• Publications & Outcomes

Robustly optimized hybrid intensity modulated proton therapy for craniospinal irradiation

Manthala Padannayil Noufal, Shamurailatpam Dayananda Sharma, Ganapathy Krishnan, Mayur Sawant, Utpal Gaikwad, Rakesh Jalali.
J Can Res Ther 2021 DOI: 10.4103/jcrt.JCRT_740_20

Dosimetric impact of random spot positioning errors in intensity modulated proton therapy plans of small and large volume tumors.

Arjunan M, Krishnan G, Sharma D S, M P Noufal, Patro KC, Thiyagarajan R, et al.
Br J Radiol 2021; 94: 20201031. https://doi.org/10.1259/bjr.20201031

A novel hybrid 3D dose reconstruction approach for pre-treatment verification of intensity modulated proton therapy plans.

Manikandan Arjunan, Dayananda Shamurailatpam Sharma, Suryakant Kaushik, Ganapathy Krishnan, Kartikeshwar C Patro, Noufal Mandala Padanthaiyil, T Rajesh and R Jalali.
Phys. Med. Biol. 66 (2021) 055015. https://doi.org/10.1088/1361-6560/abdd8b

The Role of Plan Robustness Evaluation in Comparing Protons and Photons Plans - An Application on IMPT and IMRT Plans in Skull Base Chordomas.

Manthala Padannayil Noufal, Lamberto Widesott, Shamurailatpam Dayananda Sharma, Roberto Righetto, Marco Cianchetti, Marco Schwarz.
Journal of Medical Physics. 45 (2021) 206-214 https://10.4103/jmp.JMP_45_20

Investigating the utilization of beam-specific apertures for the intensity-modulated proton therapy (IMPT) head and neck cancer plans.

Rana S, Storey M, Manthala Padannayil Noufal, Shamurailatpam D S, Bennouna J, George J, Chang J.
Med Dosim. 2020 Nov 24:S0958-3947(20)30155-2. doi: 10.1016/j.meddos.2020.10.006.

Book review “Proton Therapy Physics” 2nd edition

Dayananda Shamurailatpam Sharma
J Med Phys 2020;45:195-6. doi:10.4103/jmp.JMP_86_20

Characterization and Performance Evaluation of the First-Proton Therapy Facility in India

Shamurailatpam D S, Manikandan A, Ganapathy K, Noufal MP, Patro KC, Rajesh T, Jalali R
J Med Phys. 2020 Apr-Jun;45 (2):59-65. doi: 10.4103/jmp.JMP_12_20.

Leaf open time sinogram (LOTS): a novel approach for patient specific quality assurance of total marrow irradiation.

Thiyagarajan R, Sharma D S, Kaushik S, Sawant M, Ganapathy K, Nambi Raj NA, Chilukuri S, Sundar SC, Patro KC, Manikandan A, Noufal MP, Sivaraman R, Easow J, Jalali R.
Radiat Oncol. 2020 Oct 14;15(1):236. doi: 10.1186/s13014-020-01669-2.

Introduction of Image-Guided Pencil Beam for Skull Base Tumors in India: A Report of Two Cases and a Brief Review of the Literature.

Tonse R, Chilikuri S, Shamurailatpam D, Jalali R.
Neurol India. Jan-Feb 2020;68(1):42-44. doi: 10.4103/0028-3886.279680

Preliminary Experience of Treating Children and Young Adults With Image-Guided Proton Beam Therapy in India.

Chilukuri S, Burela N, Uppuluri R, Indumathi D, Nangia S, Panda PK, Shamurailatpam DS, Raj R, Raja T, Jalali R.
JCO Glob Oncol. 2020 Nov; 6:1736-1745. doi: 10.1200/GO.20.00319.

Total marrow and lymphoid irradiation with helical tomotherapy: A practical implementation report.

