Multiple cutaneous and haemorrhagic brain metastases as the sentinel presentation of lung adenocarcinoma.

Skin is a relatively uncommon site of metastasis in lung cancer and is associated with a poor prognosis. Although, lung cancer does not uncommonly metastasise to the brain, haemorrhagic brain metastases are rarely reported. In this report, we present a dramatic presentation of a female smoker with a 3-week history of numerous cutaneous lesions over her body and two episodes of transient memory loss. Work-up demonstrated widely metastatic, poorly differentiated lung adenocarcinoma with haemorrhagic brain metastases. She proceeded with whole brain radiotherapy, but her performance status quickly declined afterwards; she succumbed to her malignancy within 6 weeks of presentation. This case presentation demonstrates that, for patients who present with cutaneous masses, especially those aged more than 60 years, and who have extensive smoking history, metastatic lung cancer should remain on the differential diagnosis. Also, the very poor prognosis of multiple metastases may influence medical and social decisions in the patient's treatment plan.

A comparative study of concomitant boost radiation versus concomitant boost with concurrent chemoradiation versus standard fractionation chemoradiation in locally advanced head-and-neck cancer.

CONTEXT: As the number of head-and-neck cancer (HNC) patients are high in our subcontinent, the study was designed to reduce the treatment time and increase efficacy. AIMS: Comparative evaluation of the efficacy, toxicity, local control, and survival of concomitant boost radiotherapy (CBRT), CBRT with concurrent chemoradiation (CBRT + CCT) and conventionally fractionated radiotherapy with concomitant chemotherapy (CFRT + CCT) in locally advanced HNC (LAHNC). MATERIALS AND METHODS: Patients with LAHNC were randomly assigned to 3-groups of 30-patients each. Group I (CBRT) received, 45 Gy/25#/5-weeks and 18 Gy/10# concomitant boost in the last 2-week of treatment, receiving a total dose of 63 Gy. Group II (CBRT + CCT) received CBRT with concomitant cisplatin 75 mg/m 2 on day 1, 17, and 34. Group III (CFRT + CCT) received 64 Gy/32#/6.2 weeks, concurrent with injection cisplatin 75 mg/m 2 on day 1, 22, and 42. STATISTICAL ANALYSIS USED: Stata 9.0 SPSS and Chi-square test were used for analysis and disease-free survival (DFS) rates were calculated using the Kaplan-Meier method. RESULTS: The median follow-up period was 8.2 months. At last follow-up, locoregional control was 36%, 57%, and 40% and DFS was seen in 33%, 53%, and 40% of patients in Group I, II, and III, respectively. Grade-3 cutaneous reactions were significantly higher in Group-II as compared to that of Group-III (P = 0.033) and Group-I (P = 0.715). CONCLUSION: All three groups have similar response rates and DFS with manageable toxicity.

Comparison of Single Versus Multifraction Radiotherapy in Palliation of Painful Bone Metastases.

BACKGROUND: Bone is a common site of dissemination in advanced cancer accounting for one-third of all distant metastases. Various fractionation schedules of radiotherapy have been used for palliation of bone metastases. The aim of this study was to compare three schedules of external radiation therapy (8 Gy single session versus 20 Gy/5 fractions versus 30 Gy/10 fractions) for palliative management of bone metastases. METHODS: In the present study, 60 patients of bone metastases from any primary site were enrolled and randomly divided into three groups of 20 patients each by draw of lots. These patients received palliative external beam radiation therapy to the involved site. Patients were given 8 Gy single session, 20 Gy/5 fractions/1 week and 30 Gy/10 fractions/2 weeks in groups I, II and III, respectively. RESULTS: The percentage of patients with overall pain relief was 80% in group I, 75% in group II and 85% in group III (P = 0.7). The number of patients with complete pain relief was 4 (20%) in each group. Maximum patients got pain relief at 4 weeks post-radiotherapy. The number of patients with improved performance status was 4 (20%) in group II and 2 (10%) each in groups I and III (P = 0.5). Thirteen (65%) patients in each of the groups had decreased analgesic requirement at 2-month follow-up. Retreatment rate was more in the single fraction (20%) compared to only 5% in group II and none in the group III (P = 0.05). CONCLUSION: From the present study we conclude that 8 Gy single fraction is as effective as multifraction radiotherapy for the palliation of painful bone metastases. However, for a center like ours being the only Government Tertiary Cancer Care Centre in the State, general consensus drawn after this study, recommends external radiation therapy 20 Gy/5 fraction regimen to be an appropriate means of palliation of painful bone metastases.

