Publications by authors named "Raj Kumar Shrimali"

10 Publications

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Setting up a lung stereotactic body radiotherapy service in a tertiary center in Eastern India: The process, quality assurance, and early experience.

J Cancer Res Ther 2020 Jul-Sep;16(4):888-899

Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India.

Context: Stereotactic body radiotherapy (SBRT) is increasingly being used for early-stage lung cancer and lung oligometastases.

Aims: To report our experience of setting up lung SBRT and early clinical outcomes.

Settings And Design: This was a retrospective, interventional, cohort study.

Subjects And Methods: Patients were identified from multidisciplinary tumor board meetings. They underwent four-dimensional computed tomography-based planning. The ROSEL trial protocol, the Radiation Therapy Oncology Group (RTOG) 0236, and the UK-Stereotactic Ablative Body Radiotherapy Consortium guidelines were used for target volume and organs-at-risks (OARs) delineation, dosimetry, and plan quality assessment. Each SBRT plan underwent patient-specific quality assurance (QA). Daily online image guidance using KVCT or MVCT was done to ensure accurate treatment delivery.

Statistical Analysis Used: Microsoft Excel 2010 was used for data analysis.

Results: Fifteen patients were treated to one or more lung tumors. One patient received helical tomotherapy in view of bilateral lung oligometastases at similar axial levels. All the remaining patients received volumetric modulated arc therapy (VMAT)-based treatment. The prescription dose varied from 40 to 60 Gy in 5-8 fractions with alternate-day treatment. The mean and median lung V20 was 5.24% and 5.16%, respectively (range, 1.66%-9.10%). The mean and median conformity indexes were 1.02 and 1.06, respectively (range, 0.70-1.18). After a median follow-up of 17 months, the locoregional control rate was 93.3%.

Conclusions: SBRT was implemented using careful evaluation of OAR dose constraints, dosimetric accuracy and plan quality, patient-specific QA, and online image guidance for accurate treatment delivery. It was safe and effective for early-stage nonsmall cell lung cancer and lung metastases. Prospective data were collected to audit our outcomes.
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http://dx.doi.org/10.4103/jcrt.JCRT_427_18DOI Listing
November 2020

Peer-review and post-publication discourse: The challenges.

Indian J Cancer 2020 Jan-Mar;57(1):108-109

Arden Cancer Centre, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.

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http://dx.doi.org/10.4103/ijc.IJC_527_18DOI Listing
November 2020

How do clinicians rate patient's performance status using the ECOG performance scale? A mixed-methods exploration of variability in decision-making in oncology.

Ecancermedicalscience 2019 28;13:913. Epub 2019 Mar 28.

Department of Clinical Oncology, North Wales Cancer Center, Rhyl LL18 5UJ, UK.

Background: Medical decisions made by oncology clinicians have serious implications, even when made collaboratively with the patient. Clinicians often use the Eastern Clinical Oncology Group (ECOG) performance status (PS) scores to help them make treatment-related decisions.

Methods: The current study explores the variability of the ECOG score when applied to 12 predetermined specially designed clinical case vignettes presented to a group of oncology clinicians ( = 72). The quantitative analysis included evaluation of variability of ECOG PS scores and exploration of rater and patient-related factors which may influence the final ECOG rating. In-depth interviews were conducted with oncology clinicians to ascertain factors that they felt were important while making treatment-related decisions. Basic and global themes were generated following qualitative data analysis.

Results: Quantitative results showed that there was poor agreement in ECOG rating between raters. Overall concordance with the gold standard rating ranged between 19.4% and 56.9% for the vignettes. Moreover, patients deemed to have socially desirable qualities ( < 0.004) were rated to have better PS and women patients ( < 0.004) to have worse PS. Clinicians having international work experience had increased concordance with ECOG PS rating. Qualitative results showed that 'perceived socio-economic background of the patient', 'age of the patient', 'patient's and family's preferences' and 'past treatment response' were the major themes highlighted by respondents that influenced the treatment-related decisions made by clinicians.

