Factors influencing cosmetic outcome in breast conservation.

With more than 1 million new cases each year, female breast cancer is the second most common cancer in the world and the most common cancer among women. Breast cancer involves a multimodality treatment and a co-ordinated approach from various specialties. Breast-conserving therapy (BCT) is increasingly being integrated into the management of breast cancer. The obvious advantages of BCT are equivalent local and distant control rates as compared with mastectomy and the preservation of the breast. However, the key to a successful BCT is achieving a cosmetic outcome that is acceptable to the patient and the physician. Cosmesis in breast cancer is the end result of a range of factors that fall under the broad heads of surgery, radiotherapy, chemotherapy and hormonal treatment. All of these modalities can play a role in compromising breast cosmesis. This overview discusses the factors that are critical in affecting the final cosmetic outcome in patients with BCT.

Non-Hodgkin's lymphoma of Waldeyer's ring in children: outcome using chemotherapy and involved field radiotherapy.

AIM: To evaluate the prognostic factors and treatment outcome of children with non-Hodgkin's lymphoma (NHL) of Waldeyer's ring treated at a single institution. MATERIALS AND METHODS: Thirty-two children with NHL of Waldeyer's ring treated at our institute between January 1990 and December 2001 were included in this analysis. The median age at presentation was 14 years, and most of the patients (87%) were boys. The most common histological subtype was diffuse large B-cell lymphoma (75%), 25% patients had stage I and 75% had stage II disease. Treatment comprised a combination of chemotherapy and radiotherapy in most of the patients (75%). Among these patients, 71% received a radiotherapy dose of > or = 45 Gy. RESULTS: After a median follow-up of 45 months, the 5-year disease-free and overall survival rates were 76.5 and 83.2%, respectively. Age > 10 years (P = 0.032), bulky tumours (P = 0.001) and the presence of B-symptoms (P = 0.004) had a negative influence on disease-free survival. Patients treated with a combination of chemotherapy and radiotherapy had a better outcome than patients treated with chemotherapy alone (disease-free survival: 87.1% vs 56.2%, P = 0.056). The complete response (P = 0.003), disease-free survival (P = 0.001) and overall survival (P = 0.001) rates were significantly better for patients receiving a radiotherapy dose > or = 45 Gy. CONCLUSION: The age at diagnosis, the size of the tumour, and the presence of B-symptoms significantly influenced the outcome of children with NHL of Waldeyer's ring in this study. A combined modality treatment, comprising chemotherapy and radiotherapy, resulted in a satisfactory outcome in patients with this rare neoplasm.

Cosmesis, late sequelae and local control after breast-conserving therapy: influence of type of tumour bed boost and adjuvant chemotherapy.

AIMS: To study the influence of various factors affecting cosmetic outcome and late sequelae in a large cohort of women treated with breast-conserving therapy. MATERIALS AND METHODS: Between 1980 and 2000, 1022 pathological stage I/II breast cancer patients underwent breast-conserving therapy. On the basis of the type of tumour bed boost they received after whole breast radiotherapy, these women were assigned to three groups: (A) low dose rate (LDR) brachytherapy of 15-20 Gy (n=383); (B) high dose rate (HDR) brachytherapy of 10 Gy (optimised) in a single fraction (n=153); (C) electron beam 15 Gy/six fractions (n=460). Systemic adjuvant therapy was given to 757 women, of whom 570 received adjuvant chemotherapy. RESULTS: Cosmesis at the last follow-up was good or excellent in 77% of women. Post-radiation worsening of cosmesis was observed in 11.5% of women and was similar in the three boost groups. Moderate to severe late breast sequelae were observed in 22% of women in group B, which was significantly higher than the 12% in group A (P=0.002) and 9% in group C (P=0.0001). The actuarial 5-year local control rate was 91% and was 90, 92 and 93% in groups A, B and C, respectively. Tumour size (P=0.049) and adjuvant chemotherapy (P=0.04) were the significant factors affecting cosmetic outcome on univariate analysis. On multivariate analysis, adjuvant chemotherapy was the only factor leading to worsening in the cosmetic outcome, with P=0.03 (hazard ratio 1.65 [95% confidence interval 1.05-2.59]). CONCLUSION: The type of tumour bed boost did not have a significant effect on the worsening of cosmetic outcome. However, there were significantly more late breast sequelae in women treated with single fraction HDR implants. Chemotherapy had an adverse effect on the cosmetic outcome, but the late breast sequelae and local control rates were comparable.

