18-0.99], p = 0.049). For the overall cohort, 5-yr rates of grade ≥2 GU and GI toxicity were 23% (95% CI = 19-27%) and 10% (95% CI = 7-13%), respectively. Limitations include heterogeneous treatment techniques and the nonrandomized nature of the study. CONCLUSIONS AND CLINICAL IMPLICATIONS:The safety and efficacy profile of SBRT for HRLPC remains favorable at long-term follow-up, and SBRT should be integrated into shared decision-making for treatment of HRLPC.

INTRODUCTION:Management of cervical squamous cell carcinoma with unknown primary (SCCUP) continues to evolve with emphasis on tonsillectomy for identification of the primary. While the data from an HPV positive population is compelling, surgical ablation of potential primary sites in the oropharynx with the goal of identifying the primary in HPV negative tumors is debated. METHODS:In this prospective observational study, 21 patients with SCCUP underwent bilateral tonsillectomy in an attempt to identify a possible site of primary. RESULTS:Median age of this cohort was 59 years (39-74 years). Two of twenty patients were p16 positive. Only 1 patient (p16 positive) revealed a primary in the tonsil. Fifteen patients received adjuvant concurrent chemoradiation (CTRT), whereas two patients received adjuvant radiotherapy (RT). Median follow up was 17.6 months (0.26-60 months). The 2-year overall and disease-free survival rates were 81.5% (52.6%-93.7%) and 70.1% (42.1%-86.4%), respectively. No patient evinced mucosal recurrence. CONCLUSIONS:Prevalence of human papilloma virus in patients with SCCUP is very low in India. Role of bilateral tonsillectomy to identify primary lesion in p16 negative patients is questionable.

AIM:The aim of the fourth Asia-Pacific Advanced Prostate Cancer Symposium (APAC APCS 2025) was to discuss the application in the Asia-Pacific (APAC) region of outcomes from the fifth Advanced Prostate Cancer Consensus Conference (APCCC 2024). METHODS:The one-day symposium in September 2025 brought together 28 experts from 15 APAC countries or regions. The symposium covered five topics: (1) high-risk localized/locally advanced prostate cancer; (2) prostate-specific antigen persistence and recurrence; (3) radioligand therapy; (4) genetics and genomics; (5) bone protection and other aspects of supportive care. Presymposium polling and expert presentations prefaced in-depth discussions to gather insights on current practice and challenges in the region. RESULTS:APAC APCS 2025 highlighted the increasing complexities in diagnosis and management of advanced prostate cancer and the impact on practice of variations in access and cost. Panelists described variations in access and reimbursement for PSMA-PET/CT, abiraterone, androgen receptor pathway inhibitors, 177Lu-PSMA, and bone-protecting agents. While most panelists reported access to nuclear medicine expertise, access to genetic counsellors continues to be limited in many parts of the region. Discussions highlighted creative approaches used to minimize costs while maximizing options for patients. CONCLUSION:APAC Advanced Prostate Cancer Symposia are important forums for discussing APAC-specific considerations in areas where clinical evidence is evolving. In an era of increasingly sophisticated technologies, discussions highlight the importance of not losing sight of patient and clinical factors in decision-making. Multidisciplinary and personalized management is critical, along with the need for locally relevant data to inform APAC-specific guidelines.

Worst pattern of invasion (WPOI) has been evaluated in many single-institute cohorts. Our goal was to perform a large multicentre evaluation of WPOI as a prognostic marker in oral squamous cell carcinoma (OSCC). Retrospective pathology data was collated from 14 institutions and compared with clinical outcome in 1374 OSCC patients with upfront curative resection. Most cases were of oral tongue (n = 645, 47%); T2 (33%) and N0 (59%). WPOI 1-3 frequency was 29.4%, WPOI 4 47% and WPOI 5 22%. On univariable analysis, the 3-year disease free survival (DFS) was 54.2% for WPOI 5 vs. 69.7% for WPOI 1-4 (p < 0.001). The locoregional control (LRC) was 68.9% vs 79.2% (p = 0.001), and overall survival (OS) 68.4% vs 83.8% (p < 0.001). On multivariable Cox-regression in the entire cohort, WPOI 4 or 5 was strongly correlated with other known poor prognostic factors and not an independent predictor of OS (HR 1.10, 95% CI 0.92-1.52), LRC or DFS. However, in early-stage (pT1-2 N0) patients treated with surgery alone without adjuvant radiotherapy, WPOI 5 was a robust independent predictor of DFS (HR 4.36, 95% CI 1.54-12.32, p = 0.006), OS (HR 3.69, 95% CI 1.23-11.1, p = 0.020) and LRC (HR 3.52, 95% CI 2.13-5.82, p <0.001) after applying inverse probability weighting to correct for selection bias. Furthermore, in the entire cohort of early-stage patients, interaction modeling showed that adjuvant radiotherapy significantly reduces the risk for both DFS and LRC for those with WPOI-5 (Interaction p = 0.002). Therefore, it may act as a predictive biomarker for the benefit of adjuvant radiotherapy. The prognostic and predictive role of WPOI-5 should be validated in prospective trials.