Conclusion: There is considerable variability in ECOG PS determined by clinicians. Decision-making in oncology is complex, multifactorial and is influenced by rater and patient-related factors.
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http://dx.doi.org/10.3332/ecancer.2019.913DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467460PMC
March 2019

Radical radiotherapy or chemoradiotherapy for inoperable, locally advanced, non-small cell lung cancer: Analysis of patient profile, treatment approaches, and outcomes for 213 patients at a tertiary cancer center.

Indian J Cancer 2018 Apr-Jun;55(2):125-133

Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India.

Introduction: Radical radiotherapy (RT) with curative intent, with or without chemotherapy, is the standard treatment for inoperable, locally advanced nonsmall cell lung cancer (NSCLC).

Materials And Methods: We retrospectively reviewed the data for all 288 patients who presented with inoperable, locally advanced NSCLC at our institution, between May 2011 and December 2016.

Results: RT alone or sequential chemoradiotherapy (SCRT) or concurrent chemoradiotherapy (CCRT) was used for 213 patients. Median age was 64 years (range: 27-88 years). Stage-III was the biggest stage group with 189 (88.7%) patients. Most patients with performance status (PS) 0 or 1 received CCRT, whereas most patients with PS 2 received RT alone (P < 0.001). CCRT, SCRT, and RT alone were used for 120 (56.3%), 24 (11.3%), and 69 (32.4%) patients, respectively. A third of all patients (32.4%) required either volumetric-modulated arc radiotherapy (VMAT) or tomotherapy. Median follow-up was 16 months. The median progression-free survival and median overall survival (OS) were 11 and 20 months, respectively. One-year OS and 2-year OS were 67.9% and 40.7%, respectively. Patients treated using CCRT lived significantly longer with a median survival of 28 months, compared with 13 months using SCRT and RT alone (P < 0.001). On multivariate analysis, OS was significantly affected by age, stage group, treatment approach, and response to treatment.

Conclusion: RT including CCRT is feasible, safe, and well tolerated in our patient population and results in survival benefits comparable with published literature. CCRT should be considered for all patients with inoperable, locally advanced NSCLC, who are fit and have good PS.
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http://dx.doi.org/10.4103/ijc.IJC_469_17DOI Listing
April 2019

Impact of modern radiotherapy techniques on survival outcomes for unselected patients with large volume non-small cell lung cancer.

Br J Radiol 2019 Mar 29;92(1095):20180928. Epub 2018 Nov 29.

1 Department of Radiation Oncology, Tata Medical Center, Kolkata , India.

Objective:: Intensity modulated radiotherapy (IMRT) is used, where necessary, for bulky or complex-shaped, locally advanced, non-small cell lung cancer (NSCLC). We evaluate our real-world experience with radical radiotherapy including concurrent chemoradiation (CCRT), and analyse the impact of IMRT on survival outcomes in patients with larger volume disease.

Methods:: All patients treated between May 2011 and December 2017 were included. Analyses were conducted for factors affecting survival, including large volume disease that was defined as planning target volume (PTV) > 500 cc.

Results:: In 184 patients with large volume disease, the median overall survival was 19.2 months, compared to 22 months seen with the overall cohort of 251 patients who received radical radiotherapy. PTV and using CCRT were significant predictors for survival. IMRT was used in 93 (50.5%) of 184 patients with large PTV. The patients treated using IMRT had significantly larger disease volume (median PTV = 859 vs 716 cc; p-value = 0.009) and more advanced stage (proportion of Stage IIIB: 56 vs 29%; p-value = 0.003) compared to patients treated with three-dimensional conformal radiotherapy. Yet, the outcomes with IMRT were non-inferior to those treated with 3DCRT. CCRT was used in 103 (56%) patients with large volume disease and resulted in a significantly better median survival of 24.9 months. The proportional benefit from CCRT was also greater than in the overall cohort.

Conclusion:: Despite being used for larger volume and more advanced NSCLC, inverse-planned IMRT resulted in non-inferior survival.