Commissioning of motorized wedge for the first equinox-80 telecobalt unit and implementation in the Eclipse 3D treatment planning system.

A new model of the telecobalt unit (TCU), Theratron Equinox-80, (MDS Nordion, Canada) equipped with a single 60 degree motorized wedge (MW), four universal wedges (UW) for 15 degrees, 30 degrees, 45 degrees and 60 degrees have been evaluated. MW was commissioned in Eclipse (Varian, Palo Alto, USA) 3D treatment planning system (TPS). The profiles and central axis depth doses (CADD) were measured with Wellhofer blue water phantom for MW and the measured data was commissioned in Eclipse. These profiles and CADD for MW were compared with UW in a homogeneous phantom generated in Eclipse for various field sizes. The dose was also calculated in the same phantom at 10 cm depth. For the particular MW angle and the respective open and MW beam weights, the dose was measured for a field size of 10 cm x 10 cm in a MEDTEC water phantom at 10 cm depth with a 0.13 cc thimble ion chamber (Scanditronix Wellhofer, Uppsala, Sweden) and a NE electrometer (Nuclear Enterprises, UK). Measured dose with ion chamber was compared with the TPS calculated dose. MW angle verification was also done on the Equinox for four angles (15 degrees, 30 degrees, 45 degrees and 60 degrees). The variation in measured and calculated dose at 10 cm depth was within 2%. The measured and the calculated wedge angles were in good agreement within 2 degrees. The motorized wedges were successfully commissioned in Eclipse for four wedge angles.

Peripheral dose from uniform dynamic multileaf collimation fields: implications for sliding window intensity-modulated radiotherapy.

The increase in the number of monitor units in sliding window intensity-modulated radiotherapy, compared with conventional techniques for the same target dose, may lead to an increase in peripheral dose (PD). PD from a linear accelerator was measured for 6 MV X-ray using 0.6 cm3 ionization chamber inserted at 5 cm depth into a 35 cm x 35 cm x 105 cm plastic water phantom. Measurements were made for field sizes of 6 cm x 6 cm, 10 cm x 10 cm and 14 cm x 14 cm, shaped in both static and dynamic multileaf collimation (DMLC) mode, employing strip fields of fixed width 0.5 cm, 1.0 cm, 1.5 cm, and 2.0 cm, respectively. The effect of collimator rotation and depth of measurement on peripheral dose was investigated for 10 cm x 10 cm field. Dynamic fields require 2 to 14 times the number of monitor units than does a static open field for the same dose at the isocentre, depending on strip field width and field size. Peripheral dose resulting from dynamic fields manifests two distinct regions showing a crest and trough within 30 cm from the field edge and a steady exponential fall beyond 30 cm. All dynamic fields were found to deliver a higher PD compared with the corresponding static open fields, being highest for smallest strip field width and largest field size; also, the percentage increase observed was highest at the largest out-of-field distance. For 6 cm x 6 cm field, dynamic fields with 0.5 cm and 2 cm strip field width deliver PDs 8 and 2 times higher than that of the static open field. The corresponding factors for 14 cm x 14 cm field were 15 and 6, respectively. The factors by which PD for DMLC fields increase, relative to jaws-shaped static fields for out-of-field distance beyond 30 cm, are almost the same as the corresponding increases in the number of monitor units. Reductions of 20% and 40% in PD were observed when the measurements were done at a depth of 10 cm and 15 cm, respectively. When the multileaf collimator executes in-plane (collimator 90 degrees) motion, peripheral dose decreases by as much as a factor of 3 compared with cross-plane data. The knowledge of PD from DMLC field is necessary to estimate the increase in whole-body dose and the likelihood of radiation induced secondary malignancy.

Radical radiotherapy in head and neck squamous cell carcinoma: an analysis of prognostic and therapeutic factors.

