A comprehensive Study of the Out of Field Non Target Dose Associated with 6 and 10 MV Flattened and Flattening Filter Free X Ray Beam in a True Beam Linear Accelerator.

AIM: To evaluate the out-of-field dose associated with flattened (FF) and flattening filter-free (FFF) 6 and 10 MV X-ray beams in a TrueBeam linear accelerator (Linac). MATERIALS AND METHODS: Measurements were taken in a slab phantom using the metal oxide semiconductor field effect transistor (MOSFET) detector at varying depths (dmax, 5 cm, and 10 cm) for clinically relevant field sizes and up to 30 cm from the field edges for 6 and 10 MV FF and FFF beams in TrueBeam Linac. Dose calculation accuracy of the analytic anisotropic algorithm (AAA) and Acuros algorithm was investigated in the out-of-field region. Similarly, the out-of-field dose associated with volumetric modulated arc therapy (VMAT) head-and-neck plan delivered to a body phantom was evaluated. RESULTS: The out-of-field dose for both FF and FFF photon beams (6 and 10 MV) decreased with increasing distance from the field boundary and size. Furthermore, regardless of FF in the field, higher-energy photon beams were associated with lower out-of-field dose. Both algorithms underestimated the dose in the out-of-field region, with AAA failing to calculate the out-of-field dose at 15 cm from the field edge and Acuros failing to calculate out-of-field radiation at 20 cm. At 5 cm from the field edge, an average of 50% underestimation was observed, and at 10 cm, an average of 60% underestimation was observed for both FF and FFF (6 and 10 MV) beams. The VMAT head-and-neck plan performed with the FFF beam resulted in a lower out-of-field dose than the FF beam for a comparable dose distribution. CONCLUSION: Compared with flattened beams, the FFF modes on TrueBeam Linac exhibited a clinically relevant reduction in the out-of-field dose. Further dosimetric studies are warranted to determine the significant benefit of FFF beams across different cancer sites.

Comparison of two schedules of hypo-fractionated radiotherapy in locally advanced head-and-neck cancers.

Aim: In India, more than 70% patients present as locally advanced head-and-neck cancers (LAHNC), with poor performance status and are suitable candidates for palliative radiotherapy (RT) aimed at symptom relief. This prospective study aims to compare two different short course hypo-fractionated RT regimens in patients of LAHNC at a regional cancer centre of north-west India. Materials and Methods: A total of 70 patients of LAHNC were randomized to receive palliative RT in two groups of 35 each. Group A received 30 Gy/10# over 2 weeks and Group B received 20 Gy/5# over 1 week. Baseline symptoms of pain, dysphagia, insomnia, dysphonia, bleeding, fungation, and dyspnea were assessed before the start of study. The first assessment for toxicities, subjective and objective response was done at the conclusion of RT and then after 4-6 weeks. Results: Out of total 70 patients, 71% were males and 29% were females with a median age of 54 years. The most common sites were oropharynx (39%) followed by larynx (24%), oral cavity (20%), and hypopharynx (17%). Nearly 60% of the patients in both groups presented in stage IV and 40% in stage III. At conclusion of RT and at 4-6 weeks follow-up, both groups showed similar results in terms of symptom palliation, objective response, and acute toxicities. Group B showed higher incidence of Grade III and above mucositis (P = 0.027). Median overall survival was found to be 5.9 months (range 1-15 months) in group A and 6.1 months (range 1-18 months) in Group B. Conclusion: Hypo-fractionated RT promises to effectively relieve symptoms in LAHNC and reduces the need of analgesics and hospital visits. Furthermore, a shorter overall treatment time is beneficial at high volume centers and is also welcomed by patients with shorter life expectancy.

Analysis of outcomes and prognostic factors of acute lymphoblastic leukemia patients treated by MCP841 protocol: A regional cancer center experience.