Advances In Knowledge:: IMRT enables the safe use of curative CCRT for large-volume, locally-advanced NSCLC.
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http://dx.doi.org/10.1259/bjr.20180928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6540869PMC
March 2019

Development and validation of a decision support tool to select IMRT as radiotherapy treatment planning modality for patients with locoregionally advanced non-small cell lung cancers (NSCLC).

Br J Radiol 2019 Feb 9;92(1094):20180431. Epub 2018 Nov 9.

1 Department of Radiation Oncology, Tata Medical Center , Rajarhat, Kolkata , India.

Objective:: Radiation planning for locally-advanced non-small cell lung cancer (NSCLC) can be time-consuming and iterative. Many cases cannot be planned satisfactorily using multisegment three-dimensional conformal radiotherapy (3DCRT). We sought to develop and validate a predictive model which could estimate the probability that acceptable target volume coverage would need intensity modulated radiotherapy (IMRT).

Methods:: Variables related to the planning target volume (PTV) and topography were identified heuristically. These included the PTV, it's craniocaudal extent, the ratio of PTV to total lung volume, distance of the centroid of the PTV from the spinal canal, and the extent PTV crossed the midline. Metrics were chosen such that they could be measured objectively, quickly and reproducibly. A logistic regression model was trained and validated on 202 patients with NSCLC. A group of patients who had both complex 3DCRT and IMRT planned was then used to derive the utility of the use of such a model in the clinic based on the time taken for planning such complex 3DCRT.

Results:: Of the 202 patients, 93 received IMRT, as they had larger volumes crossing midline. The final model showed a good rank discrimination (Harrell's C-index 0.84) and low calibration error (mean absolute error of 0.014). Predictive accuracy in an external dataset was 92%. The final model was presented as a nomogram. Using this model, the dosimetrist can save a median planning time of 168 min per case.

Conclusion:: We developed and validated a data-driven, decision aid which can reproducibly determine the best planning technique for locally-advanced NSCLC.

Advances In Knowledge:: Our validated, data-driven decision aid can help the planner to determine the need for IMRT in locally advanced NSCLC saving significant planning time in the process.
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http://dx.doi.org/10.1259/bjr.20180431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404834PMC
February 2019

Resource requirements and reduction in cardiac mortality from deep inspiration breath hold (DIBH) radiation therapy for left sided breast cancer patients: A prospective service development analysis.

Pract Radiat Oncol 2018 Nov - Dec;8(6):382-387. Epub 2018 Mar 21.

Department of Surgical Oncology, Tata Medical Center, Newtown, Kolkata, West Bengal.

Introduction: Use of deep inspiration breath hold (DIBH) radiation therapy may reduce long-term cardiac mortality. The resource and time commitments associated with DIBH are impediments to its widespread adoption. We report the dosimetric benefits, workforce requirements, and potential reduction in cardiac mortality when DIBH is used for left-sided breast cancers.

Methods And Materials: Data regarding the time consumed for planning and treating 50 patients with left-sided breast cancer with DIBH and 20 patients treated with free breathing (FB) radiation therapy were compiled prospectively for all personnel (regarding person-hours [PH]). A second plan was generated for all DIBH patients in the FB planning scan, which was then compared with the DIBH plan. Mortality reduction from use of DIBH was calculated using the years of life lost resulting from ischemic heart disease for Indians and the postulated reduction in risk of major cardiac events resulting from reduced cardiac dose.

Results: The median reduction in mean heart dose between the DIBH and FB plans was 166.7 cGy (interquartile range, 62.7-257.4). An extra 6.76 PH were required when implementing DIBH as compared with FB treatments. Approximately 3.57 PH were necessary per Gy of reduction in mean heart dose. The excess years of life lost from ischemic heart disease if DIBH was not done in was 0.95 per 100 patients, which translates into a saving of 12.8 hours of life saved per PH of work required for implementing DIBH. DIBH was cost effective with cost for implementation of DIBH for all left-sided breast cancers at 2.3 times the annual per capita gross domestic product.

Conclusion: Although routine implementation of DIBH requires significant resource commitments, it seems to be worthwhile regarding the projected reductions in cardiac mortality.
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http://dx.doi.org/10.1016/j.prro.2018.03.007DOI Listing
January 2019

Acute toxicity and its dosimetric correlates for high-risk prostate cancer treated with moderately hypofractionated radiotherapy.

