A 53-year-old female presented with a large (945 cc) unresectable leiomyosarcoma of the uterus, with metastasis in the lungs, significant abdominal/pelvic pain and evidence of hydronephrosis secondary to obstruction caused by the mass. In an effort to palliate symptoms, radiation was recommended.

Given the size of the lesion, the patient was treated with crossfire GRID, a type of spatially fractionated radiotherapy (18 Gy × 1), followed four weeks later by a short course of external beam radiation (4 Gy × 5).

The patient experienced significant symptom relief. Her abdominal/pelvic pain resolved, and a stent was placed to relieve her hydronephrosis. The tumour volume had decreased significantly (5·5 months post-treatment 276 cc, 8·5 months post-treatment 17 cc). Unfortunately, at 9 months post-treatment, the patient died from progression of her metastatic disease in the lungs.

The use of GRID radiotherapy resulted in effective and sustained palliation of a large uterine leiomyosarcoma in this patient’s case.

Sarcomas occurring during pregnancy are rare and they present significant challenges in clinical management, to optimise, investigations and treatment choices to ensure both maternal and foetal well-being.

A 32-year-old G1P0 female presented with a rapidly growing swelling in her right axilla. Ultrasound-guided core needle biopsy revealed a high-grade pleomorphic malignant tumour. The dilemmas and choices weighing the risks of staging studies, risks of contrast-enhanced scans, surgery during pregnancy and pre- and post-operative radiotherapy to both the mother and foetus are discussed in this case report

Decision of unenhanced whole-body MRI was chosen for staging studies to mitigate radiation and contrast risks to the foetus and mother. Imaging studies revealed a 10 cm tumour in the right axilla, displacing the subclavian neurovascular structures but without evidence of metastatic disease. Concerns about pre-operative radiotherapy including proton beam radiotherapy, given risk of tumour progression and surgical challenges post-radiation therapy, a consensus decision was reached to proceed with surgical resection followed by delivery of the baby and post-operative radiotherapy. Successful limb-preserving sarcoma surgery was performed at 26 weeks of gestation. She gave birth to a healthy female child at 38 weeks of gestation, and she is receiving post-operative radiotherapy.

Sarcomas diagnosed during pregnancy are rare and delicate balance is required for optimising oncologic outcomes and minimising risks to the mother and the foetus. Decision-making involving multiple specialties and multidisciplinary teams, a treatment plan was formulated that prioritised the safety of the patient and her baby.

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy. Surgery is the mainstay of treatment, still even after a R0 surgical margins, there is a high risk of recurrence.

A 26-year-old female diagnosed with a large functioning ACC treated with a trimodality approach (surgery, radiotherapy and chemotherapy). Postoperative radiotherapy was proposed regarding the high risk of recurrence. A dose of 50.4 Gy in 28 fractions was delivered to the patient using a volumetric-modulated arc therapy plan. Radiotherapy was safe and well tolerated, and no local recurrence was observed so far (13 months after radiotherapy).

Due to the rarity of ACC and the lack of evidence regarding this entity, therapeutic approach can be challenging. Recent evidence suggests that radiotherapy could have an important role in the therapeutic arsenal.

Secondary oesophageal carcinoma from a breast primary is an infrequent phenomenon. Given the rarity of this presentation, there is a general lack of consensus on management guidelines.

Herein, we report a case of a 65-year-old female presented with dysphagia, 14 years post-surgery for breast cancer. She was diagnosed with oesophageal metastases and was treated with combination of systemic chemotherapy, hormonal therapy and local radiotherapy. Our patient tolerated the treatment well and achieved a significant symptomatic improvement post-radiotherapy. We also performed a review of literature on oesophageal metastases from breast primary, aiming to improve the diagnostic accuracy and treatment efficacy in this rare presentation.

We conclude that patients who present with persistent dysphagia post-breast cancer treatment should undergo an endoscopic ultrasound (EUS)-guided fine-needle biopsy (FNB) to rule out oesophageal metastasis. We suggest systemic chemotherapy with hormonal therapy and radiotherapy for local control as a management of choice in this condition. Even though prognosis is difficult to predict in these patients, this combined modality of treatment seems to achieve better overall survival.

An astroblastoma is a rare primary glial tumour occurring preferentially in young adults. It is characterised by a perivascular arrangement of tumour cells forming perivascular pseudorosettes mimicking ependymomas. The histogenesis of astroblastoma is unclear.