Automating prostate radiotherapy treatment planning is dosimetrically complex, particularly for extreme hypofractionated regimens. In this study, we introduce Dose-PlanNet, a physics-guided 3D deep learning architecture designed to predict dose distributions. This model's performance was evaluated on a cohort of patients treated in a prospective trial where two different dose fractionation regimens were employed. Dose-PlanNet achieved comparable target coverage (D_95), though statistical analysis revealed a marginal reduction in target homogeneity (p<0.001) offset. However the model achieved statistically significant improvements in high-dose organ-at-risk sparing (p<0.001). When evaluated against strict Prospective Randomized protocol volumetric constraints, automated plans met prespecified clinical acceptance criteria in 11 out of 14 Moderate Hypofraction Arm plans and 9 out of 12 Stereotactic Body Radiation Therapy Arm plans. This pipeline demonstrates that physics-informed deep learning can accelerate radiotherapy workflows while safely maintaining the stringent dosimetric quality required for high-precision clinical deployment.

Purpose Periampullary, pancreatic ductal, distal bile duct and duodenal carcinomas have overlapping gross presentation and morphology. Exact site of origin is often difficult to establish conclusively, yet they have differing AJCC TNM staging systems. This makes grossing Whipple's specimens daunting in centers with limited volume, increasing the chance of inaccurate staging. The aim of this study is to validate an alternative size-based staging system for ampullary cancers, using pancreatic ductal adenocarcinoma staging characteristics, which can simplify pathological assessment of Whipple's specimens. Methods Clinicopathologic data from all consecutive patients of ampullary adenocarcinoma were retrospectively reviewed. Prognostic correlation of this alternative size-based staging system (using cut-offs of 2 and 4 cm) was done with disease free survival (DFS) and overall survival (OS). This alternative staging proposal was compared with the current AJCC8 tumour staging system and other histological prognostic parameters. Results After applying exclusion criteria, 146 cases were analyzed in this study. The tumor size-based stage did not correlate significantly with DFS (p = 0.4) or OS (p = 0.3), but the AJCC8 T stage did (p = 0.03). Multivariate analysis using both AJCC T stage and size-based categorization, also did not show any prognostic correlation with outcome, though positive surgical margins, perineural invasion and the pN2 nodal status were established as independent prognostic factors. Conclusions Tumor size-based staging (using pancreatic ductal cancer criteria) is currently inferior to AJCC TNM stage for ampullary carcinoma and needs further evaluation in large multi-institutional studies.

AIMS:Laryngeal conservation in advanced disease is possible with chemo-radiation (CTRT); however, it is at the expense of significant toxicity. There is sparse data from the Indian subcontinent addressing the same. MATERIALS AND METHODS:A retrospective cohort study of Stage III-IVa/b patients treated between May 2011 and April 2022. We assessed survival outcomes, organ preservation rates, and toxicities. RESULTS:300 patients, with a median age of 63 years (57;69), were identified. Median follow-up was 4.1 years (3.5; 4.4). Dysphagia was the most common grade 3 toxicity (119; 40%). The 5-year overall survival (OS) was 61% (55%; 69%). Sitewise, laryngeal cancers (64% (55%; 74%)) fared better than hypopharyngeal cancers (55% (45%; 67%)) with respect to 5-year OS. The larynx preservation rate was 84% (79%; 90%) at 5 years. CONCLUSION:Functional laryngeal preservation is achievable in locally advanced laryngeal and hypopharyngeal cancers with definitive CTRT. Outcomes aligned with established and published data.