AIMS: Head and neck squamous cell carcinoma (HNSCC) continues to be a leading cancer in developing countries. Definitive radiation therapy either primary or as postoperative adjuvant is offered to most patients. We aimed to identify prognostic and therapeutic factors that affect locoregional control and survival in patients undergoing radical radiotherapy for head and neck squamous cell cancers. MATERIALS AND METHODS: A retrospective analysis of 568 previously untreated patients with squamous head and neck cancers, who received radical radiotherapy between 1990 and 1996, using local control, locoregional control and disease-free survival (DFS) as outcome measures. RESULTS: With a median follow-up of 18 months for living patients, the 5-year local control, locoregional control and DFS for all 568 patients were 53%, 45% and 41%, respectively, for all stages combined. The 5-year local control, locoregional control and DFS as per the American Joint Committee on Cancer stage grouping were 78%, 70% and 70%; 64%, 59% and 57%; 51%, 42% and 37%; and 40%, 27% and 22% from stages I to IV, respectively, with highly significant P values. Patients receiving higher doses (> or = 66 Gy) had a significantly better outcome compared with lower doses. The 5-year local control (59% vs 48%, P = 0.0015), locoregional control (47% vs 41%; P = 0.0043) and DFS (44% vs 37%; P = 0.0099) were significantly better in patients receiving > or = 66 Gy. Site of primary also affected outcome significantly, with oral cavity lesions faring badly. CONCLUSION: Tumour stage remains the most important factor affecting outcome in radical radiotherapy of HNSCC. A definite dose-response relationship exists with higher total doses, leading to better local control, locoregional control and DFS in all stages. Site of primary affects outcome too, with laryngeal primaries doing well and oral cavity cancers faring the worst.

Consolidation radiation after complete remission in Hodgkin's disease following six cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy: is there a need?

PURPOSE: Combined modality treatment using multidrug chemotherapy (CTh) and radiotherapy (RT) is currently considered the standard of care in early stage Hodgkin's disease. Its role in advanced stages, however, continues to be debated. This study was aimed at evaluating the role of consolidation radiation in patients achieving a complete remission after six cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy using event-free survival (EFS) and overall survival (OS) as primary end points. PATIENTS AND METHODS: Two hundred and fifty-one patients with Hodgkin's disease attending the lymphoma clinic at the Tata Memorial Hospital (Mumbai, India) from 1993 to 1996 received induction chemotherapy with six cycles of ABVD after initial staging evaluation. A total of 179 of 251 patients (71%) achieved a complete remission after six cycles of ABVD chemotherapy and constituted the randomized population. Patients were randomly assigned to receive either consolidation radiation or no further therapy. RESULTS: With a median follow-up of 63 months, the 8-year EFS and OS in the CTh-alone arm were 76% and 89%, respectively, as compared with 88% and 100% in the CTh+RT arm (P =.01; P =.002). Addition of RT improved EFS and OS in patients with age < 15 years (P =.02; P =.04), B symptoms (P =.03; P =.006), advanced stage (P =.03; P =.006), and bulky disease (P =.04; P =.19). CONCLUSION: Our study suggests that the addition of consolidation radiation helps improve the EFS and OS in patients achieving a complete remission after six cycles of ABVD chemotherapy, particularly in the younger age group and in patients with B symptoms and bulky and advanced disease.

Influence of dose-rate and dose per fraction on clinical outcome of breast cancer treated by external beam irradiation plus iridium-192 implants: analysis of 289 cases.

PURPOSE: To study the influence of Iridium 192 implant dose-rate and dose per fraction of external irradiation on clinical outcome, the results in 289 patients with early breast cancer were analyzed retrospectively. METHODS AND MATERIALS: From 1980 to 1990, 118 T1 and 171 T2 lesions of breast were treated definitively by radiotherapy, following conservative surgery. External irradiation dose of 45 Gy was delivered either with 2.5 Gy or 1.8 Gy per fraction to the entire target volume, plus boost to the primary tumor. Boost dose of 15 to 30 Gy was given to the primary tumor either with iridium-192 implants or electrons. The implant dose-rate varied between 20 cGy/hr to 160 cGy/hr. RESULTS: The minimum follow-up was of 12 months and maximum of 11 years (median: 56 months). Out of 273 tumors boosted with implants, the 270 patients were divided into five groups according to dose-rate as, groups 1 (20-29 cGy/hr, n = 17), group 2 (30-49 cGy/hr, n = 144), group 3 (50-69 cGy/hr, n = 69), group 4 (70-99 cGy/hr, n = 27) and group 5 (100-160 cGy/hr, n = 13). The local failure rate was significantly increased in the group of patients treated with implant dose-rate < 30 cGy/hr (p < 0.05). While the incidence of late normal tissue complications and poor cosmetic outcome was significantly higher in the group of patients treated with implant dose-rate > 100 cGy/hr (p < 0.05). CONCLUSION: The present analysis indicate that the implant dose-rate should be maintained between 30-70 cGy/hr to maximize local control and reduce the late normal tissue injury. Also the increase in dose per fraction of external irradiation while not influencing local control rate was crucial for incidence of late complications and cosmetic outcome.