We present the history of a 13-year-old girl with chief complaints of headache associated with vomiting, blurring of vision on the left eye and a history of diplopia on the right eye. She underwent left parietal parasagittal craniotomy and near-total excision of tumour. She was planned for postoperative radiotherapy 5,940 cGy in 28 fractions along with concurrent temozolamide100 mg. She had no neurological deficit or complaints during her last visit.

Astroblastomas are a distinct clinic pathologic entity, with well-described radiologic, pathologic and cytogenetic features. Its recurrence is high, and efforts must be made to elucidate the role and usefulness of radiotherapy and chemotherapy in these tumours.

Myositis ossificans (MO) is a rare disorder of ectopic ossification in soft tissue or muscle, usually associated with trauma or hereditary conditions. Surgical excision is the mainstay of treatment with anti-inflammatory medications. Radiotherapy is used as an adjuvant therapy, to treat residual lesions and to relieve symptoms.

A 36-year-old male presented with a localised tender swelling in left popliteal fossa and progressive pain in lower limb for 6 weeks and restricted mobility for 3 weeks. A local excision of calcified mass arising from fascia of left popliteal fossa was consistent with MO features. Due to persistent symptoms and a residual lesion on imaging, adjuvant external beam radiation therapy (EBRT) was planned with a low dose of 10 Gy (Gray) in 2 fractions on 2 consecutive days in a prone position after 2 weeks using 6 MV (mega voltage) photon beam on linear accelerator (LINAC).

Radiotherapy resulted in a significant clinical improvement without any related acute toxicities. Patient is disease-free and on regular follow-up without any progression after 2 years.

Post-operative EBRT can stabilise residual MO and treat intractable pain when lesion lies in the vicinity of a neurovascular bundle

Cancer during pregnancy has an incidence of 1/1,000, and when diagnosed, the most common ones are breast cancer (1/10,000), Hodgkin’s lymphoma (1/6,000), and head and neck cancer (1/10,000). If a diagnosis is made during pregnancy, the treatment cannot wait until delivery, and there is concern about the effects that radiotherapy may have on the foetus. The multidisciplinary group has to assess and ethically make decisions with regard to the mother and foetus.

A 35-year-old female, a carrier of Behcet’s disease, underwent 5 years of treatment with hydroxychloroquine, prednisone and low-molecular-weight heparin (the patient being a carrier of Behcet’s disease, there is a high risk for cancer of the oral cavity and oropharynx with an HR of 2·11, so the cancer could be related to the tonsil). The patient’s oncological situation started on December 2017 with a volume increase in preauricular, parotid and right mandibular angle, with a progressive growth. At this time, the foetus was of 17·5 weeks of gestation. An oral cavity tumour that invaded the right retromolar triangle was observed, and upon biopsy, a basaloid squamous cell carcinoma was diagnosed.

Radiotherapy treatment was started at 22 weeks of gestation; intensity-modulated radiation therapy (IMRT) was planned with a dose of 69·96 Gy to the primary tumour and 59·4 Gy to ganglion levels II, III and IV, bilaterally in 33 fractions. At fraction 27 a significant decrease in tumour volume was noted, so adaptive radiotherapy was performed to complete the treatment. Currently the patient has no clinical evidence of tumour pathology.

The risk of radiation exposure in pregnant women (after 20 weeks of gestation), being treated for cancers of the tonsil, reaching the foetus is minimal, with a reduced risk of a few or no effects.

Radiotherapy in tonsil cancer has been shown to be effective in combination with chemotherapy for local control of the disease. In the case of this pregnant patient, radiotherapy, as the only modality, provided local control and little exposure of radiation to the foetus.

Orbital metastases lead to many distressful symptoms.

A case-report of a 44-year-old woman with a melanoma metastasis in the orbital cavity, is reported. A patient presented with headache, proptosis and diplopia. The stereotactic radiotherapy of 19.5 Gy in three fractions using CyberKnife was performed. Follow-up examination 7 months later revealed satisfactory local control of the tumour, alleviation of orbital symptoms with no negative impact on visual function.

Stereotactic radiotherapy seems to be a safe and effective treatment of orbital metastases from melanoma.

