Breast Cancer Management Consensus By The Society of Surgeons and Surgical Oncology Society of Pakistan.

The Society of Surgeons of Pakistan and The Society of Surgical Oncology of Pakistan with factions from various major centres comprising of surgical oncology, medical and radiation oncology collaborated to reach consensus on breast cancer management guidelines and a framework of "good practice" minimum standards of care. The aim of the task force was to enhance treatment standards, which have a direct correlation with improving patient mortality and morbidity and long-term survival whilst taking into consideration economic limitations of access to leading centers of excellence as well as minimum expertise required in health care. These multidisciplinary guidelines, whilst not exhaustive, aim to provide an algorithm of care for breast cancer patients at tertiary care centres and district level hospitals to provide most appropriate treatment.

Clinical Practice Guidelines For The Management Of Colorectal Cancer, A Consensus Statement By The Society Of Surgeons® And Surgical Oncology Society Of Pakistan®.

A joint effort by the Society of Surgeons Pakistan and Society of Surgical Oncology Pakistan, these guidelines provide a framework for the practicing surgeons involved in care and management of patients with colorectal cancer. The guidelines take into account the issues related to our local circumstances and provide a minimum standard of care that must be given to these patients. The Guideline Committee had members from all disciplines, including surgery, surgical oncology, medical oncology and radiation oncology. The guidelines have attempted to simplify things to understand and follow for the practicing surgeons. With these guidelines we wish to eliminate disparities in treatment among institutions and prevent any under treatment of patients.

Smokeless tobacco use and risk of oral cavity cancer

Background/aim/AIM: Smokeless tobacco has been associated with oral cavity cancer for several decades. The incidence of oral cavity cancer is higher in some parts of the world especially South and South-East Asia including Pakistan. The aim of current study was to evaluate the risk of oral cavity cancer among smokeless tobacco users in our country. Materials and methodsAND METHODS: A case-control study was conducted between November 2016 and September 2017. Patients diagnosed with oral cavity cancer receiving treatment were included as cases and the attendants of various cancer patients visiting the hospital during the study period were included in the study as controls. Odds ratios (OR) and 95% confidence intervals (CI) were calculated and all reported P-values were considered significant at < 0.05. Results: The crude OR for the "ever smokeless tobacco users" among cases and controls came out to be 4.98 (95%CI; 2.76­9.01). The OR for snuff users among cases and controls was 4.82 (95%CI; 2.37­9.80) and that for betel leaf users was 4.42 (95%CI; 1.66­11.91) after adjusting for smoking and age. Conclusion: Our study provided strong evidence for snuff and betel leaf to be independent risk factors for oral cavity cancer.

THE Role of Preoperative carcinoembryonic antigen in recurrence of resectable colorectal carcinoma.

In colorectal carcinoma, carcinoembryonic antigen (CEA) is a recommended marker for surveillance after curative resection. The aim of the present study was to determine the association of preoperative CEA with recurrence of colorectal carcinoma in our population. The study included 55 patients with all operable stages of colorectal adenocarcinoma treated during the 2012-2014 period, evaluated retrospectively and followed-up for recurrence for 2 years. Data on the baseline (preoperative) CEA levels were retrieved from patient files. On data analysis, SPSS 16.0 was used. In patients with normal preoperative CEA, the rate of recurrence was significantly low (p=0.008) and the likelihood of no recurrence 1.55-fold greater as compared to patients with raised initial CEA levels (p=0.028). In patients with raised preoperative CEA, the risk of recurrence was 5.26-fold greater as compared to those with normal CEA levels (p=0.028). A significant weak positive correlation (rs=0.297) was found between raised CEA and recurrence. A highly significant (p=0.002) moderate positive correlation was recorded in patients aged <50 and moderate positive correlation of borderline significance in males (rs=0.324, p=0.058). Sensitivity was 94.4% and specificity 32.4% in predicting recurrence. Accordingly, preoperative elevated CEA showed a significant weak positive correlation with recurrence while normal preoperative CEA moderately decreased the likelihood of recurrence.