The predictive role of bioeffect dose models in radiation-induced late effects in glottic cancers.

Late radiation-induced laryngeal oedema for different doses per fraction was analyzed in 208 cases with squamous cell carcinoma of the vocal cord. The series comprised 156 cases with T1N0M0 and 52 cases with T2N0M0 lesions. Radical radiotherapy was given with three different regimens delivering 3.33 Gy, 2.5 Gy, and 2.25 Gy per fraction. There were 52 cases of late radiation-induced laryngeal oedema. A strong correlation (p less than 0.015) between the dose per fraction and the risk of the late complication in the vocal cord has been demonstrated. The analysis suggests that the empirical models like Nominal Standard Dose (NSD) or Time-Dose Factors (TDF) do not predict correctly the late normal tissue reactions for different dose fractionations. The analysis with extrapolated response dose (ERD) values of the linear-quadratic (L-Q) model also fail to correlate with the late complications (p greater than 0.5). Care should be exercised when using these bioeffect dose models to calculate regimens iso-effective for late damage, even when modest changes in fraction size from 2 to 3 Gy are contemplated.

Total body irradiation in chronic myeloid leukemia.

Total body irradiation (TBI), given as 10 rad daily for five days a week for a total dose of 150 rad has been used in an attempt to control the chronic phase of chronic myeloid leukemia (CML). Thirteen patients with CML received fractionated TBI leading to rapid and good control of WBC count without any adverse reaction. The chronic phase of CML could also be controlled with TBI, even in three patients who were resistant to busulfan. Following TBI, WBC count remained under control for a period of 32 weeks as compared to 40 weeks following busulfan alone. Repeat TBI was also well tolerated with good response. It appears that TBI is an effective and safe therapy for controlling the chronic phase of CML.

Radiation therapy in T1-T2 glottic carcinoma: influence of various treatment parameters on local control/complications.

PURPOSE: To evaluate the influence of various treatment parameters on local control as well as complications in T1 and T2 glottic carcinomas. METHODS AND MATERIALS: Between 1975 and 1989, 676 patients with early glottic carcinoma (460 T1 and 216 T2) received curative radiation with three different treatment regimens, as follows: Regimen 1-50 Gy/15 Fr/3 weeks (3.33 Gy/daily) for 192 patients; Regimen 2-60-62.5 Gy/24-25 Fr/5 weeks (2.5 Gy/daily) for 352 patients; and Regimen 3-55-60 Gy/25-30 Fr/5-6 weeks (2-2.25 Gy/daily) for 132 patients. RESULTS: The local control at 10 years was 82% and 57% for T1 and T2 lesions respectively (p = 0.0). For the T1N0M0 group, field size had significant impact on local control with both univariate (p = 0.05) and multivariate (p = 0.03) analysis. For T2N0M0, group field size (p = 0.03) as well as registration year (p = 0.016) were significant in univariate analysis whereas only field size remained significant on multivariate analysis. Persistent radiation edema was noted in 146 (22%) patients and was significantly worse with larger field size (p = 0.000) but not related to different treatment regimens. CONCLUSION: The shorter fractionation schedule had comparable local control, without increased complications in comparison to the protracted schedule and is best suited for a busy department.

Therapeutic factors influencing the cosmetic outcome and late complications in the conservative management of early breast cancer.

PURPOSE: To investigate the impact of clinical and physical parameters on the cosmetic result and complications, in cancer breast treated with conservative surgery and definitive irradiation. METHODS AND MATERIALS: Between October 1980 and December 1990, 289 patients were treated with lumpectomy and/or axillary dissection, radical irradiation with or without adjuvant therapy. The radiation therapy technique consisted of external beam therapy followed by an Ir-192 implant or electron beam boost. Univariate and multivariate analysis were used to evaluate the correlation between multiple factors affecting the cosmetic outcome and the complications. RESULTS: Of 289 patients, cosmesis was evaluable in 285 and recorded as excellent to good in 226 (79%), fair in 35 (12%), and poor in 24 (9%). On multivariate analysis of these results, a high dose per fraction (p = .0018), and use of electrons as boost to the tumor bed (p = .001) were found to be significant. When patients boosted with electrons were excluded, a high boost dose (p = .0433) was also found significant. Fifteen (5%) patients developed severe late radiation sequelae and 14 (5%) moderate or severe arm edema. On multivariate analysis only dose per fraction of 2.5 Gy (p < .0001) and higher boost doses (p = .017) were significant. CONCLUSION: In 289 patients of early breast cancer treated with conservative surgery and radical irradiation, multivariate analysis suggests that higher dose per fraction with teletherapy and higher brachytherapy boost dose adversely affect cosmesis and contribute to the late complications.