BACKGROUND: A dramatic improvement in the survival of acute lymphoblastic leukemia (ALL) patients in the last three decades has been observed. MCP 841 protocol is an old but effective tool with tolerable toxicities. The objective of this study was to estimate the relapse-free survival of ALL patients treated uniformly with MCP 841 protocol on the basis of various prognostic factors. MATERIALS AND METHODS: The study design was retrospective and it was conducted in a regional cancer center of Northwest India. Three hundred and ten ALL patients who underwent treatment with MCP 841 protocol and regular follow-up for up to 5 years were selected for this study. Relapse-free survival was calculated by Kaplan-Meier analysis and Cox regression analysis was used to calculate the hazards ratio (HR) using Statistical Package for the Social Sciences (SPSS) software for windows version 20.0. RESULTS: Fifty-four percent patients were <15 years of age and 69% were males. 53.2% patients were in remission at the end of 5 years of starting the treatment. Relapse-free survival at 5 years by Kaplan-Meir analysis for B-cell ALL was 62% [HR 0.67 {95% confidence interval (CI) 0.47-0.95}] with patients with unknown lineage taken as reference] while for T cell it was 28% [HR 1.41 (95% CI 1.19-1.63), P 0.001]. Patients with total leukocyte count (TLC) <1 lakh/cmm at presentation, relapse-free survival was 68% and those with TLC >1 lakh/cmm had 41% survival [HR 2.14 (1.76-2.48) with, P < 0.001]. CONCLUSION: MCP 841 protocol is a useful tool for the treatment of ALL in children when more aggressive protocols can not be used.

Pros and Cons of Adding of Neoadjuvant Chemotherapy to Standard Concurrent Chemoradiotherapy in Cervical Cancer: A Regional Cancer Center Experience.

BACKGROUND: The present study summarizes the results of treatment in the form of disease-free survival and overall survival in bulky stage IB2 and locally advanced (stages II-IVA) squamous cell carcinoma of the uterine cervix. The treatment has been given in the form of NACT followed by CCRT in one arm and CCRT in the other arm. MATERIALS AND METHODS: This retrospective study analyzed 713 cervical cancer patients who were treated at our center during 2007 and 2008; out of 713 patients, data of 612 patients have been compared. The patients' data were analyzed retrospectively. Patients had undergone PF 28.6 %, TPF 21.5 %, and only CCRT 49.9 %. Majority of patients were in the age group 41-50 years, while stage wise, mainly stage IIIb and IIb. Disease-free survival was observed on the basis of stage and NACT. The survival analyses were performed using the Kaplan-Meier method. All statistical calculations were done with SPSS Statistics version 20.0. RESULTS: For cancer cervix NACT versus CCRT, the DFS rate was at 5 years (58.3 vs. 41.8 % p = 0.001). NACT followed by CCRT demonstrated significantly superior DFS as compared to definitive CCRT, respectively, TPF (hazard ratio (HR) = 0.248, 95 % confidence interval (CI) 0.123-0.500; p < 0.001), PF (HR = 0.445, 95 % CI 0.266-0.722; p = 0.002). The results of univariate stage, age, and multivariate study show that stage hemoglobin level, interval between external-intracavitary radiation, and type of neoadjuvant chemotherapy were the factors affected survival cervical patients treated with radiation. The grade 3/4 hematologic toxicities were more in the NACT group than CCRT (p < 0.001) while the non-hematological toxicity was not significant; the TPF group experienced more toxicity than PF (p = 0.029). This treatment regimen is feasible as evidenced by the acceptable toxicity of NACT and by the high compliance to radiotherapy. The grade 3/4 hematologic toxicities were more in NACT groups than CCRT (p < 0.001); the TPF group experienced more toxicity than PF (p = 0.029). CONCLUSION: TPF/PF as NACT is feasible and produces impressive responses in cancer cervix.

Metronomic therapy with oral 6-mercaptopurine in elderly acute myeloid leukemia: A prospective pilot study.