Major Risk Factors in Head and Neck Cancer: A Retrospective Analysis of 12-Year Experiences.

BACKGROUND: Head and neck cancer (HNC) is the seventh most common type of cancer in the world and constitute 5% of the entire cancers worldwide. The global burden of HNC accounts for 650,000 new cases and 350,000 deaths worldwide every year and a major proportion of regional malignancies in India. More than 70% of squamous cell carcinoma of the head and neck are estimated to be avoidable by lifestyle changes, particularly by effective reduction of exposure to well-known risk factors such as tobacco smoking and alcohol drinking. METHODS: A retrospective analysis of 12 years (2001 - 2012) of HNC patients attending RCC, PGIMS Rohtak was done. Total numbers of cancer patients seen were 26,295 and out of these 9,950 patients were of HNCs, which were retrospectively analyzed for their associated risk factors in different HNC subtypes. Most of the patients, i.e. 92.3%, were presented as locally advanced HNC (stages III and IV). RESULTS: It has been observed that smoking and alcohol are the strongest independent risk factors responsible for increased risk of HNC and are further having synergetic correlations. CONCLUSION: The present study confirms the principal role of alcohol consumption and smoking in HNC carcinogenesis, as well as the differential associations with HNC subtypes, and a significant, positive, multiplicative interaction with different risk factors.

Comparative Evaluation of Three Palliative Radiotherapy Schedules in Locally Advanced Head and Neck Cancer.

BACKGROUND: The aim of the study was to evaluate and compare the efficacy, tolerability and toxicity of three palliative radiotherapy (RT) schedules in locally advanced head and neck carcinoma (LAHNC), i.e. Quad Shot schedule, Christie schedule and conventional palliative schedule. METHODS: The patients were randomly divided into three groups of 30 each. Group I patients were planned for 14.8 Gy in 4 fractions over 2 days, repeated three weekly for two more cycles. Group II patients were planned for 50 Gy in 16 fractions over 3.1 weeks. Group III patients were planned for 20 Gy in 5 fractions over 5 days, repeated after an interval of 3 weeks. The quality of life was assessed before and after RT using University of Washington Quality of Life questionnaire version 4. RESULTS: Local control rates were 84%, 76%, and 76% for groups I, II and III, respectively. Disease status at 6-month follow-up was no evidence of disease (20%, 28%, and 16%), residual disease (72%, 48%, and 76%), and recurrent disease (8%, 24%, and 8%) in groups I, II and III, respectively. Grade III acute skin reactions were 28%, 44%, and 16% in groups I, II and III, respectively. Grade III acute mucosal reactions were 36%, 56%, and 24% in group I, II and III, respectively. Quality of life improved in all groups after RT. CONCLUSION: Quad Shot schedule may be used in LAHNC with better local control and acceptable toxicity as compared to conventional palliative RT schedule in Indian setting.

Exploring signet-ring cells in pregnant female.

INTRODUCTION: Primary signet-ring cell carcinoma (SRCC) of the colon and rectum are rare form, which present at an advanced stage and have poor prognosis. Different treatment policies of SRCC during different gestational age of pregnancy are explored from the literature. CASE STUDY: A 26-year-old young pregnant female with 10-week gestation presented with constipation and blood in stools and on per rectal examination a tender circumferential stricture was present 2 cm above the anal verge. Magnetic resonant imaging (MRI) pelvis of the patient revealed rectal thickening, the biopsy of which revealed characteristic appearance of "linitis plastica" and diagnosed as poorly differentiated adenocarcinoma with signet ring morphology with wide spread positivity for cytokeratin & p53. With this diagnosis, patient underwent medical termination of pregnancy (MTP). DISCUSSION: SRCC of the colon comprises about only 1% of all cases of colon cancer. When compared with other types of adenocarcinoma, patients with SRCC in the colon are younger and more likely to experience lymph node metastasis. Its incidence in pregnancy is estimated to be less than 0.1%. Certainly, any pregnant patient who reports rectal bleeding or has hemoccult positive stool on examination deserves careful evaluation to rule out cancer. The complex treatment of colorectal cancer in pregnancy is based on the gestational age of the fetus, tumor stage and need for emergent vs. elective management.

A journey into insidious world of MALT lymphoma of the ileum: from the beginning to the end.