Histiocystic sarcoma is a rare, but aggressive tumour that often involves extranodal sites. Histiocystic sarcoma is recognised by the World Health Organization as one of six subtypes of dendritic cell neoplasms. Diagnosis is difficult due to overlapping immunohistochemistry with other dendritic cell neoplasms. The optimal roles for chemotherapy, radiotherapy and surgery in the treatment of histiocytic sarcoma remain unknown.

We report a case of a patient with histiocytic sarcoma diagnosed after excisional biopsy and immunohistochemistry testing.

The patient underwent external beam radiation therapy (EBRT). After 18 Gray (Gy), the 8 cm lesion had regressed to ~5 cm in diameter. The treatments were continued to a total dose of 45 Gy with the lesion regressing to less than a centimeter by the end of treatment. Local control was maintained but the patient died of acute myelogenous leukemia 5 months after her treatment.

This case suggests that histicytic sarcomas can be controlled locally with EBRT.

Success with acupuncture-like transcutaneous nerve stimulation (ALTENS) in the treatment of radiation-induced xerostomia has not been reported after an extended time.

We report a case of successful ALTENS therapy 5 years after radiation treatment.

The patient discontinued treatments in a second course due to complete resolution of symptoms.

This case report demonstrates a potential for offering ALTENS to those long suffering from radiation-induced xerostomia.

Choroidal metastases are the most frequent intraocular secondary tumours, with a prevalence of 2–7% according to the literature. Our aim was to review a clinical case of choroidal metastasis.

We present a case of a 63-year-old male patient diagnosed in 2018 with lung adenocarcinoma cT4N0M1. The patient had three metastases in the brain, which were successfully treated with radiosurgery (RS). The patient was treated with chemotherapy with pemetrexed–cisplatin schedule. Five months after diagnosis, the patient presented with decreased vision in the right eye. After ophthalmologic evaluation, he was diagnosed with a right choroidal metastasis, which was treated with external beam radiotherapy with 20 Gy in five fractions, resulting in improved visual acuity and a complete clinical and radiological response.

The patient took part in a clinical trial that continued with systemic chemotherapy. Twenty-two months after radiotherapy to the eye, the patient has good visual acuity without any side effects.

Choroidal metastasis treated with radiotherapy achieves good local control, with limited side effects, allowing an improvement in visual acuity and consequently, an improvement in the patient´s quality of life.

Accupuncture-like transcutaneous electrical nerve stimulation (ALTENS) therapy has been shown in prospective studies to be effective in the treatment of radiation-induced xerostomia. Those studies treated patients within 27 months from end of radiation with ALTENS delivered in the clinic using a Codetron unit. However, that unit is no longer produced and there is limited data on success of ALTENS when delivered at home.

A 50-year old man with xerostomia, 8 years post-radiation for T4N1 squamous cell carcinoma of the tonsillar fossa, was given ALTENS with a currently commercially available unit from Girish Surgical. He used the unit at home, 20 minutes daily for 8 weeks.

After 8 weeks of ALTENS therapy the patient saw a reduction in the Self-Reported University of Michigan Xerostomia-Related Quality of Life Scale from 20 to 1.

This case report demonstrates (1) the Girish Surgical unit is effective, (2) self-administration of ALTENS in patients who cannot come to clinic regularly may be practical and (3) ALTENS can still offer durable benefit to patients even 8 years after chemoradiation therapy.

Metastasis to the thyroid gland is a rare event.

We describe an unusual case of a 38-year-old woman with a history of small-cell lung cancer (SCLC), presenting with a new nodule in the thyroid gland, found to be metastatic SCLC, without evidence of widespread dissemination.

A new thyroid nodule should be carefully evaluated for metastasis in a patient with a history of prior malignancy.

Imaging protocols are implemented to identify and minimise set-up errors. A crucial component to the success of these protocols is staff compliance.

This is case report describing a retrospective review of radiation therapists’ compliance to a palliative imaging protocol in a single large institution in one calendar year.

The review showed a non-compliance to protocol for 8% of treatments. The most frequent protocol deviation was a failure to calculate the mean set-up displacement after 2/3 days of consecutive imaging.

Despite the presence of institutional evidence-based palliative imaging protocol unwanted deviations in practice can occur.

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.

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.

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.