Srinivas Chilukuri, Sham Sundar, Rajesh Thiyagarajan, Jose Easow, Mayur Sawant, Ganapathy Krishnan, Pankaj Kumar Panda, Dayananda Sharma, Rakesh Jalali.
Radiat Oncol J 2020;38(3):207-216. doi.org/10.3857/roj.2020.00528

Ambient neutron and photon dose equivalent H*(10) around a pencil beam scanning proton therapy facility.

Sharma D S, Patro KC, Manthala Padannayel N, Arjunan M, Krishnan G, Thiyagarajan R, Chilukuri S, Jalali R.
Br J Radiol. 2019 Oct; 92 (1102):20190382. doi: 10.1259/bjr.20190382.

Preliminary Experience of Treating Children and Young Adults With Image-Guided Proton Beam Therapy in India

Srinivas Chilukuri, MD, MBBS, Nagarjuna Burela, MD, Ramya Uppuluri, MD, D. Indumathi, Sapna Nangia, Pankaj Kumar Panda, BDS, Dayananda Sharma Shamurailatpam, Revathi Raj, DCH, MRCP, Thirumalai Raja, MD, and Rakesh Jalali, MD

ISNO Position Statement on Treatment Guidance in Neuro-oncology During Pandemics.

Gupta T, Singh VP, Balasubramian A, Menon H, Kurkure PA, Kumar S, Jalali R.
Neurol India. 2020 Jul-Aug;68(4):769-773. doi: 10.4103/0028-3886.293460. PMID: 32859812.


The entire world including India is currently fighting the coronavirus disease 19 (COVID-19) pandemic that threatens to disrupt healthcare systems globally in terms of capacity and resources. This outbreak necessitates an urgent review of existing management guidelines for commonly encountered tumors of the brain and central nervous system (CNS). Such a review should include a reassessment of benefit-risk ratio to align with local, national, and international priorities without compromising on delivery of care in terms of safety, compassion, efficiency, and effectiveness. Towards this end, the Indian Society of Neuro-Oncology (ISNO) constituted an online expert panel with adequate representation from all major treatment modalities (neuro-surgery, radiation oncology, and pediatric/medical oncology) to formulate a “COVID-19 context” position statement to guide the care of neuro-oncology patients during the ongoing crisis.

The ISNO position statement suggests graded prioritization (based on clinical presentation, type of tumor, expected prognosis, and relevance of immediate therapy) for efficient utilization of resources and provides a framework through a set of general considerations, treatment modality-based considerations, and disease-specific considerations for the guidance of healthcare professionals involved in the delivery of care and services to patients with CNS tumors. The views expressed herein represent the current consensus of key opinion leaders from within the Indian neuro-oncology community and should not be in any case considered binding medically or legally to individual physicians and/or hospitals who may formulate their guidelines based on local setup and health-environment and update them periodically based on emerging evidence through the COVID-19 pandemic.

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Reassuring quality of life in younger childhood (4 years) brain tumor survivors treated with proton beam therapy.

Chilukuri S, Jalali R.
Neuro Oncol. 2020;noaa173. doi:10.1093/neuonc/noaa173


Treatment outcomes for brain tumors affecting the very young have been traditionally associated with poor outcomes.1 For children younger than 6 years, there has been a strong thrust to choose relatively intensive and prolonged systemic therapy regimens to delay and/or avoid radiation therapy. Most of these attempts, however, have failed to establish standard of care. Current Children’s Oncology Group (COG) protocols for ependymoma and atypical teratoidrhabdoidtumor (ATRT) have incorporated a cutoff age limit for immediate postoperative focal radiation of 6 months of age for infratentorial lesions and 12 months for supratentorial lesions.2 And yet for children less than 3 years old,...

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An Insight Into Pharyngeal Closure Techniques During A Laryngectomy-Can We Minimize Pharyngocutaneous Fistulas? I. Pharyngocutaneous Fistula (PCF) -Incidence, Risk Factors and Prognostication.