INTRODUCTION: Lymphoma of the mucosa-associated lymphoid tissue (MALT) has been used to describe a marginal zone B-cell lymphoma derived from gastrointestinal lymphoid tissue. mucosa-associated lymphoid tissue lymphoma (MALToma) of the ileum are extremely rare and only few reports with endoscopic features have been reported. CASE STUDY: We present a 55-year-old male patient with history of abdominal pain and loss of appetite since 2½ years. Abdomino-pelvic ultrasonography was normal, but computed tomography (CT) scan of the abdomen showed, dilated segment of ileum containing both contrast and debris. He underwent segmental resection of ileum associated with stricture site, histopathology of which revealed MALToma of ileum. Patient was subsequently treated with low dose chemotherapy and strictly followed up. DISCUSSION: Primary treatment possibility should be considered as the treatment of H. pylori infection while surgical resection for superficial lesions followed by low dose chemotherapy is recommended. The present case report explore MALToma of the GI tract, its diagnostic criterions, role of radiological and pathological tools, various investigative techniques and role of surgery and chemotherapy in such cases.

Into the wild world of eosinophilic granuloma.

Langerhans cell histiocytosis (LCH) is a group of relatively rare disease processes of reticuloendothelial system with an abnormal proliferation of Langerhans cells or their precursors. A wide spectrum of treatment modalities is available for LCH which includes surgery, curettage, steroids, radiation, various chemotherapy regimens, either in combination or alone have so far been adopted. There are several case reports of eosinophilic granuloma but for recurrent cases very few have discussed on treatment of LCH in adults. We report a case of a 21-year-old man presented with eosinophilic granuloma with recurrence of the lesions after 6 years of the initial treatment. Patient was treated with combination chemotherapy with three weekly CHOP regimen and the patient is disease free after 6 months of follow-up. Contrary to other reports, this case demonstrates that a good response with standard therapy is possible.

The uncovered story of leiomyosarcoma of the cervix: a rare case report and review of literature.

Sarcomas of the uterine cervix are uncommon tumours arising from uterine cervix constituting less than 1% of all cervical malignancies. Leiomyosarcoma of uterine cervix is extremely rare. Combined modality of treatment including surgery, radiotherapy and chemotherapy should be used in these patients to achieve better survival. We present a rare case of leiomyosarcoma of uterine cervix presented with bleeding per vaginam and bulky cervical mass. Simple hysterectomy was carried out and operative findings revealed a large growth arising from the anterior cervical lip. Diagnosis in this case was made by subjecting the resected specimen to histopathological and immunohistochemical analysis. Postoperatively patient received adjuvant combination chemotherapy (VAC) followed by radiotherapy. Patient is asymptomatic without any evidence of tumour recurrence after 6 months of follow-up.

Hodgkin's lymphoma with cutaneous involvement.

We report a case of a 22-year-old previously healthy woman with Hodgkin's lymphoma who presented initially with multiple lymphadenopathy and later, with a solitary cutaneous ulcer. Unlike Non-Hodgkin's lymphoma subtypes, skin involvement of Hodgkin's lymphoma is extremely rare. The prognosis of Hodgkin's lymphoma with skin infiltration is felt to be extremely poor. Contrary to other reports, this case demonstrates that a good response with standard therapy is possible.

Giant neurilemmoma of the vagus nerve: a case report and review of literature.

Cervical vagal neurilemmomas are rare, usually asymptomatic, slow-growing tumours and defined as a benign, encapsulated neoplasm that arises in the nerve fibre. Magnetic resonant imaging (MRI) plays a central role in diagnosing vagal nerve neoplasm and in fact, provides important pre-operative information useful in planning optimal surgical treatment. A rare case of giant neurilemmoma is presented with a large swelling in the right side of the neck associated with breathlessness and paroxysmal cough. X-ray chest revealed large homogenous opacity in apical area of the right lung extending into the lower neck. MRI revealed a large 6 x 8 x 13 cm soft tissue, well defined mass with lobulated contours on the right side of the neck. The mass was pushing sternomastoid muscle anteriorly and carotid artery was pushed anteromedially. The mass was abutting the brachial plexus and compressing internal jugular vein. The mass was extending into the mediastinum up to the level of carina. The mass was also pushing the vessels in superior mediastinum towards left and was compressing the veins. Tumour was extending posterior to trachea and pushing trachea anteriorly and towards left and also compressing it. There was also erosion of adjacent anterior aspect of the right upper ribs. Subclavian artery was also encased by the mass. Multiple enlarged lymph nodes were seen in right cervical area. A provisional diagnosis of malignant schwannoma of right vagus nerve was made. Cytology from the fine needle aspirate of the right lower Cervical region of the swelling revealed features of neurilemmoma. Complete surgical resection is the treatment of choice with excellent prognosis, as the tumour was benign, and recurrence is nearly unknown, so it is possible and indeed recommended to preserve nerve integrity with careful dissection.