Proliferating trichilemmal tumour (PTT) is a benign tumour originating from the outer root sheath of a hair follicle. In rare instances, malignant transformation has been reported, evidenced by regional or distant metastases. Malignant transformation of PTT is often confused with squamous cell carcinoma. PTT usually occur as a solitary lesion on the scalp. It was first described as a proliferating epidermoid cyst by Wilson-Jones in 1966.

A female patient presented with a growing lesion on scalp in the right parietal region. She had already undergone excision for the same 8 months ago. The cyst was surgically removed and scalp was treated with electron therapy using a field dimension of 8×8 cm in 2011. Now, the patient is disease free with good quality of life.

Oncologists can consider electron therapy in management of PTT. This can improve cosmesis and quality of life of these patients.

Radiation-induced malignancies are a rare phenomenon. Post-radiation sarcoma accounts for 0·5–5·5% of all sarcomas. Adjuvant radiotherapy (RT) after surgery plays a significant role in the treatment of breast cancer. Sarcomas of the breast, chest wall, sternum, axilla or supraclavicular region have been reported as a rare complication of RT for breast cancer. Osteosarcoma (OS) of the sternal bone is a rarely reported entity. OS of the sternum secondary to therapeutic ionising radiation is an even rarer diagnosis, and no such cases have been reported in India as per our literature search. Here we report such a case of post-radiation sarcoma after breast cancer treatment—OS presenting in the sternum and both the second ribs in a young lady.

Our patient developed a sarcoma within a previously irradiated field. The latent period was 7·5 years. She initially suffered from a breast carcinoma for which she underwent radical surgery in the form of modified radical mastectomy. She also received 50 Gy RT dose to the chest wall and axilla. She subsequently developed an OS of chest wall in the high-dose region of RT. Another key factor is the high possibility of familial/hereditary cancer inheritance syndrome like Li-Fraumeni in our patient. Though she was never tested for p53 mutations, her young age at first diagnosis (26 years), extremely strong positive family history and spectra of cancers affecting her first-degree blood relatives (brain tumours, leukaemia) strongly hint at the possibility of such a cancer syndrome. Retrospectively, the question certainly arises, given her young age and family history, whether this patient was a right candidate for RT even once as compared to the fact that she received radiation twice.

Jugulotympanic glomus tumours (JTGT) are highly vascular neoplasms composed of paraganglionic tissue of neural crest origin. Because of the neoplasm’s slow growth potential, any claimed efficacy associated with applied treatment must be supported by long-term effects observed in patients.

This report presents a case of advanced stage JTGT in a 66-year-old woman treated by γ knife radiosurgery (GKRS).

Sustained tumour control with preservation of lower cranial nerve function was observed for more than 10 years after completion of treatment.

GKRS even with large intracranial extension of JTGT in patients may help to achieve long-term disease control with minimal morbidity.

Nasopharyngeal carcinoma (NPC) is a prevalent disease in Southern China. Radiation therapy remains the primary treatment modality for NPC due to its high radiation sensitivity. Conventional volumetric-modulated arc therapy (VMAT) can achieve excellent target volume coverage and superior conformal dose distributions while sparing organs at risk (OARs). However, VMAT may also produce substantial volume of low-dose region in the surrounding normal tissue. Our oncology centre has incorporated the concept of anterior cervical field with VMAT in clinical practice of NPC treatment planning. The purpose of this treatment-comparison case study is to demonstrate the lower neck OARs sparing ability of hybrid volumetric-modulated arc therapy (hybrid-VMAT) over conventional VMAT for NPC.

Four patients diagnosed with NPC of different clinical lymph node staging (N staging) were enrolled for this treatment-comparison case study. Planning target volumes and OARs were delineated with reference to Radiation Therapy Oncology Group (RTOG) 0225/0615. Additional OARs from lower neck region, including thyroid, trachea, cervical spine and pharyngeal constrictor muscles (PCMs), were also delineated. Two treatment techniques, hybrid-VMAT and VMAT, were created for each patient’s dataset.

Both treatment techniques produced adequate target coverage and reduced radiation dose to the OARs as suggested in RTOG 0225/0615. Hybrid-VMAT plans achieved superior dose reduction in larynx, oesophagus, middle PCM, inferior PCM, cervical spine and trachea comparing with VMAT plans. Hence, the clinical usability and functional outcome of hybrid-VMAT should be further investigated for NPC radiation therapy.