Resection and reconstruction of malignant tumor involving sternum.

We present a series of four cases of chest wall tumor, which underwent sternum resection. The methods of resection and reconstruction chest wall defect are discussed and the final outcome highlighted.

Polymodal therapy for high grade gliomas: a case report of favourable outcomes following intraoperative radiation therapy.

High grade gliomas, frequently with their infiltrative nature, often make the outcome from neurosurgical intervention alone unsatisfactory. It is recognized that adjuvant radiochemotherapy approaches offer an improved prognosis. For these reasons, we opted for surgical debulking, intraoperative radiation therapy (IORT) in combination with whole brain irradiation therapy and chemotherapy (temozolamide cycles) in the management of a 42 year-old lady with Glioblastoma Multiforme (GBM). Her troublesome symptoms improved after 3 months of this polymodal therapy and remained independently functional for more than two years.

LINAC based radiosurgery and radiotherapy for neurosurgical diseases: what have we learnt so far.

BACKGROUND: Stereotactic radiosurgery uses a single fraction high dose radiation while stereotactic radiotherapy uses multifractionated lower dose focused radiation. MATERIALS AND METHODS: Radiosurgery used rigid CRW head frame while stereotactic radiotherapy utilized GTC or HNL relocatable frames. Stereotactic planning and radiation involved Radionics X-plan and LINAC system. RESULTS: Since December 2001, we have treated 83 lesions from 77 patients using either radiosurgery or fractionated stereotactic radiotherapy. Eighty six percent (86%) of our treated lesions showed favourable outcomes with median follow-up of 32 months (0-7 years). CONCLUSIONS: Our lessons from LINAC precision radiation therapy uphold its value as a promising and effective tool in treating a range of nervous system pathologies.

Radiation effects on the intima-media thickness of the common carotid artery in post-radiotherapy patients with head and neck malignancy.

BACKGROUND: Post-radiation large vessel injury has not received as much attention as microvascular irradiation injury. A few studies have shown that common carotid intima-media thickness (IMT) is increased after radiotherapy to the head and neck. However, in most of these studies, the irradiated subjects also had other major risk factors for atherosclerosis. In this study, irradiated subjects with major risk factors such as hypertension, diabetes, history of previous cerebrovascular accident and connective tissue disorder were excluded. OBJECTIVE: To show in a cross-sectional study if radiotherapy to the carotid area has any effect on the IMT of the common carotid artery. SUBJECTS AND METHODS: 13 patients with head and neck malignancies who had completed radiotherapy to the carotid region at least 1 year previously underwent ultrasound of the carotid artery. IMT measurements were compared with those of 13 healthy controls, matched for age, sex and race, with no history of radiotherapy. RESULTS: The irradiated subjects had significantly larger IMT measurements (mean 0.74 mm) than the non-irradiated subjects (mean 0.46 mm). The difference was significant (p<0.001) with a confidence interval of 95%. CONCLUSIONS: This study shows that there is a measurable, significant (p<0.001) increase in IMT of the common carotid artery after radiotherapy for head and neck malignancy compared with non-irradiated matched controls. This knowledge is important for risk-benefit assessment of prophylactic or therapeutic neck irradiation. Increased awareness of this complication should provide an opportunity to intervene and prevent future cerebrovascular accidents in the majority of such patients.

An extensive sinonasal osteosarcoma mimicking chondrosarcoma.

Osteosarcoma is a rare tumour in the sinonasal region. Early diagnosis is essential for adequate management and better prognosis and this requires a meticulous histopathological examination. Reported is a case of osteosarcoma misdiagnosed as chondrosarcoma and treated by surgery followed by radiotherapy. However, appropriate diagnosis and pre-operative chemotherapy would have been significant in the prognosis. The pitfall of accurate diagnosis and the subsequent treatment is discussed in order to find the ways to maximize five years survival which is not more than 25% in this type of lesions.

Prognostic factors of differentiated thyroid cancer patients in Hospital Universiti Sains Malaysia.