Kadapathri A, Munnangi A, Hedne N, Mohiyuddin S, Pillai V, Shetty S, Narayana S
IOSR Journal of Dental and Medical Sciences. 35-39. DOI: 10.9790/0853-1906163539


In this age of chemoradiation for carcinoma of laryngopharynx, post-operative pharyngocutaneous fistula (PCF) is has become quite common. It results in significant morbidity and prolonged patient stay. Although conservative management is the mainstay of its treatment, it causes tremendous psychological impact on the patient due to repeated visits to hospital, in ability to take oral feeds, social stigma because of neck wound. We have explored literature to present various risk factors associated with this complication and how to treat it. The technique of pharyngeal closure during a laryngectomy surgery has an important role in preventing a pharyngocutaneous fistula. All surgeons dealing with laryngopharyngeal malignancies need to know the available evidence and described techniques in literature to minimize the incidence of post-operative fistulae. We present to you an extensive literature review regarding pharyngoplasty techniques.

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Characterization and Performance Evaluation of the First-Proton Therapy Facility in India.

Shamurailatpam DS, Manikandan A, Ganapathy K, Noufal MP, Patro KC, Rajesh T, Jalali R. J Med
Phys. 2020;45(2):59-65. doi:10.4103/jmp.JMP_12_20


Purpose: The purpose of this study is to evaluate the performance characteristic of volumetric image-guided dedicated-nozzle pencil beam-scanning Proton therapy (PT) system.

Materials and methods: PT system was characterized for electromechanical, image quality, and registration accuracy. Proton beam of 70.2-226.2 MeV was characterized for short- and long-term reproducibility in integrated depth dose; spot profile characteristics at different air gap and gantry angle; positioning accuracy of single and pattern of spot; dose linearity, reproducibility and consistency. All measurements were carried out using various X-ray and proton-beam specific detectors following standard protocols.

Results: All electro-mechanical, imaging, and safety parameters performed well within the specified tolerance limit. The image registration errors along three translation and three rotational axes were ≤0.5 mm and ≤0.2° for both point-based and intensity-based auto-registration. Distal range (R90) and distal dose fall-off (DDF) of 70.2-226.2 MeV proton beams were within 1 mm of calculated values based on the international commission on radiation units and measurements 49 and 0.0156× R90, respectively. The R90 and DDF were reproducible within a standard deviation of 0.05 g/cm2 during the first 8 months. Dose were linear from 18.5 (0.011 MU/spot) to 8405 (5 MU/spot) MU, reproducible within 0.5% in 5 consecutive days and consistent within 0.8% for full rotation. The cGy/MU for 70.2-226.2MeV was consistent within 0.5%. In-air X(Y) spot-sigma at isocenter varies from 2.96 (3.00) mm to 6.68 (6.52) mm for 70.2-226.2 MeV. Maximum variation of spot-sigma with air-gap of ±20 cm was ±0.36 mm (5.28%) and ±0.82 mm (±12.5%) along X- and Y-direction and 3.56% for full rotation. Relative spot positions were accurate within ±0.6 mm. The planned and delivered spot pattern of known complex geometry agreed with (γ%≤1) for 1% @ 1 mm >98% for representative five-proton energies at four gantry angle.

Conclusion: The PT-system performed well within the expected accuracy level and consistent over a period of 8 months. The methodology and data presented here may help upcoming modern PT center during their crucial phase of commissioning.

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Memantine for Prevention of Brain Irradiation-Induced Cognitive Toxicity: A Tale of an Underappreciated and Underused Intervention.

Chilukuri S, Burela N.
JCO Glob Oncol. 2020 Sep;6:1384-1388. doi: 10.1200/GO.20.00342. PMID: 32926643.

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Total marrow and lymphoid irradiation with helical tomotherapy: a practical implementation report.

ChilukuriS, Sundar S,Thiyagarajan R,Easow J,Sawant M, Krishanan G, Panda PK, Sharma D, JalaliR


Objective: To standardize the technique; evaluate resources requirements and analyze our early experience of total marrow and lymphoid irradiation (TMLI) as part of the conditioning regimen before allogenic bone marrow transplantation using helical tomotherapy.