Sonographically guided metalic clip placement for tumour localization in early breast cancer patients undergoing neoadjuvant chemotherapy.

OBJECTIVE: To determine the outcome of sonographically-guided indigenous low-cost metallic clip placement for tumour localisation in patients of early breast cancer undergoing neoadjuvant chemotherapy. . METHODS: The prospective analytical study was conducted at the Institute of Nuclear Medicine and Oncology, Lahore, Pakistan, from May 2016 to December 2017, and comprised biopsy-proven breast cancer cases. Under sonographic guidance, metallic clips were placed as markers within the lesions before their scheduled preoperative neoadjuvant chemotherapy. The procedure was performed using an 18 gauge lumbar puncture needle and 25 gauge needle by a locally devised simple and cost-effective technique. Post-procedure mammography was performed to confirm the location of clips within the lesions and to evaluate its role in imaging assessment of treatment response after neo adjuvant chemotherapy. SPSS 20 was used for data analysis. RESULTS: There were 30 women with a mean age of 40.43+11.35 years (range: 21-60 years). These women had 32 lesions with a mean size of 26.72+9.85mm (range: 8-58mm). Breast conserving surgery was performed on 28(87.5%) lesions and negative margins were achieved in all these cases. Modified radical mastectomy was performed on 4(12/5%) non-responding lesions. No complication was noted in association with metallic clip placement, and the clips were easily visualised on mammograms without causing any interference with treatment response. CONCLUSIONS: Sonographically-guided metallic clip placement by a simple indigenously devised technique before neoadjuvant chemotherapy was found to be a well-tolerated, safe and cost-effective method for accurate preoperative localisation of tumour bed and to assess response to therapy.

Real-World Challenges of Managing Diffuse Large B-Cell Lymphoma in a Developing Country.

PURPOSE: To highlight challenges and cancer care disparities in patients of diffuse large B-cell lymphoma management in resource-constrained settings. MATERIALS AND METHODS: This multicenter retrospective study included 738 patients from 12 public and private sector hematology-oncology centers across Pakistan. Patients were divided into limited-resource and enhanced-resource settings as per national diffuse large B-cell lymphoma (DLBCL) guidelines. RESULTS: The median age at diagnosis was 47 years (range, 14-89). Male:female ratio was 2.5:1. Majority of the patients (69.3%) were treated in limited-resource settings. Computed tomography was used as a staging modality in 442 (60%) patients. Limited-stage DLBCL was present in 13.5% of patients, while 86.3% had advanced-stage disease at diagnosis. First-line regimens included rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone in 56% and cyclophosphamide, doxorubicin, vincristine, prednisone in 34% of patients, while 10% of patients received palliative regimens upfront. Of evaluable data, complete remission was documented in 299 (74.4%) patients, 39 (9.8%) had partial response and 63 (13.5%) had progressive disease. Disease-free survival (DFS) and overall survival (OS) status were not available for 345 (46.8%) patients at the time of data collection. Overall study cohort had a median follow-up of 2.2 years with a median OS of 3.6 years (95% CI, 3.1 to 4.1), median DFS of 3.1 years (95% CI, 2.6 to 3.6), and a 5-year OS of 40% and DFS of 36%. CONCLUSION: Patients from low- and middle-income countries present at an earlier age and have more advanced disease. Patients were frequently lost to follow-up, and record keeping was inadequate more so in patients treated in limited-resource settings. There is a need to establish a national lymphoma registry, improve record keeping, and standardize treatments to ensure improvement in treatment outcomes.

Preparation of (99m)Tc-labelled methotraxate by a direct labeling technique as a potential diagnostic agent for breast cancer and preliminary clinical results.