INTRODUCTION: The aim of this study was to identify the prognostic factors that influence the survival of differentiated thyroid cancer patients treated at Hospital Universiti Sains Malaysia (HUSM). METHODS: A total of 178 patients diagnosed with and treated for differentiated thyroid cancer in HUSM between January 1974 and July 2003 were included in this retrospective cohort study. The additional follow-up period was one year after the end of the recruitment phase. The data was collected from the medical records of the patients. RESULTS: The overall five- and ten-year relative survivals of differentiated thyroid cancer patients in HUSM were 90.6 percent (95 percent confidence interval [CI] 84.4-94.4) and 85.3 percent (95 percent CI 76.0-91.2), respectively. The significant prognostic factors for differentiated thyroid cancer were age (hazard ratio [HR] 6.9; 95 percent CI 1.7-28.6), loss of appetite (HR 10.9; 95 percent CI 2.7-43.7), tumour size (HR 3.7; 95 percent CI 1.1-13.8), regional recurrences (HR 3.2; 95 percent CI 1.1-9.8), high-risk stage (HR 19.9; 95 percent CI 4.4-90.4), and treatment (HR 0.2; 95 percent CI: 0.1-0.5). CONCLUSION: The survival rates obtained in this study were slightly lower than other studies but the pattern of survival rates between groups were similar. Prognostic factors identified in this study were similar to those of other studies, suggesting that the experience of HUSM was almost similar with that of other institutions.

Aggressive giant cell tumour of bone.

INTRODUCTION: The surgical treatment of Stage III or aggressive giant cell tumour of the bone, whether to perform intralesional or en-bloc resection, remains controversial. The aim of this study is to identify the effectiveness of en-bloc resection for local control and final oncological outcome of the disease. METHODS: The data of 20 consecutive patients with Stage III giant cell tumour were retrospectively reviewed to determine the local control and oncological outcome after treatment with wide resection. RESULTS: The majority of the patients presented late with mean duration of symptoms of 24 months, and four patients presented with recurrences. All patients were treated with wide resection except for two patients who underwent ablative surgery due to major neurovascular involvement. Ten patients required free vascularised tissue transfer to cover massive soft tissue defect. Local recurrence occurred in one patient who was again treated with wide resection and vascularised flap. Six patients had pulmonary metastases. Two patients with resectable disease were treated with thoracoscopic surgery and they remained disease-free 36 months after surgery. Two patients with multiple lung metastases were treated with chemotherapy and the disease remained non-progressive. The remaining two patients who refused chemotherapy showed radiological progression, and one succumbed to the disease with massive haemoptysis. CONCLUSION: Aggressive giant cell tumour of bone should be treated with wide resection for better local control, and treatment of pulmonary metastases is mandatory for overall prognosis.

Early Malaysian experience on the use of head and neck localizers in the precision radiotherapy of intra and extra cranial sites for first 28 cases.

Precision Radiotherapy at high doses require a fixed, referable target point. The frame system fulfills the required criteria by making the target point relocatable and fixed within a stereotactic space. Since December 2001, we have treated 28 central and peripheral nervous system lesions using either radiosurgery as a single high dose fraction or fractionated 3-dimensional conformal radiotherapy using a lower dose and a multi-leaf collimator. Various pathological lesions either benign or malignant were treated. Eighty six percent of our treated lesions showed growth restraint, preventing them from causing new symptoms with a median follow-up duration of 20.5 months. However, the true benefit from this technique would require a long-term follow-up to document the progress.

Abdominal aorta and inferior vena cava thromboses in advanced stage of malignant fibrous histiocytoma.

Asymptomatic simultaneous thrombosis of abdominal aorta and inferior vena cava is a rare complication in advanced malignancy. We described an incidental finding of this clinical entity in our patient who presented with advance stage of malignant fibrous hystiocytoma of soft tissue and pathological fracture. The radiological evaluation with spiral computed tomography scan of abdominal aorta and inferior vena cava are presented and the subsequent management highlighted.

Intrarectal formalin application, an effective treatment for grade III haemorrhagic radiation proctitis.

Haemorrhagic radiation proctitis (HRP) is infrequently seen amongst the patients who are either undergoing or have undergone radiotherapy to the pelvis. We treated 16 documented cases of HRP, who did not respond to conventional steroid retention enemas, with 4% formalin application. It was observed that the rectal bleeding was controlled completely in 81% cases in median follow up of 11 months (range 6-17 months) and diversion colostomy could be avoided in all the cases. The effectiveness of local formalin application in severe HRP is described in this article.

Vertebral haemangioma presenting as Kasabach-Merritt syndrome.

A case of spinal cord compression due to vertebral haemangioma is described as presenting as part of the Kasabach-Merritt syndrome, which is characterized by bleeding disorder, thrombocytopenia and leukopenia. A dramatic improvement in neurological status and coagulation profile following surgical decompression and postoperative radiotherapy is reported. A brief review of the literature on the usefulness of radiotherapy is discussed.