Methods: Computed tomography (CT) scanning and treatment were performed in head first supine (HFS) and feet first supine (FFS) orientations with an overlap at mid-thigh. Patients along with the immobilization device were manually rotated by 180° to change the orientation after the delivery of HFS plan. The dose at the junction was contributed by a complementary dose gradient from each of the plans. Plan was to deliver 95% of 12 Gy to 98% of clinical target volume with dose heterogeneity 10% and pre-specified organs-at-risk dose constraints. Megavoltage-CT was used for position verification before each fraction. Patient specific quality assurance and in vivo film dosimetry to verify junction dose were performed in all patients.

Results: Treatment was delivered in two daily fractions of 2 Gy each for 3 days with at least 8-hour gap between each fraction. The target coverage goals were met in all the patients. The average person-hours per patient were 16.5, 21.5, and 25.75 for radiation oncologist, radiation therapist, and medical physicist, respectively. Average in-room time per patient was 9.25 hours with an average beam-on time of 3.32 hours for all the 6 fractions.

Conclusion: This report comprehensively describes technique and resource requirements for TMLI and would serve as a practical guide for departments keen to start this service. Despite being time and labor intensive, it can be implemented safely and robustly.

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Empirical 188Re-HDD/lipiodol intra-arterial therapy based on tumor volume, in patients with solitary inoperable hepatocellular carcinoma.

Shinto, AjitSugunan; Karuppusamy, Kamaleshwaran K.; Kurup, Radhakrishnan E.R.; Pandiyan, Arun; Jayaraj, Arnold V.
Nuclear Medicine Communications: September 21, 2020 - Volume Publish Ahead of Print - Issue - doi: 10.1097/MNM.0000000000001296


Objective: This study aimed to assess the potential benefits and tolerability of an empirical dose of approximately 0.8–1.2 mCi (29.6–44.4 MBq) of 188Re-4-hexadecyl-1-2,9,9-tetramethyl-4,7-diaza-1,10-decanethiol/lipiodol (188Re-HDD/lipiodol) per milliliter of tumor volume, administered after super-selection of the tumor feeding branches of hepatic artery for treatment of inoperable hepatocellular carcinoma (HCC).

Methods: Patients with advanced HCC or classified as inoperable, with no demonstrated extrahepatic disease and no significant comorbidities were eligible. The patients selected for this study had a single tumoral lesion, measuring less than 150 cc. The range of total activity administered was between 30 and 100 mCi (1.2–3.7) GBq 188Re-HDD/lipiodol, administered in the super selected branches of the hepatic artery supplying the tumor in 42 Patients. Whole-body scintigraphies and single-photon emission computed tomography-computed tomography (SPECT-CT) of the liver including tumor were performed at four-time points after injection. Absorbed doses to the various organs were calculated according to the Medical Internal Radiation Dose formalism. Blood and urine samples were collected at multiple time points until 72 h after injection. Hematological, hepatic and pulmonary toxicity was assessed until 12 weeks after administration using the Common Toxicity Criteria for Adverse Events (version 3.0) scale. Responses were evaluated on contrast enhanced computed tomography (CECT) and by alfa-fetoprotein (AFP) level monitoring.

Results: About 40.6 ± 4.8% of the injected activity was excreted in the urine by 72 h after injection. The mean absorbed dose to the liver, lungs, stomach, kidney and intestine was 14.4 ± 1.8, 4.8 ± 0.6, 5.5 ± 1.1, 5.1 ± 0.7, and 6.5 ± 1.0 Gy (mean ± SD), respectively. Up to 6 days after administration, 26 of 44 patients had adverse events consisting of aggravations of preexisting laboratory changes (24 patients), fatigue (5 patients), vomiting (6 patients), fever (2 patients), right hypochondrial pain (8 patients), and pain at site of femoral catheter insertion (8 patients). Toxicity assessment at weeks 6 and 12 revealed two cases of mild worsening of liver function tests and no lung or hematological toxicity noted. Two patients were lost to follow-up after the 6-week visit. The response was assessed on CECT in all the remaining patients and the classification of results was more standardized when using European Association for the Study of the Liver (EASL) criteria rather than response evaluation criteria in solid tumors (RECIST) criteria. According to EASL criteria, 8 patients had a partial response, 28 patients had a complete response, 4 patients had progressive disease and 4 patients with stable disease were reported. Thirty-six patients had a baseline elevated AFP and on follow-up at 6 weeks, 6 of these patients showed stable AFP, progression in 4 patients and 26 showed a reduction.