Methotrexate (MTX) is being used in clinical oncology for the treatment of a wide variety of cancers. The aim of the present study was to label directly MTX with (99m)Tc by using Sn/pyrophosphate as reducing agent and to use this labeled compound as a potential anticancer radiopharmaceutical for breast cancer imaging. We studied the labeling efficiency of the (99m)Tc-MTX compound by paper chromatography and instant thin layer chromatography (ITLC) in acetone and saline and found it to be more than 95%. In vitro stability of labeled MTX in serum was studied up to 5h. Partition coefficient in n-octanol and saline indicated that the labeled radiopharmaceutical was hydrophilic. We then tested (99m)Tc-MTX in 5 breast cancer female patients. Protein bound (99m)Tc-MTX showed rapid clearance from blood. The biodistibution data suggested that (99m)Tc-MTX was cleared by the kidneys and the liver. Patients ' data also showed highly significant uptake of (99m)Tc-MTX in breast cancer. In conclusion, this study indicated that (99m)Tc-MTX may be used as a potential diagnostic agent for breast cancer patients imaging and may show treatment efficiency in case MTX is to be used for treatment.

Sentinel Lymph Node Mapping in Breast Cancer: Initial Experience of a Multidisciplinary Team.

INTRODUCTION: Breast cancer is one of the leading causes of cancer-related deaths in women; it is the most frequently diagnosed cancer in women in the United States with a lifetime risk of dying of about 3.4%. Regional lymph node involvement is quite early in breast carcinoma and axillary lymph node metastasis is an important predictor of recurrence and survival, particularly in invasive ductal histology of breast carcinoma. Localization of sentinel lymph node/nodes followed by frozen section and histopathological evaluation helps to prevent unnecessary axillary nodal dissection and, hence, reduces associated post-surgical morbidity. Sentinel nodes are the first ones to receive lymph-borne metastatic cells and, hence, lymphoscintigraphy followed by biopsy is quite reliable to detect nodal metastasis, particularly at an early stage (I, II) of breast cancer. METHODS: Here we will share our experience of introducing procedure, personnel training, and workflow of sentinel lymph node lymphoscintigraphy in breast cancer patients at our cancer institute to help other centers establish programs for this study. RESULTS: Initially, 10 procedures were performed, all of which were successful in the localization of sentinel nodes and played a substantial part in the surgical planning of breast cancer. Planar lymphoscintigraphy and single-photon emission computerized tomography (SPECT)-CT images of our first patient revealed radiotracer avidity in the lymph node in the ipsilateral axilla, which was later on diagnosed as metastatic resulting in axillary nodal clearance. CONCLUSIONS:  In multidisciplinary/closely-placed surgical, pathological, and hybrid imaging facility settings, lymphoscintigraphy provides a quick, accurate, and better way of nodal localization leading to correct surgical decision-making. In addition to planar imaging, SPECT-CT acquisition significantly improves the specificity of the lymphoscintigraphy procedure, which is beneficial for patients to avoid false-positive results, thus saving breast cancer patients from potential adverse effects of surgery.

Diagnosis and Management of Diffuse Large B-Cell Lymphoma: Society of Medical Oncology, Pakistan Society of Hematology, and Pakistan Society of Clinical Oncology Joint Clinical Practice Guideline.

Diffuse large B-cell lymphoma (DLBCL) is the commonest non-Hodgkin lymphoma encountered by hematopathologists and oncologists. Management guidelines for DLBCL are developed and published by countries with high income and do not cater for practical challenges faced in resource-constrained settings. This report by a multidisciplinary panel of experts from Pakistan is on behalf of three major national cancer societies: Society of Medical Oncology Pakistan, Pakistan Society of Hematology, and Pakistan Society of Clinical Oncology. The aim is to develop a practical and standardized guideline for managing DLBCL in Pakistan, keeping in view local challenges, which are similar across most of the low- and middle-income countries across the globe. Modified Delphi methodology was used to develop consensus guidelines. Guidelines questions were drafted, and meetings were convened by a steering committee to develop initial recommendations on the basis of local challenges and review of the literature. A consensus panel reviewed the initial draft recommendations and rated the guidelines on a five-point Likert scale; recommendations achieving more than 75% consensus were accepted. Resource grouping initially suggested by Breast Health Global Initiative was applied for resource stratification into basic, limited, and enhanced resource settings. The panel generated consensus ratings for 35 questions of interest and concluded that diagnosis and treatment recommendations in resource-constrained settings need to be based on available resources and management expertise.