Results of radical radiotherapy in carcinoma of the uterine cervix stage I-III.

A retrospective analysis is described of 271 diagnosed cases of carcinoma of the uterine cervix who were treated with radical radiotherapy between January 1987 and July 1988 at the Institute Rotary Cancer Hospital. The mean age at presentation was 49 years and 89% of the tumours were FIGO Stage II and III. The median duration of follow-up was 60 months. The early cases were treated with two intracavitary insertions of 34 Gy each to point A with a Selectron LDR intracavitary system, followed by 36 Gy external radiotherapy to the parametrium. Late stage disease was treated with 50 Gy of external radiotherapy, followed by a single intracavitary insertion of 30 Gy to point A. To compensate for the higher dose rate of the Selectron (180 cGy/h) a dose reduction factor of 15% was applied over the intracavitary dose. There were 2.5% and 4.7% of late Grade III bladder and bowel complications, respectively, requiring surgical intervention. There was no relationship between haemoglobin level at diagnosis and the development of late complications. The actuarial 5-year survivals were 65%, 63% and 35% for Stages I, II and III disease, respectively. This study from the Indian subcontinent shows the effectiveness of radiotherapy in Stages I, II and III carcinoma of the uterine cervix, with acceptable morbidity rates.

Hemostatic radiotherapy in carcinoma of the uterine cervix.

OBJECTIVE: To evaluate the treatment of hemorrhagic carcinoma of the uterine cervix with hemostatic radiotherapy (external and intracavitary radiotherapy). METHOD: Twenty cases of refractory hemorrhagic carcinoma of the uterine cervix receiving hemostatic radiotherapy between April 1987 and May 1992 were analyzed. The age of the patients ranged between 30 and 60 years with a median of 42 years. RESULTS: The mean tumor volume was 130 mm3; all cases were classified as FIGO stage IIb (n = 8), IIIb (n = 11) or IVa (n = 1). Radiotherapy was carried out either by the external or intracavitary technique. The control of hemorrhage was 100% within 12-48 h after radiotherapy. However 85% of patients failed locally in the form of residual, recurrent pelvic or metastatic disease, within 24 months of follow-up. CONCLUSION: Hemorrhagic cervical cancer has a poor prognosis.

Role of radiotherapy in cavernous hemangioma liver.

OBJECTIVE: To study the effectiveness of local radiotherapy for controlling cavernous hemangioma of liver. METHODS: This is a retrospective analysis of four diagnosed cases of cavernous hemangiomas of the liver treated with radiotherapy. Hepatic irradiation was given in a tumor dose of 30 Gy in 15 fractions over 3 weeks period. RESULTS: Three of the four cases showed a complete clinical regression of the liver lesions over a period of 8-14 months, but in one case there was only 75% regression of the mass at 12 months of follow up. CONCLUSIONS: Localized radiotherapy is effective in the treatment of giant cavernous hemangiomas of the liver and a tumor dose of 30 Gy is optimum with minimal morbidity.

Adjuvant treatment in colorectal cancer. Experience from a referral center in eastern peninsular Malaysia.

BACKGROUND: Colorectal cancer is one of the most common malignancies in the West, but in Asia the incidence is low. However in Malaysia, colorectal cancer is increasing with a reported figure of 15% of all cancer cases. Adjuvant chemo and radiotherapy are now more frequently used in such patients. The present retrospective analysis was performed to document the effect of such therapy among patients with colorectal cancer in Malaysia. MATERIALS AND METHODS: This is a retrospective study on the use of adjuvant treatment in colorectal cancers. Patients with histopathological evidence of risk factors were subjected to adjuvant radiotherapy and/or chemotherapy. Cancers confined to rectum and rectosigmoid were subjected to pelvic radiotherapy to a tumor dose of 45 Gy in 20 fractions over 4-week period. 5-flurouracil based chemotherapy was predominantly offered for colonic cancers. RESULTS: One hundred thirty patients with colorectal cancers received adjuvant treatment with a median age of 58 years (range 22-76 years). The male to female ratio was 1.4:1. There were 76% Malays, 19% Chinese, 2% Indians and 3% Siamese subjects in this study. Modified Dukes' stage B2 (28%) and C (38%) constituted the majority, which were distributed in rectum (40%), rectosigmoid (19%), and in the remaining colon (41%). Thirty-one patients received 5-fluorouracil with folinic acid based regime and 35 patients received 5-fluorouracil with levamisole based regimen. Locoregional radiotherapy was offered to 56 (43%) patients. Following treatment, the 2-year actuarial survival was 28% and 54% in colon and rectum cancer respectively. CONCLUSIONS: This study showed that colorectal cancer is not infrequent among Malays in this region and rectal cancers had better survival than the colonic cancers.