INTRODUCTION: Acute myeloid leukemia (AML) in elderly patients differs biologically from that in younger patients and is known to have unfavorable chromosomal rearrangements, higher resistance, and lower tolerance to chemotherapy. In such circumstances, instead of giving full-blown chemotherapy, palliative metronomic chemotherapy (MCT) could be a treatment option. PATIENTS AND METHODS: We performed a prospective pilot study of old AML patients (age >60 years) not amenable to curative treatment. Thirty-two patients were enrolled into the study and were treated with daily oral 6-mercaptopurine 75 mg/m(2). The following inclusion criteria were used: age >60 years, nonpromyelocytic AML, the absence of uncontrolled comorbidities, and patient not amenable to curative treatment. Overall survival (OS) was calculated using Kaplan-Meier method and Cox regression analysis were used to calculate the hazards ratio of significant factors. RESULTS: The median age of the patients was 69 years (range: 61-86 years) with male: female ratio of 2.5:1. About 59.4% of patients had Eastern Cooperative Oncology Group performance status of 2 while rest had the status of 3. The median OS was 6 months (95% confidence interval [CI]: 4.4-7.6). Males had median OS of 7 months (95% CI: 5.4-8.6) versus females with OS of 3 months (95% CI: 1.5-4.4; P = 0.008). There was no survival difference on the basis of baseline hemoglobin or French-American-British class. There were no Grade 4 toxicities and no episode of febrile neutropenia. CONCLUSIONS: MCT with oral 6-mercaptopurine is an attractive treatment option in elderly AML patients who are not amenable to curative therapy with minimal toxicities.

Management of uveal tract melanoma: A comprehensive review.

Uveal tract melanoma is the most common primary intraocular malignancy in adults, accounting for about 5-10% of all the melanomas. Since there are no lymphatic vessels in the eye, uveal melanoma can only spread hematogenously leading to liver metastasis. A wide variety of treatment modalities are available for its management, leading to dilemma in selecting the appropriate therapy. This article reviews the diagnostic and therapeutic modalities available and thus, can help to individualize the treatment plan for each patient.

Giant cell variant of malignant fibrous histiocytoma of male breast: A rare case report.

Malignant fibrous histiocytoma (MFH) is the most common form of soft tissue sarcoma during middle and late adulthood in the deep connective tissue of the extremities, abdominal cavity, and retroperitoneum. However, primary breast sarcoma is a rare disease entity, comprising less than 1% of all breast malignancies. MFH of the male breast is very rare. We present a case of MFH of giant cell variant of the right breast in a 50-year-old male who presented with a painless lump. Following cytological investigation, simple mastectomy was performed. Immunohistochemical staining confirmed the diagnosis.

Necessity of CT-MRI based treatment planning for cervical tumors with retroverted uterus: A case report with review of literature.

Treatment of carcinoma cervix is a complex issue influenced by numerous factors, including the patient's age, clinical stage of the disease, position of the uterus, comorbidities, etc. The major drawback of the conventional four-field box technique is the lack of complete information about the flexion of the uterus and topography of the tumor. These are further influenced by bladder and rectal filling, which may lead to geographical miss of the clinical target volume (CTV). This problem was noticed mainly in the anterior and posterior borders of the lateral fields and in the superior and lateral borders of the anteroposterior fields. We demonstrate the need for computed tomographic-magnetic resonance imaging (MRI)-based 3D planning of each patient and necessity of sagittal MRI for designing lateral portal in case of conventional four-field technique through an example of a patient's sagittal MRI of pelvis showing retroverted uterus.

Astroblastoma of cerebrum: A rare case report and review of literature.

Astroblastoma is a rare neuroepithelial primary brain tumor of uncertain origin. They form 0.45-2.8% of all the neuroglial tumors. This tumor is usually localized in the cerebral hemisphere of young adults and children. The authors report a case of low-grade astroblastoma in a 16-year-old male and review the relevant literature. The patient presented with 2 months history of progressive headache with projectile vomiting for last 2 months. He underwent gross total resection of the lesion through right temporo-occipital craniotomy. Since tumor showed no evidence of high-grade lesion, adjuvant radiotherapy was not planned. However, the patient developed recurrence of the tumor after 12 months. Localized three-dimensional conformal radiotherapy was planned. In patients harboring anaplastic astroblastoma, gross-total resection and adjuvant therapy after the initial surgery seems to be the best choice. They can be easily misdiagnosed as they are rarely encountered in clinical practice and share common radiological and histopathologic appearance with other glial neoplasms.

Sociodemographic Parameters of Esophageal Cancer in Northwest India: A Regional Cancer Center Experience of 10 Years.

