PURPOSE To evaluate and report the frequency of changes in radiation therapy treatment plans after peer review in a simulation review meeting once a week. MATERIALS AND METHODS Between July 1 and August 31, 2016, the radiation plans of 116 patients were discussed in departmental simulation review meetings. All plans were finalized by the primary radiation oncologist before presenting them in the meeting. A team of radiation oncologists reviewed each plan, and their suggestions were documented as no change, major change, minor change, or missing contour. Changes were further classified as changes in clinical target volume, treatment field, or dose. All recommendations were stratified on the basis of treatment intent, site, and technique. Data were analyzed by Statistical Package for the Social Sciences and are presented descriptively. RESULTS Out of 116 plans, 26 (22.4%) were recommended for changes. Minor changes were suggested in 15 treatment plans (12.9%) and a major change in 10 (8.6%), and only one plan was suggested for missing contour. The frequency of change recommendations was greater in radical radiation plans than in palliative plans (92.3% v 7.7%). The head and neck was the most common treatment site recommended for any changes (42.3%). Most of the changes were recommended in the technique planned with three-dimensional conformal radiation therapy (50%). Clinical target volume (73.1%) was identified as the most frequent parameter suggested for any change, followed by treatment field (19.2%) and dose (0.08%). CONCLUSION Peer review is an important tool that can be used to overcome deficiencies in radiation treatment plans, with a goal of improved and individualized patient care. Our study reports changes in up to a quarter of radiotherapy plans.

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Cerebral metastasis as an initial clinical presentation of prostate carcinoma is extremely rare. Usually, patients have widespread metastasis in the body before presenting with brain metastasis. In the absence of extensive metastasis, especially without bony metastasis, only brain metastasis is an unusual presentation of the disease. We report a case of a 59-years-old patient who presented with a lack of concentration and decreased vision. Magnetic resonance imaging (MRI) of the brain revealed a large right parietal-occipital space-occupying lesion. He underwent surgery and the pathological diagnosis of the tumor turned out to be metastatic prostate carcinoma. Further evaluation by a whole-body computed tomography (CT) scan revealed an enlarged prostate with no other metastatic deposit and a mildly raised level of prostate-specific antigen (PSA). It was possible for us to provide this patient with multi-modality treatment with the help of multidisciplinary tumor board meetings. Further studies addressing the biological as well as clinical characteristics of prostate carcinoma with this rare metastatic presentation will help us to define prognostic factors and therapeutic intervention and will help us to understand the basis of this unique presentation without bone metastasis.

SUMMARYA 49-year-old man with a history of left nasal discharge and nasal cavity blockage for 5 months was diagnosed with sino-nasal mucosal malignant melanoma on nasal biopsy. On CT scan, the tumour involved the nasal cavity, left maxillary sinus, ethmoid sinus and medial left orbit. The tumour was grossly excised and adjuvant radiation therapy was offered. The patient was planned for an Intensity Modulated Radiotherapy technique to keep tolerance doses of organs at risk within normal limits and at same time deliver the intended dose of radiation to the tumour site, using 66 Gy in 33 fractions. Owing to the anatomical complexity of the sino-nasal region, precision radiotherapy (RT) is mandatory to optimally irradiate the tumour area while sparing critical surrounding normal structures from late toxicity of RT. Established dose constraints for at-risk organs can only be accomplished through this novel technique of RT. However, despite advances in techniques, current treatment modalities have not significantly made an impact on survival of these patients. BACKGROUND

Background: There is an ongoing debate on the optimal sequencing of androgen deprivation therapy (ADT) and radiotherapy (RT) in patients with localized prostate cancer (PCa). Recent data favors concurrent ADT and RT over the neoadjuvant approach. Methods: We conducted a systematic review in PubMed, EMBASE, and Cochrane Databases assessing the combination and optimal sequencing of ADT and RT for Intermediate-Risk (IR) and High-Risk (HR) PCa. Findings: Twenty randomized control trials, one abstract, one individual patient data meta-analysis, and two retrospective studies were selected. HR PCa patients had improved survival outcomes with RT and ADT, particularly when a long-course Neoadjuvant-Concurrent-Adjuvant ADT was used. This benefit was seen in IR PCa when adding short-course ADT, although less consistently. The best available evidence indicates that concurrent over neoadjuvant sequencing is associated with better metastases-free survival at 15 years. Although most patients had IR PCa, HR participants may have been undertreated with short-course ADT and the absence of pelvic RT. Conversely, retrospective data suggests a survival benefit when using the neoadjuvant approach in HR PCa patients. Interpretation: The available literature supports concurrent ADT and RT initiation for IR PCa. Neoadjuvant-concurrent-adjuvant sequencing should remain the standard approach for HR PCa and is an option for IR PCa.

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