Management of retinoblastoma with radiation.

OBJECTIVE: To evaluate the role of radiation therapy in the management of retinoblastoma. DESIGN: Retrospective analysis. METHOD: From January 1993 to March 1994, one hundred and eleven children (150 eyes) of retinoblastoma were referred for radiotherapy. The diagnosis was based on clinical examination and ocular ultrasonogram for both the eyes. The radiation treatment policy involved 40 Gy in 20 fractions over 4 weeks delivered with sedation for children under 1 year of age, 36 Gy in 9 fractions over 3 weeks under ketamine anesthesia for 1-4 years of age and for >4 years of age, a dose of 50 Gy in 25 fractions over 5 weeks. The initial tumor regression was evaluated by A and B mode ultrasonography and/or CT scan. RESULTS: The age distribution ranged from two months to six years (median - 20 months). Bilaterality was observed in 39 out of 111 cases (35%). The male to female ratio was 1.8:1. Eighty two of the 111 children were treated by definitive external beam radiation to one or both eyes. Fifteen cases received adjuvant radiotherapy after enucleation, and 14 had extensive disease for which palliative radiotherapy was offered. We observed a complete response in 54% of cases, partial response in 32%, and none in 14% of cases. Forty per cent (40%) eye survival was documented at the end of 28 months. The complication rate encountered was about 15%. CONCLUSION: Radiotherapy is an effective modality of treatment in significant number of patients with retinoblastoma. However, it requires appropriate fractionation, precise colimation and careful immobilization with general anesthesia.

Brain metastasis as first presentation on carcinoma of the esophagus--a case report.

Cancer of the esophagus can metastasize to lymph nodes, lungs, liver etc. Brain accounts for less than 1% of cases. We encountered one unique case of carcinoma of esophagus who presented with brain secondaries as an initial manifestation. Cancer of the esophagus accounts for less than 1% of the cancers. Due to its inaccessible anatomical location, the diagnosis often gets delayed till late. Initially it tends to spread locally followed by metastasis to the lymph nodes and then to the distant organs. Distant metastasis per se is a relatively rare phenomenon, as locally advanced disease is a common cause of death.

Human leucocytic antigens (HLA) in breast cancer.

HLA frequencies of fifty (50) female breast cancer patients were compared with 200 age matched female controls. A total of 20 HLA-A locus, 35 HLA-B locus and 8 HLA-C locus antigens were studied. The HLA-A2, A11, Aw19 and A30; HLA-B8, B14 and HLA Cw6 were found significantly higher than the controls. The HLA-A11, HLA-Aw19 and HLA-B8 were found protective whereas, HLA-A2, HLA-B14 and HLA-Cw6 were a risk for breast cancer. The prective antigens' probable involvement through immunogenic mechanism in breast cancer is emphasized in this article.

Metastatic disease of the proximal femur.

Since January 1999, ten patients had undergone surgical treatment for metastatic bony lesions of proximal femur at this centre. Seven of these patients were treated for complete pathological fractures, one for impending fracture and one for revision of internal fixation and loosening of hemiarthroplasty. Primary malignancies were located in breast in four cases, prostate in three and one in lung, thyroid and neurofibrosarcoma. Two patients had died within six months after surgery, four after 1 year while the remaining four were still alive. The mean duration of survival was eleven months. Nine patients had been ambulating pain free and there were no failure of reconstruction.

Assessment of knowledge, attitude and exposure to oncology and palliative care in undergraduate medical students.

We conducted a questionnaire survey among 261 year-4 and year-5 medical students containing 27 questions related to cancer, radiotherapy, general oncology and palliative care to assess their knowledge, understanding, and exposure to oncology and palliative care in our medical school. Out of 261 students, 139 students returned their questionnaire for analysis. Twenty nine percent (29%) of the students had rarely visited the Radiotherapy and Oncology unit. There were profound deficiencies in the basic knowledge of cancer (46%), principles of radiotherapy treatment (59%), palliative care (64%), and cancer prevention (48%). They reported no specific teaching about early detection of common malignancies and cancer prevention. The main input of instruction about cancer came from surgery (46%) and pathology (28%) teachings. This study revealed that there is deficiency in cancer education in the undergraduate teaching program in our institution.