BACKGROUND: Despite various advances in the treatment of Esophageal Cancer (EC), being one of the least responsive tumors to cancer therapy, the overall prognosis remains poor. Therefore, it is significant to understand various sociodemographic factors associated with EC to find out various schemes for primary prevention of the disease. MATERIALS AND METHODS: This is a retrospective analysis of medical records of the EC patients registered in the regional cancer center of northwest India from January 2003 to December 2012. The site of the disease and the histology were also recorded in addition to the various sociodemographic parameters. RESULTS: Out of 55,742 patients registered in our hospital; 3,667 were diagnosed to have EC. Male:female ratio was 1.15:1. The mean age was 54.6 ± 11.74 years; 66.15% of the patients were illiterate and 48.6% belonged to the low socioeconomic status. Smoking and alcohol consumption were identified as risk factors in 48 and 25.6% of the patients, respectively. CONCLUSIONS: The etiology in majority of the patients is linked to tobacco and alcohol, thus, modification of life style with limiting the use of addictions may be an effective strategy in the prevention of this dreaded and mostly incurable disease.

Isolated clival metastasis as the cause of abducens nerve palsy in a patient of breast carcinoma: A rare case report.

Metastatic lesions to the clivus have been reported in various cancers including lung cancer, prostate carcinoma, skin melanoma, and hepatocellular carcinoma. There have been only a few reports of breast cancer presenting with isolated clival metastasis. We report a case of 35-year-old lady, who was known case of breast carcinoma presented with diplopia as the only sign of clival metastasis. The etiology was established by magnetic resonance imaging which showed an enhancing lesion in the clivus. The diagnosis of clival metastasis from breast cancer was confirmed by transsphenoidal biopsy.

Analysis of patterns of palliative radiotherapy in north west India: a regional cancer center experience.

BACKGROUND: Palliative radiotherapy (PRT) is the eventual requirement in 30-50% of all cancer patients. PRT is primarily aimed to relieve pain and prevent/treat collapse or fracture in case of bone metastasis, to reduce edema in patients with cranial metastasis, and to control distressing symptoms of rapid primary growth. An audit of PRT planned in a busy cancer center can help in the characterization of the requirements of the patients and the formulation of institutional policies. MATERIALS AND METHODS: In total, 516 patients who received PRT in our regional cancer center from January 2012 to December 2012 and whose complete records were available for analysis were selected for this retrospective study. Medical records and radiotherapy files were analyzed to obtain data such as sociodemographic parameters, prescription of PRT, and follow up. Descriptive statistics were evaluated in terms of frequencies and percentages to allow comparisons. RESULTS: Of the 516 patients, 73% patients were male; the median age of the patients receiving PRT was 62 years (range 13-83 years). About 48% (n = 248) patients received PRT at the primary site while rest (52%) were given PRT at the metastatic site. The most common indication of PRT was pain (56.8% cases), followed by cytostatic PRT (19.8%) and raised ICT (12.4%). The median dose prescribed was 30 Gy (range 8-36 Gy) delivered in 1-12 fractions over the duration of 1-18 days. The overall response rate was about 43% at 2 weeks of completion of PRT; the median follow-up of the patients was 154 days (range 9-256 days). The long-term symptom relief at median follow up was 8%. CONCLUSIONS: Good clinical judgment and expertise is required in prescribing correct fractionation schedule to achieve effective symptom palliation with lowest possible cost and inconvenience to the patients and relatives. Hypofractionated radiotherapy is a feasible treatment option in patients with advanced incurable disease to achieve effective palliation.

Addition of magnetic resonance imaging to computed tomography-based three-dimensional conformal radiotherapy planning for postoperative treatment of astrocytomas: Changes in tumor volume and isocenter shift.