Evaluation of paclitaxel and carboplatin versus combination chemotherapy with fluorouracil, doxorubicin and cyclophosphamide as a neoadjuvant therapy in patients with inoperable breast cancer.

OBJECTIVE: To compare the results of patients with locally advanced breast cancer receiving two different regimens Fluorouracil, Doxorubicin and Cyclophosphamide (FAC) and Paclitaxel and Carboplatin. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: The Oncology Department, Institute of Nuclear Medicine and Oncology (INMOL), Lahore, from March 2007 to September 2008. METHODOLOGY: Patients with inoperable locally advanced breast cancer of stage were included. Sixteen patients were given FAC regimen and 9 patients were given Paclitaxel and Carboplatin, each combination was cycled after 21 days for four times. Before enrollment, detailed medical histories, physical examinations and performance status assessments were done as well as postchemotherapy evaluation with regular follow-up visits was done. Complete Response (CR, ¯100%) is defined as the disappearance of all known disease parameter i.e. disappearance in detectable tumour size, node free disease and surgery is possible. Partial Response (PR, ¯ > 50%) was defined by 50% or greater decrease in the sum of the areas of bidimensionally measured lesions i.e. change of N2 to N1 or no status and some surgical procedure is possible to downstage the disease. Minor Response (MR) was defined as a decrease in the tumour insufficient to quality for partial response. Static disease or no evaluable reflected no significant change in disease and no evidence of new disease. Progression of disease (> 25%) was defined as a 25% or greater increase in the area of any lesion > 2 cm or in the sum of the products of the individual lesions or the appearance of new malignant lesions, surgery not possible. RESULTS: Twenty five patients completed neoadjuvant chemotherapy. Sixteen (66%) patients received FAC and 9 (37%) patients received PC chemotherapy. Overall CR (breast and axilla) was 54%, PR was 16% and minor response (MR) was 8%. FAC treatment induced more emesis, mucositis, alopecia and cardiotoxicity. No death occurred. CONCLUSION: The Paclitaxel and Carboplatin regimen was better tolerated; both regimens were effective in improving disease and overall survival.

Acute Side Effects with High Dose Rate Computed Tomography-guided Three-dimensional Brachytherapy in Carcinoma Cervix.

OBJECTIVES: To determine the frequency and grades of acute side effects with three-dimensional brachytherapy in carcinoma cervix using RTOG/EORTC acute radiation morbidity scoring criteria. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Radiotherapy, Institute of Nuclear Medicine and Oncology (INMOL), Lahore, Pakistan from July 2016 to September 2017. METHODOLOGY: A total of 55 histologically proven patients of squamous cell carcinoma of the cervix, aged between 16-70 years, were included. Patients with previous radiotherapy in pelvic area, inflammatory bowel diseases and known diabetics, were excluded. All patients were given a radiation dose of 7 Gray in 4 insertions through 3-dimensional conformal brachytherapy planning. Acute vaginal, gastrointestinal, and genitor-urinary side effects of brachytherapy were assessed. RESULTS: Mean age of the patient population was 47.09 ±13.10 years (Range: 21-68). Mean time to presentation was 5.65 ±2.32 months and mean tumor size was 3.67 ±1.47 cm. Majority, i.e. 18 (32.7%) patient presented in stage III. Most of the patients, 26 (47.3%), had ECOG-2 performance status. Grade-1 genitourinary toxicity was significantly high (p <0.001). In lower gastrointestinal toxicity, Grade-1 was the highest being 54.5%. Conversely, vaginal toxicities of grade-2 and 3 were most commonly seen. Stratification of acute side effectswith respect toage, stage and tumor size revealed no significant association except in mucosal membrane toxicity, which was affected by tumor size (p = 0.004). CONCLUSION: Three-dimensional brachytherapy in carcinoma cervix is a safe and tolerable procedure with minimal acute side effects. Key Words: Cervical cancer, Brachytherapy, Acute toxicities, Computed tomography.

