Impact of acute hematological toxicity on treatment interruptions during cranio-spinal irradiation in medulloblastoma: a tertiary care institute experience.

To analyze treatment interruptions due to acute hematological toxicity in patients of medulloblastoma receiving cranio-spinal irradiation (CSI). Prospectively collected data from case records of 52 patients of medulloblastoma treated between 2011 and 2014 was evaluated. Blood counts were monitored twice a week during CSI. Spinal irradiation was interrupted for patients with ≥grade 2 hematological toxicity and resumed after recovery to grade 1 level (TLC >3000; platelet count >75,000). Treatment interruptions and hematological toxicity were analyzed. Median age was 11 years. All patients received adjuvant CSI of 36 Gy, followed by boost of 18 Gy to posterior fossa, at 1.8 Gy per fraction. Concurrent chemotherapy was not given. Adjuvant chemotherapy was given after CSI for high risk patients. Spinal fields were interrupted in 73.1% of patients. Cause of first interruption was leucopenia in 92.1%, thrombocytopenia in 2.6%, and both in 5.3%. Median number of fractions at first interruption was 8, with 25% of interruptions in first week. Median duration for hematological recovery after nadir was 5 days for leucopenia and 3 days for thrombocytopenia. Half of the patients had at least 2 interruptions, and 19% subsequently developed grade 3 toxicity. On multivariate analysis, significant correlation with duration of delay was observed for pre-treatment haemoglobin, number of fractions at first interruption, grade and duration of recovery of leucopenia. Acute hematological toxicity with CSI is frequently under-reported. Patients with low pre-treatment hemoglobin, early onset leucopenia, profound leucopenia and prolonged recovery times are at a higher risk of having protracted courses of irradiation. Frequent monitoring of blood counts and timely interruption of spinal fields of irradiation at grade 2 level of hematological toxicity minimizes the risk of grade 3 and grade 4 toxicity, while reducing the interruptions in irradiation of the gross tumour bed.

Primary Intramedullary Spinal High-Grade Glioma: A Case Series with Review of Literature.

AashitaBackground Primary intramedullary high-grade glioma (HGG) and glioblastoma of spinal cord are uncommon tumors of central nervous system. Treatment recommendations are based on current guidelines of intracranial HGG and glioblastoma multiforme (GBM). Methods We retrospectively analyzed records of 9,686 patients who reported to our center over past 7 years. Only three cases of primary intramedullary HGG of spinal cord were found. Results In this article, we have reported three cases of primary intramedullary HGG of spinal cord. A comparison of intracranial and intramedullary spinal HGG and review of literature is presented. Conclusion Despite aggressive treatment using surgery, radiation, and chemotherapy, the survival rates are dismal. Emerging evidence has shown difference in biological behavior of intracranial and spinal HGG. Genetic studies to understand the biology and prospective studies are needed.

Müllerian duct anomalies and their effect on the radiotherapeutic management of cervical cancer.

Radiotherapy plays a major role in the treatment of cervical cancer. A successful radiotherapy program integrates both external beam and brachytherapy components. The principles of radiotherapy are strongly based on the anatomy of the organ and patterns of local and nodal spread. However, in patients with distorted anatomy, several practical issues arise in the delivery of optimal radiotherapy, especially with brachytherapy. Müllerian duct anomalies result in congenital malformations of the female genital tract. Though being very commonly studied for their deleterious effects on fertility and pregnancy, they have not been recognized for their potential to interfere with the delivery of radiotherapy among patients with cervical cancer. Here, we discuss the management of cervical cancer among patients with Müllerian duct anomalies and review the very sparse amount of published literature on this topic.

Impact of age on outcomes in young women with breast cancer.