Total Neoadjuvant treatment (TNT) has now become the standard of care in locally advanced rectal cancer(LARC) and has shown promising results. However, use and outcome of different TNT regimens in real-world practice is largely unknown.Here we report the feasibility and efficacy of RAPIDO regimen which we adopted since 2021 for LARC. A retrospective review of prospectively collected data, conducted at Tata Medical Center, Kolkata between January 2021 to June 2024. 95 consecutive patients with localized rectal adenocarcinoma, treated with short course radiotherapy 25 Gy/5frs/1week followed by CAPOX based chemotherapy with or without surgery were analysed. Data was collected in the Redcap Database. The median age of the cohort was 53 years. Lower rectal disease, T4,N2,EMVI(Extramural Vascular Invasion) Grade 3/4, MRF (Mesorectal fascia) involvement were seen in 51(54

Background:The rising cancer burden in low- and middle-income countries (LMICs) has been accompanied by an increase in clinical trials. However, there is a paucity of research from LMICs on patient preferences for trial participation. Methods:We undertook a cross-sectional qualitative study using in-depth interviewing to explore the views of Indian cancer patients (n = 11), caregivers(n = 10) and public (n = 10), regarding clinical trials. Clinical researchers (n = 10) were also interviewed. Data were analysed using the framework of qualitative content analysis. Results:Five themes were identified regarding clinical trials: a) Perception: Only a minority had a prior understanding; when explained, most were willing to be randomised and attend additional monitoring visits. b) Recruitment: Consensus that trial discussions should be with the patient, with caregivers and family included where appropriate, variability in when a patient should be first approached. c) Patient information: Need for both written and audio-visual information material using simple local language. d) Benefits/adverse effects : Discussion of all pros and cons, including the possibility of dying was preferred. There were divided views regarding disclosure of all versus common risks. Challenges in understanding quantitative risks/benefits were voiced. e) Consent: Honesty and transparency, imbalance of power/trust between trialists and participants and financial vulnerability of patients were voiced by participants. Conclusion:Cancer clinical trials in LMICs can be enriched by patient and public involvement during planning research and conduct of the clinical trial. The financial vulnerability of patients and the power imbalance between them and researchers need to be addressed, especially in international multiregional clinical trials.

Open source segmentation models often do not provide comprehensive segmentation of both organs-at-risk and target volumes. In order to bridge this gap, we utilize the NNUNet framework and create an end-to-end pipeline for prostate cancer segmentation. To demonstrate the real-world efficacy of our approach, we conduct a clinical case study. First, we prepare a new dataset from real prostate cancer patient data. Then, we discuss the diverse challenges encountered during this process and provide solutions to overcome those. Next, we evaluate the results based on clinical viability. The results not only showcase the accuracy and reliability of this pipeline, but also emphasize its potential for practical applications in Radiation Therapy Planning. Code is available at CHAVI-India/draw .

This study proposes a scoring system for adjuvant irradiation for stage I/II oral squamous cell carcinoma (OSCC). Derivation cohort (119 patients, operated between 2011 and 2014) and a validation cohort (204 patients, operated between 2016 and 2019) were included. In derivation cohort, on univariate analysis, tumor size >2 cm [3-year Disease Free Survival (DFS) 72.5% vs 95.6%, P = 0.039], lymphovascular invasion (58.3% vs 83.6%, P = 0.024), perineural invasion (75% vs 85.6%, P = 0.013), and depth of invasion ≥0.5 cm (73.8% vs 97.5%, P = 0.017) predicted 3-year DFS. Tongue lesions and poor differentiation were added as poor prognosticators based on previously published reports. Patients were grouped as low risk (<3 risk factors) and high risk (≥3 risk factors), with only high-risk group receiving adjuvant irradiation in validation cohort. Overall, 47/119 (39.5%) patients in the derivation cohort and 50/204 (24.5%) patients in validation cohort received adjuvant irradiation. In derivation cohort, 3-year DFS was 93% and 72.5% in the low and high-risk group, respectively. 3-year DFS was 90.7% and 85.8% in the low and high-risk group, respectively for validation cohort. The proposed scoring system reduced the use of adjuvant irradiation by 38%, with similar DFS.