Cancer Epidemiology in Lahore, Pakistan - 2010-2015.

OBJECTIVE: To study the cancer incidence rates in Lahore, which has an estimated annual population count of 10.3 million. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Data on new cancer cases diagnosed between 2010 and 2015, among the residents of Lahore district, Pakistan, was reviewed retrospectively in 2015-2017. METHODOLOGY: Nineteen collaborating centres of the population-based Punjab Cancer Registry (PCR), representing both the government and private sectors, reported their cases to the coordinating office located within the Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC). The age-standardised incidence rates (ASIR) per 100,000 population, over a six-year period, were computed. Sixteen 5-year age groups were created beginning from 0-4 to 70-74 years, followed by 75+ years. Graphs on the five-year age-specific incidence rates by gender, were also generated. RESULTS: Between 2010 and 2015, 33,028 new malignancies were recorded in Lahore, with the crude average annual incidence rate being 53.1. In adults, the highest ASIRs were noted for cancers of the breast (77.3) among females and of prostate (11.4) in men. Age-specific incidence rates for female breast cancer showed an upward trend at the age of 20 years, reaching a figure of 160 at the age of 55 years. Among males, the rates for prostate cancer started to increase at the age of 55 years and reached a peak of 93 at 75 years. CONCLUSION: These results warrant expanding cancer registration in the region and sharing statistics with policy-makers to establish hospitals accordingly to manage cancer, along with exploring various risk factors within the population.

Intracranial haemangiopericytoma: a very rare entity having a high malignant/metastatic potential.

Intracranial haemangiopericytomas are very rare tumours. Their radiological appearance resembles that of meningioma. Recommended treatment is total surgical excision, if possible, followed by radiotherapy. A vigilant, long-term clinical and radiological follow up is very essential due to a high rate of late onset recurrence along with neural and extraneural metastases. A case report and review of literature is presented.

Epidemiology and Treatment Outcomes of Sinonasal Tumors: A Single Institute's Experience in Pakistan.

OBJECTIVE: To find the epidemiology and risk factors of sinonasal tumors and treatment outcomes in squamous cell carcinoma. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: The Institute of Nuclear Medicine and Oncology Lahore (INMOL), Lahore, from May 2016 to March 2017. METHODOLOGY: All histopathologically proven cases of paranasal sinuses and nasal cavity were selected from the hospital record for epidemiological analysis. Survival outcomes of patients with squamous cell histopathology were determined, which is commonly occurring type. Relevant information was obtained from patient record and telephone communication. The data were analysed using SPSS V.20. RESULTS: Sinonasal malignancies are rare, making (n=81) 0.2% of all registered tumors; out of which, 46 (56.7%) had squamous cell histology. Median age was 50.0 years (IQR: 60.7-40.0) with male predominance (1.7:1). Most of patients presented at advanced stage, T3/ T4 in more than two-thirds of cases, and associated with nodal metastasis in 43.5% of squamous cell carcinoma. In patients with squamous cell histology, median disease-free survival was 19.00 months (SE: 1.65, 95% CI, 15.75 - 22.25), median overall survival remained 34.00 months (SE: 1.84, 95% CI, 30.00 - 38.00). Nodal status had significant effect (p<0.001) on survival. Radiotherapy had significant effect on improved survival (p=0.001) and distant metastasis remained negative prognostic factor (p=0.001). Disease stage was also significantly associated with overall survival (Log Rank 0.014). Tumour size, surgery, chemotherapy, and chemoradiotherapy were not significantly associated with survival. Cumulative survival at 1, 2, and 3 years was 87%, 48% and 29%, respectively. CONCLUSION: Sinonasal malignancies are rare, advanced stage is common, and radiotherapy improves overall survival.