INTRODUCTION: Postoperative radiotherapy is the current gold standard treatment in astrocytomas. Computed tomography (CT)-based radiotherapy planning leads to either missing of the tumor volume or underdosing. The aim of this prospective study was to study the changes in tumor volume on addition of magnetic resonance imaging (MRI) to CT-based three-dimensional radiotherapy treatment planning of astrocytomas. MATERIALS AND METHODS: Twenty-five consecutive patients of astrocytoma (WHO grades I-IV) for postoperative three-dimensional conformal radiotherapy were included in this prospective study. Postoperative tumor volumes were contoured on CT-based images and recontoured on CT-MRI images after automated MRI co-registration on treatment planning system Eclipse 8.9.15 as per ICRU-50 report. Tumor volumes were compared with each other. RESULT: The MRI-based mean and median tumor volume was 24.24 cc ± 13.489 and 18.72 cc (range 5.6-46.48 cc), respectively, while for CT it was 19.4 cc ± 11.218 and 16.24 cc (range: 5.1-38.72 cc), respectively. The mean and median isocenter shift between CT and MRI was 4.05 mm and 4.39 mm (range 0.92-6.32 mm), respectively. There is a linear relationship between MRI and CT volume with a good correlation coefficient of R (2) = 0.989, and MRI-based tumor volume was 1.208 times as compared to CT volume. Statistical analysis using paired sample t-test for the difference in CT and MRI tumor volume was highly significant (P < 0.001). CONCLUSION: Addition of MRI to the CT-based three-dimensional radiation treatment planning reduces the chances of geographical miss or tumor under dosing. Thus, MRI should be an integral part of three-dimensional planning of astrocytomas.

Cancer related fatigue: A ubiquitous problem yet so under reported, under recognized and under treated.

BACKGROUND: Cancer related fatigue (CRF) is a problem that is highly under reported, under recognized and thus, under treated. About 80% of patients receiving chemotherapy/radiotherapy experience CRF, making it the most common side effect of cancer treatment. Functional assessment of chronic illness therapy fatigue (FACIT-F) version-4 is a 13 item questionnaire that has been used to measure the level of fatigue of cancer patients during their daily activities over the past 7 days. MATERIALS AND METHODS: 92 patients of age 18 years and above attending the oncology Out Patient Department (OPD) of a regional cancer center were recruited in this study and were given FACIT-F questionnaire. The relevant sociodemographic parameters were obtained from the medical records of the patients. The internal consistency of the 13 items was measured using the Cronbach's alpha. RESULTS: The Cronbach alpha coefficient for FACIT-F scale in our study was found to be 0.74. Kendall's coefficient of concordance was estimated to be 0.080. The correlation between Eastern Cooperative Oncology Group (ECOG) performance status and mean score of FACIT-F was studied, Pearson correlation coefficient was estimated to be 0.271 (P = 0.009). CONCLUSIONS: FACIT-F is a brief, simple, easy to administer and patient friendly tool to measure the fatigue in last 7 days. CRF should be given adequate attention from the beginning of the treatment to improve the quality of life of cancer patients.

Comparison of single versus multiple fractions for palliative treatment of painful bone metastasis: first study from north west India.

BACKGROUND: Bone metastasis is a usual cause of pain in advanced cancer. Conventional radiation schedules require larger hospital stay and thus are not suitable for patients with poor general condition. This prospective observational study aims to compare the pain-relieving efficacy of different radiation fractionation schedules, i.e., 8 Gy administered in a single fraction versus 30 Gy administered in 10 fractions. MATERIALS AND METHODS: Two hundred and fifty consecutive patients of bone metastasis were evaluated for the study, with 63 patients being excluded due to non-fulfillment of the inclusion criteria. The response to radiotherapy leading to pain relief as per the Visual Analog Scale was recorded at the end of treatment, 8 days, 15 days and 1 month during the follow-up visits. RESULTS: Sixty-two percent of the patients received a single fraction while the remaining received 10 fractions. In the 10-fraction group, overall response was present in 60% of the patients. Stable pain was present in 23% of the patients while 9% patients had progressive pain. At 1 month of completion of treatment, 9% patients were lost to follow-up. In the single-fraction arm, overall response was seen in 58%, stable pain in 27% and progressive pain in 7% of the patients. Six percent of the patients were lost to follow-up. CONCLUSIONS: Single-fraction treatment for bony metastasis is as effective as multiple fractions to relieve bony pain and provides treatment convenience to both the patient and the caregiver.