Predictive role of TDF values in late rectal recto-sigmoid complications in irradiation treatment of cervix cancer.

Radiation-induced late rectal and recto-sigmoid complications for different doses per fraction were analyzed retrospectively in 203 cases of Stage IIIB carcinoma of the uterine cervix. The patients were treated with a combination of external irradiation and a single intracavitary insertion during January 1979 to December 1983. The external irradiation was randomised to deliver by four different fractionation regimens having dose per fraction of 2 Gy, 3 Gy, 4 Gy and 5.4 Gy. The doses for various fractionations were matched with the daily regimen using the time-dose factors (TDF) model. A single intracavitary insertion delivered a dose of 22 to 24 Gy to point A using Fletcher-Suit applicator. All patients had a minimum follow-up of 30 months. Thirty nine cases of late radiation induced rectal and recto-sigmoid complications were observed. The complication rate of 8.2% for daily treatment regimen delivering 2 Gy per fraction was increased to 33.3% for once weekly treatment regimen delivering 5.4 Gy per fraction (p = 0.041). Despite similar Time-Dose Factors (TDF) values in four different treatment regimens, the complication rate increased significantly in the once weekly regimen. The analysis suggest that the Time-Dose Factors (TDF) values do not predict correctly the late normal tissue reactions for different dose fractionation schedules.

Treatment volume from total reference air kerma (TRAK) in intracavitory applications and its comparison with ICRU reference volume.

PURPOSE: A systematic dosimetry study conforming to International Commission on Radiation Units and Measurements Report Number 38, was carried out for, cancer of Cervix Stage I and II cases at Tata Memorial Hospital. METHODS AND MATERIALS: The reference Volume dimension were noted for each applicator. Also 3-D dosimetry was performed for selected cases, and actual geometric volume enclosed by various isodose surfaces were obtained. A relation was derived, which gave the volume enclosed by any isodose surface as a function of total reference air kerma of the sources in the applicator. The volume enclosed by reference isodose surface was compared with the product of its dimensions height, width, and thickness. RESULTS: The volume enclosed by any isodose surface of an intracavitary application can be easily derived from total reference air kerma of the sources within the applicator. CONCLUSION: Ratio of the volume enclosed by reference isodose surface with the product of its dimensions (HWT) could be a predictive parameter for clinical outcome, besides the reference volume specified by the report.

Primary carcinoma of the vagina: Tata Memorial Hospital experience.

PURPOSE: Carcinoma of the vagina is a rare gynecological malignancy comprising approximately 2% of all the gynecological malignancies. We have analyzed the treatment outcome of the patients treated at the Tata Memorial Hospital from January 1984 to December 1993. METHODS AND MATERIALS: In this 10-year period, 134 patients of primary vaginal cancers were registered at our hospital. Of these, 75 patients received complete treatment and are analyzed. RESULTS: Disease-free survival (DFS) for the whole group is 50%, and overall survival (OAS) is 60%. Most locoregional recurrences and distant failures are noted in the 2 years following treatment. DFS at 5 years is as follows: Stage I (5 patients), Stage IIA (37 patients), Stage IIB (15 patients), Stage III (14 patients), and Stage IV (4 patients); are 40%, 55%, 60%, 50%, and 25%, respectively. The DFS for patients with complete response (42 patients) to external radiation at 5 years is 68%, with partial response (25 patients) is 35%, and with poor or no response (6 patients) is 18% (p = 0.0000). We observed that brachytherapy was an important part of the treatment, and patients who received brachytherapy (59 patients), either with a vaginal intracavitary applicator (30 patients) or interstitial implant (29 patients) had a DFS of 53% and 56%, respectively, while 15 patients who received external radiation alone had a DFS of 30%. Patients receiving brachytherapy within 4 weeks of external radiation had a DFS of 60% as compared to 30% when the interval was more than 4 weeks. CONCLUSION: The factors indicating prognosis are: site and extent of involvement, presence of lymph nodes at presentation, technique of brachytherapy, and interval between external radiation and brachytherapy.