Disease Characteristics and Treatment Outcome of Testicular Germ Cell Tumors Treated with Platinum-Based Regimens.

OBJECTIVE: To determine the disease characteristics of testicular germ cell tumor, biochemical/radiological response to chemotherapy and common toxicity profile. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Institute of Nuclear Medicine and Oncology (INMOL), Lahore, from January 2010 to December 2013. METHODOLOGY: Fifty-one patients with histologically proven testicular germ cell tumor, who fulfilled the pre-defined eligibility criteria, were selected. Presenting symptoms and disease stage were studied. Patients were staged according to the AJCC 2010 staging criteria and prognosis was classified according to the IGCCCG Classification of Metastatic Germ Cell Cancer. Initial chemotherapy treatment was based upon the International Germ Cell Consensus Classification, 1997. Patients were also evaluated for chemotherapy-induced toxicity based on Common Toxicology Criteria version 4. SPSS version 16.0 was used for statistical analysis. RESULTS: Main presenting symptoms included testicular pain (37.3%), testicular swelling (25.5%), and abdominopelvic pain (11.8%). Most of the patients had mixed germ cell histology (p <0.001) and presented with advanced disease stage. Out of 51 patients, 41 (80.3%) achieved complete clinical remission after first line chemotherapy. All patients having complete response achieved 2-year survival and 37 (90.2%) had no evidence of recurrent disease. Four patients with recurrent disease achieved complete remission with second line chemotherapy. Five (9.8%) had partial response after first line chemotherapy while 2 (3.9%) progressed on treatment. All patients developed alopecia, 21 (41.1%) experienced other toxicities which were managed symptomatically and with minor dose modifications. CONCLUSION: Many patients with germ cell tumors presented with pain, and in an advanced stage, with mixed histology. Overall response rate was 90.2% with platinum-based chemotherapy.

Thirty Years Cancer Incidence Data for Lahore, Pakistan: Trends and Patterns 1984-2014

This research was conducted to generate trends and patterns of most common male and female cancers from 1984-2014 for the city population of Lahore Pakistan. Cancer incidence data gathered for different organs were processed through cleaning, integration, transformation, reduction and mining for ultimate representation. Risk of cancer appeared to be continuously increasing among both males and females. Overall, lymphomas and breast cancer are the most common neoplasm in males and females, respectively, in Lahore with almost the highest rates in the Asian Pacific region. The incidence of head and neck, brain, and lung cancers, as well as leukemia have rapidly increased among males, whereas, ovarian, cervix, head and neck and lymphomas have become more common among females. The present communication should be helpful for adequate strategic planning, identification of risk factors and taking appropriate prevention and control measures at the national level.

Studying the efficacy of escalated dose conformal radiation therapy in prostate carcinoma - Pakistan experience.

BACKGROUND: Our objective in this study was to evaluate the role and benefits in terms of local toxicity and biochemical disease-free survival (bDFS) following escalated-dose conformal radiation therapy in prostate adenocarcinoma. METHODS: The study population was composed of 53 patients with histologically proven T1b-T4, NO, MO prostate adenocarcinoma, having any Gleason score with prostate-specific antigen (PSA) of less than 50 ng/mL at diagnosis, given escalated dose EBRT (74 Gy) during the period between January 2011 and December 2013, retrospectively and evaluated for a period of 2 years post-radiation. Patients were followed up for a period of 2 years, beginning after completion of escalated dose external beam radiotherapy (EBRT) for biochemical failure as defined in ASTRO consensus committee guidelines 1996 and investigated for gastrointestinal, genitourinary skin toxicity. RESULTS: Out of 53 patients, 35 showed no biochemical failure at the end of 2 years following the completion of definitive escalated dose conformal radiotherapy while 18 were observed to have biochemical relapse. Acute gastrointestinal grade 1 toxicity was found in 26 patients, grade 2 in 24, and grade 3 only in 3 patients. Late gastrointestinal grade 0 toxicity was found in 16 patients, grade 1 in 28, grade 2 in 7 and grade 3 only in 2 patients. Grade 1 acute genitourinary toxicity was the highest in frequency observed in 28 of the total population followed by grade 2 in 21, grade 0 and grade 3 each, only in 2 patients. Late genitourinary Grade 0 toxicity was observed in 32 patients, grade 1 in 19, grade 2 and 3 only in 1 patient of the total population, respectively. CONCLUSION: Our data were comparable to international studies of dose escalation using 3D and beneficial as compared to conventional radiation therapy delivered by 2D in terms of biochemical failure rate and treatment related toxicity.