Conclusion: After the administration of 1.2–3.7 GBq 188Re-HDD/lipiodol based on empirical activity calculation of 0.8–1.2 mCi/mL of tumor volume, more than half of the patients in the present study had an objective response on imaging and biochemically. No significant adverse side effects were noted and most of the laboratory markers as well as symptoms returned to normal after 48–72 h post-administration. Selective administration of the radiopharmaceutical into the tumor feeding arteries gives a good anti-tumoral effect with minimal side effects and damage to surrounding normal liver tissue.

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Implementing an intensive care registry in India: preliminary results of the case-mix program and an opportunity for quality improvement and research.

Neill K. J. Adhikari, RajeshwariArali, UdaraAttanayake, ………Raymond Dominic Savio et al.
Wellcome Open Research 2020; 5:182. (https://doi.org/10.12688/wellcomeopenres.16152.1)


Background: The epidemiology of critical illness in India is distinct from high-income countries. However, limited data exist on resource availability, staffing patterns, case-mix and outcomes from critical illness. Critical care registries, by enabling a continual evaluation of service provision, epidemiology, resource availability and quality, can bridge these gaps in information. In January 2019, we established the Indian Registry of Intensive care to map capacity and describe case-mix and outcomes. In this report, we describe the implementation process, preliminary results, opportunities for improvement, challenges and future directions.

Methods: All adult and paediatric ICUs in India were eligible to join if they committed to entering data for ICU admissions. Data are collected by a designated representative through the electronic data collection platform of the registry. IRIS hosts data on a secure cloud-based server and access to the data is restricted to designated personnel and is protected with standard firewall and a valid secure socket layer (SSL) certificate. Each participating ICU owns and has access to its own data. All participating units have access to de-identified network-wide aggregate data which enables benchmarking and comparison.

Results: The registry currently includes 14 adult and 1 paediatric ICU in the network (232 adult ICU beds and 9 paediatric ICU beds). There have been 8721 patient encounters with a mean age of 56.9 (SD 18.9); 61.4% of patients were male and admissions to participating ICUs were predominantly unplanned (87.5%). At admission, most patients (61.5%) received antibiotics, 17.3% needed vasopressors, and 23.7% were mechanically ventilated. Mortality for the entire cohort was 9%. Data availability for demographics, clinical parameters, and indicators of admission severity was greater than 95%.

Conclusion: IRIS represents a successful model for the continual evaluation of critical illness epidemiology in India and provides a framework for the deployment of multi-centre quality improvement and context-relevant clinical research.

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Basic Critical Care for Management of COVID-19 Patients: Position Paper of Indian Society of Critical Care Medicine, Part II.

Deven Juneja, Raymond Dominic Savio et al.
Indian J. of Critical Care Medicine 2020; https://www.ijccm.org/ doi/IJCCM/pdf/10.5005/jp-journals-10071-23593.

Winning over Cancer with Apollo Proton Cancer Centre

The growing burden of cancer across the globe tells an ominous tale. To counter this growing threat, Apollo Hospitals introduces Proton Beam therapy with focused cancer management teams that will provide optimal solutions like never before. We believe it is critical to redefine our purpose, to reboot our commitment on the single-minded focus to win over cancer. APCC stands as a ray of hope for millions of patients as they join us in the battle to win over cancer.