Med Dosim 2017 Spring;42(1):18-23. Epub 2017 Jan 24.

Department of Radiation Oncology, Tata Medical Center, Kolkata, India.

Aims: To report the acute toxicity and the dosimetric correlates after moderately hypofractionated radiotherapy for localized prostate cancer.

Methods: A total of 101 patients with localized prostate cancer were treated with image-guided intensity-modulated radiation therapy. Patients were treated to 65Gy/25Fr/5 weeks (n = 18), or 60Gy/20Fr/4 weeks (n = 83). Most (82.2%) had high-risk or pelvic node-positive disease. Acute toxicity was assessed using Radiation Therapy Oncology Group (RTOG) acute morbidity scoring criteria. Dose thresholds for acute rectal and bladder toxicity were identified.

Results: The incidence of acute grade 2 GI toxicity was 20.8%, and grade 2 genitourinary (GU) toxicity was 6.9%. No Grade 3 to 4 toxicity occurred. Small bowel toxicity was uncommon (Gr 2 = 4%). The 2Gy equivalent doses (EQD2) to the rectum and bladder (α/β = 3) calculated showed that the absolute doses were more consistent predictors of acute toxicities than the relative volumes. Those with grade 2 or more GI symptoms had significantly higher V (13.2 vs 9.9cc, p = 0.007) and V (20.6 vs 15.4cc, p = 0.005). Those with grade 2 or more GU symptoms had significantly higher V (30.4 vs 18.4cc, p = 0.001) and V (44.0 vs 28.8cc, p = 0.001). The optimal cutoff value for predicting grade 2 acute proctitis, for V was 9.7cc and for V was 15.9cc. For grade 2 GU symptoms, the threshold values were 23.6cc for V and 38.1cc for V.

Conclusions: Hypofractionated radiotherapy for prostate cancer is well tolerated and associated with manageable acute side effects. The absolute dose-volume parameters of rectum and bladder predict for acute toxicities.
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http://dx.doi.org/10.1016/j.meddos.2016.10.002DOI Listing
September 2017

Dose-dense and dose-intense chemotherapy for small cell ovarian cancer: 2 cases and review of literature.

Med Oncol 2011 Sep 2;28(3):766-70. Epub 2010 Apr 2.

Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, G12 0YN, Scotland, UK.

Small cell carcinomas of the ovary (SCCO) are rare and aggressive malignant neoplasms carrying a poor prognosis. Although multi-modality treatment including chemotherapy leads to a high initial response rate, the majority of these patients relapse quickly and die within 2 years of diagnosis. Because these tumours are rare, there is no consensus to support any particular approach to management. We present 2 cases and review the relevant literature to make a number of recommendations. The treatment of these unusual cases should to be individually discussed in a multi-disciplinary team and multi-modality treatment including surgery, chemotherapy and radiotherapy should be considered for patients with limited disease. Conservative, fertility-preserving surgery may be considered in younger women with early-stage disease. Induction chemotherapy with weekly dose-dense and dose-intense carboplatin and taxane is useful. Prophylactic cranial irradiation (PCI) may be considered in patients in remission after primary treatment with chemotherapy or surgery.
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http://dx.doi.org/10.1007/s12032-010-9509-0DOI Listing
September 2011

Positron emission tomography with computed tomography (PET-CT) to evaluate the response of bone metastases to non-surgical treatment.

BMJ Case Rep 2010 May 6;2010. Epub 2010 May 6.

Beatson West of Scotland Cancer Centre, Clinical Oncology, Gartnavel General Hospital, Glasgow, UK.

A case of solitary bone metastasis from breast cancer, where MRI assessment of treatment response was inaccurate and whole-body fluorodeoxyglucose ((18)FDG) positron emission tomography with computed tomography (PET-CT) proved more reliable and objective, is presented.
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http://dx.doi.org/10.1136/bcr.11.2009.2457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047492PMC
May 2010