Efficacy and Toxicity of Concurrent Chemoradiation in Inoperable Oral Carcinoma in Pakistani Population.

OBJECTIVE: To evaluate the efficacy of concurrent chemoradiation in patients with locally advanced inoperable squamous cell carcinoma of oral cavity in terms of local control and toxicity. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Institute of Nuclear Medicine and Oncology (INMOL), Lahore, from January 2008 to December 2013. METHODOLOGY: Sixty-nine patients with locally advanced inoperable oral cavity cancer, registered in INMOL hospital from January 2008 to December 2013 who fulfilled a pre-defined eligibility criteria, were enrolled in the study. Concurrent chemoradiation protocol consisted of conventional fractionation delivering 70 Gy with weekly Cisplatin (50 mg/m2) during the course of radiation. Tumor response was calculated by RECISTcriteria version 1.1 along with the median overall survival and disease-free survival. Acute treatment related toxicities were graded as (G). RESULTS: Thirty-six (52.17%) patients showed complete response; while 19 (27.54%), 8 (11.59%) and 6 (8.7%) were observed with partial response, stable and progressive disease, respectively. Treatment response was significant (p<0.001) in terms of responders vs. non responders to treatment. Median overall survival was 18.00 months; whereas, median disease-free survival remained 14.00 months. Main toxicities included mucositis (G3 and G4, 71%), xerostomia (G2 and G3, 82.5%), vomiting (G3 and G4, 51%), myelosuppression (G3 and G4, 26.2%), dermatitis (G3 and G4, 49.2%), and fatigue (G3 and G4, 57.9%). CONCLUSION: Platinum based CCR Tremained effective for inoperable oral cancer patients.

Cervical cancer: outcome of treatment and causes of failure.

OBJECTIVE: To summarize the data and look into the various treatments offered to cervical cancer patients at Institute of Nuclear Medicine and Oncology (INMOL) to highlight the most likely causes of treatment failure. METHODS: In this retrospective study, case files of all patients presenting with invasive carcinoma of uterine cervix during 1993-2002 were studied in respect to personal profile, disease related risk factors, pathological characteristics, treatment administered and outcome in the form of tumour response and survival. RESULTS: Early age at marriage, multiple marriages of self or spouse, multiparty, prolonged use of contraceptives and smoking were some of the risk factors for cervical cancer in this group of patients. Out of 618 patients presenting with invasive cervical cancer, 65% presented in advanced stages II and III. Apart from advanced stage at presentation, anaemia, poor nutrition, and ignorance about self-hygiene and lack of follow-up were main causes of treatment failure. Outcome of treatment was improved when chemotherapy was added to radiation. CONCLUSION: Advanced stage at diagnosis and lack of follow-up were main causes of treatment failure. Implementation of screening programs on national level for early detection is therefore recommended.

Unusual Presentation of Bone Metastasis from Hepatocellular Carcinoma Mimicking as Breast Lump.

A 55-year female presented with left breast lump. Her sonomammography was unremarkable. Core biopsy showed it to be metastatic hepatocellular carcinoma (HCC). Biphasic computerized tomography (CT) of liver confirmed presence of primary liver masses while CTchest showed involvement of left anterior chest wall, rather than primary breast mass. F18-Fluorodeoxyglucose (FDG) positron emission tomography CT(PET-CT) imaging confirmed primary liver tumor with bony metastases.