Dosimetry of intracavitary applications in carcinoma of the cervix: rectal dose analysis.

The International Commission on Radiation Units and Measurements (ICRU), in its Report-38, has given certain recommendations regarding the specifications of bladder and rectal reference points in the intracavitary treatment of carcinoma of the cervix. Conforming to this report, 182 intracavitary applications performed in stage I and II cervix cases were analyzed. In 113 applications, the maximum rectal dose was found to be in a point on the anteroposterior line drawn through the centre of colpostat sources. However, for our type of applications, the point on the anteroposterior line drawn through the lower end of the uterine tube seldom gets maximum dose. In addition, it was observed that there are other dose points than the ICRU reference point receiving doses close to maximum dose. It was concluded that doses to multiple rectal reference points should be recorded, in addition to the ICRU-defined rectal reference point.

Head and neck extranodal non-Hodgkin's lymphomas in Indian patients.

Though radiotherapy has traditionally been the treatment of the choice for the patients with localised extranodal lymphomas of the head and neck areas, its adequacy as the sole modality of treatment has come to be questioned. The disease is shown to relapse in other distant extranodal sites especially the gastrointestinal tract. The addition of systemic chemotherapy has been suggested. Fifty-five patients with localised head and neck extranodal lymphomas were treated at the Tata Memorial Hospital during the period 1976-1982, 35 with radiation therapy alone and 20 with combination therapy. The total survival at 5 years was 65% for patients treated with radiation alone and 85% for those treated with combination therapy. The 5 year disease-free survival dropped to 45% for the former group but was 74% for the latter group. This difference was statistically significant (p less than 0.01). We infer that localised extranodal lymphomas be regarded as a systemic disease and be treated by a multimodal approach.

Primary extranodal mucosa associated lymphoid tissue (MALT) lymphoma of the prostate.

Low-grade B-cell mucosa associated lymphoid tissue (MALT) lymphoma can rarely present primarily in extranodal sites other than stomach, which is the most common site for it. Until now only four cases of primary prostatic MALTomas have been described in the literature and we report the fifth. We describe a case of primary prostatic MALToma in a 67-year-old man and the diagnosis was made on the trans-urethral resection specimen of the prostate. As the disease was limited to prostate (stage IEA), the patient was treated with external beam radiation therapy to a total dose of 4400cGy in 22 fractions. The patient achieved completed remission and has remained free of disease in the following 36 months.

The Pattern of Malignant Lymphoma in India: A Study of 1371 Cases.

A retrospective clinical and histopathological analysis was performed of 1371 patients with Non-Hodgkin's lymphomas presenting between January 1981 and December 1985. Pathologic material was reviewed and classified according to the modified Rappaport classification. The most common histologic type encountered was diffuse histiocytic lymphoma (29.5%), followed by diffuse poorly differentiated lymphoma (28%). A very low incidence of nodular lymphomas (10.6%) was seen. Twenty three percent of the patients had clinically stage 1 disease; 24.6% stage 11; 25.9% stage 111 and 26.2% stage IV disease. Bone marrow involvement was seen in 22.6% of patients. B symptoms were seen in 23.9% of patients. Primary extranodal lymphoma was seen in 307 (22.4%) patients. The commonest site of extranodal involvement was head and neck (36.1%) followed by gastrointestinal tract (24.4%). Treatment results could be analysed in only 599 patients. The response rate was 89% and complete response was seen in 67.5% patients. The overall survival for treated patients was 37.5% after 36 months, which is comparable to that reported by other investigators. This series is compared with different series reported from Asian as well as Western countries in order to highlight some common features as well as other major differences.

Osteosarcoma: experience of the Tata Memorial Hospital, Bombay, India.

This is a report on the management of 210 patients with biopsy-proven OS seen at the Tata Memorial Hospital, Bombay, India from January 1985 to December 1988. The treatment administered to these patients reflects the constraints experienced in cancer management by developing nations. The small number of patients who received neoadjuvant chemoradiotherapy showed the highest survival figures of 30% at 5 years. In the context of the developing countries, limitations of affordability of optimum chemotherapy and the lack of adequate monitoring and support facilities warrant modifications in the currently recommended therapy schedule to suit indigenous needs.