BACKGROUND: In this study, we compared outcomes in young and very young patients with breast cancer (BC). MATERIALS AND METHODS: Between January 1990 to December 2010, 414 young women (age ≤35 years) with BC were registered in the radiotherapy (RT) outpatient department. Patients were divided into young (31-35 years) and very young (18-30 years). They were compared for clinical, pathological characteristics, and treatment-related factors such as RT and systemic therapy. Outcomes compared between the two groups were locoregional recurrence rate (LRR), local recurrence-free survival (LRFS), disease-free survival (DFS), overall survival (OS), and toxicities. LRFS, DFS, and OS were estimated using the Kaplan-Meier method. RESULTS: Out of 414 patients, 138 and 276 were very young and young, respectively. Clinical, pathological, and treatment characteristics were balanced between the two groups except for more patients in the young group who had pN3 disease and received hormonal therapy; 41 (15%) versus seven (5%) and 171 (62%) versus 62 (45%) in the very young group, respectively. Median follow-up was 84 months (range 12-363 months). LR was seen in 16 (11.6%) and 25 (9%) patients in the very young and young groups, respectively (p = 0.28). The hazard ratios for LR, disease recurrence, and death in the very young group relative to the young group were 1.11 (p = 0.25), 1.0 (p = 1.0), and 1.05 (p = 0.79), respectively. Estimated 10-year LRFS, DFS and OS were 80% versus 86%, 63% versus 61%, and 66% versus 64% in the very young and young groups, respectively. Lymphedema, cardiac toxicity, and second malignancy developed in seven (5%) versus 23 (8%), one (1%) versus three (1%), and seven (5%) versus 18 (7%) patients in the very young and young groups, respectively. CONCLUSION: In very young and young patients with BC, there was no significant difference in LRR, LRFS, DFS, or OS. Toxicities were also comparable between the two groups.

A Rare Occurrence: Triple 'True' Metachronous Endometrial, Nasal Cavity and Recto-Sigmoid Cancer.

Incidence of multiple primary malignancies is reportedly increasing globally. Limited cases of triple metachronous cancers are available in the literature. Here, we report a case of a female with an unusual combination of triple metachronous malignancy over a span of 15 years involving endometrium, nasal cavity and rectosigmoid that has not been reported before in the literature. Keywords: multiple primary malignancy; triple metachronous cancer; nasal squamous cell cancer; endometrial cancer; recto-sigmoid cancer; Lynch Syndrome.

Prospective randomized study comparing concomitant chemoradiotherapy using weekly cisplatin & paclitaxel versus weekly cisplatin in locally advanced carcinoma cervix.

BACKGROUND: To evaluate the benefit with the addition of paclitaxel to cisplatin-based concurrent chemoradiotherapy (C-CRT) for the treatment of locally advanced carcinoma of the uterine cervix in terms of local control, disease free survival (DFS) and overall survival (OS). METHODS: From 1/7/2011 to 31/5/2012, 81 women (median age of 50 years) with newly diagnosed, histopathologically proven carcinoma cervix with FIGO stages IIA to IIIB were randomized to two arms-cisplatin 40 mg/m(2)/week for 5 weeks was given in single agent cisplatin (control arm), while cisplatin 30 mg/m(2)/week and paclitaxel 50 mg/m(2)/week for 5 weeks were given in cisplatin and paclitaxel (study arm). External beam radiotherapy (EBRT) was delivered to a total dose of 50 Gray (Gy) in 25 fractions (#) followed by intracavitary (I/C) brachytherapy or supplement EBRT at 20 Gy/10# with 2 cycles of respective chemotherapy. This prospective trial was registered with clinicaltrials.gov (NCT01593306). RESULTS: Patients (n=81) had a maximum follow up of 36 months with a median follow up of 29 months. At first follow up study arm showed complete response in 84% vs. 75.6% in control arm (P=0.4095). An increase in toxicities was observed in the study arm in comparison to the control arm in terms of haematological grade II (35% vs. 12.2%), gastrointestinal (GI) grade III (20% vs. 7.4%) and GI grade IV (12.5% vs. 2.4%) toxicities. At median follow-up, the study arm demonstrated enhanced outcomes over the control arm in terms of DFS (79.5% vs. 64.3%; P=0.07) and OS (87.2% vs. 78.6%; P=0.27). CONCLUSIONS: Despite the expected increase in manageable toxicities, these early results reveal promise with the inclusion of paclitaxel into the standard cisplatin based chemoradiation regime. Larger multi-institutional studies are justified to confirm a potential for the enhancement of response rates and survival.

MRI for the detection of prostate cancer origin vertebral metastases in the preosteoblastic phase.

This report describes the case of a gentleman aged 59 years presenting with low-back pain, who had underwent radical prostatectomy for prostate cancer 8 years ago. On evaluation, a slightly elevated serum alkaline-phosphatase level prompted a search for bone metastases. Although x-ray radiography and a bone scan were apparently normal, an MRI scan revealed the presence of metastatic marrow infiltration in the lumbar vertebrae. The patient subsequently was initiated on therapy with androgen-deprivation therapy and bisphosphonates, and currently enjoys symptom-free and progression-free survival. The images in this paper intend to impress upon the limitations of bone scan and x-ray radiography with regard to the detection of vertebral marrow infiltration in the absence of cortical bone invasion. In addition, a brief review of the pathophysiology of vertebral metastases arising from prostate cancer is included.