High Ligation of Inferior Mesenteric Artery in Left Colonic and Rectal Cancers: Lymph Node Yield and Survival Benefit.

During surgery for colorectal cancer, the inferior mesenteric artery (IMA) may be ligated either directly at the origin of the IMA from the aorta (high ligation) or at a point just below the origin of the left colic artery (low ligation). Sixty patients of left colonic and rectal cancer undergoing elective curative surgery in 2007 and 2008 were selected for this observational study. The resected lymph nodes were grouped into three levels: along the bowel wall (D1), along IMA below left colic (D2), and along the IMA and its root (D3). Statistical analysis was performed with SPSS version 20.0. D2 level was involved pathologically in 20 (33.3 %) and D3 in six out of 44 (13.6 %) patients. The median nodal yield with high and low ligation were 33 and 25, respectively (p = 0.048). Median overall survival for high ligation was 62 months versus 42 months for low ligation (p = 0.190). High ligation of the IMA for rectal and left colonic cancers can improve lymph node yield, thus facilitating accurate tumor staging and thus better disease prognostication, but the survival benefit is not significant.

HMB-45 negative multifocal malignant perivascular epithelioid cell tumor of the soft tissue responding to sirolimus: First case report from India.

Perivascular epithelioid cell tumor (PEComa) is a group of sarcomas that exhibit a myomelanocytic phenotype and possess a unique cell type in the perivascular epithelioid cell. Traditionally HMB-45 immunoreactivity is the first criteria required to consider a tumor to be PEComa. We report a case of multifocal PEComa with negative HMB-45 marker. The patient presented with three big ulceroproliferative lesions; two over right thigh and one over the scalp in the right frontal region. The patient was prescribed with oral sirolimus to which good response was seen. To the best of our knowledge, this is the first case of HMB-45 negative multifocal malignant PEComa from India.

Diagnosis of post-radiotherapy local failures in nasopharyngeal carcinoma: a prospective institutional study.

BACKGROUND: This prospective study was conducted to evaluate and compare the efficacies of nasopharyngoscopy and CT scan in the diagnosis of local failure of external beam radiotherapy (EBRT) for nasopharyngeal carcinoma. METHODS: Total 52 patients of histopathologically proven nasopharyngeal carcinoma treated with external beam radiotherapy (EBRT), were included in this study. For every patient computed tomography (CT), nasopharyngoscopy and nasopharyngeal biopsies were performed 3 months after completion of EBRT. RESULTS: Three months after completion of EBRT, 9 patients (17.3%) had evident disease on histological examination of biopsies. Nasopharyngoscopy showed 77.78% sensitivity, 93.03% specificity, 70% positive predictive value and 95.24% negative predictive value in diagnosing the residual/recurrence of tumor. There was statistically significant agreement between the endoscopic findings and the histological findings (Kappa reliability coefficient=0.562, p<0.01). On the other hand, CT scan showed a 55.56% sensitivity, 39.53% specificity, 16.13% positive predictive value and 80.95% negative predictive value in diagnosing the residual tumor/recurrence. There was no statistically significant agreement between the CT scan findings and the histological findings (Kappa reliability coefficient = 0.038, p>0.05). CONCLUSION: Nasopharyngoscopy should be considered the primary follow-up tool after radiotherapy of nasopharyngeal carcinoma. CT scan should be reserved for patients with histological or any symptomatic indications. Routine postnasal biopsies are not required.

Double primary malignancies: a clinical & pathological analysis report from a regional cancer institute in India.

BACKGROUND: Patients which have diagnosed with a cancer, have a life time risk for developing another de novo malignancy depending on various inherited, environmental and iatrogenic risk factors. Cancer victims could survive longer due to settling treatment modalities, and then would likely develop a new metachronous malignancy.This article aims to report our observed trend of increasing, in prevalence of both synchronous and metachronous second primary malignancy, among the cancer victims, and to review the relevant literature. METHODS: A hospital based retrospective gathering of prospective data, among the patients that have diagnosed with second de novo malignancy.The study has conducted over a 4 years period from 2009 to 2012. All patients that have diagnosed with a histologically proven second malignancy as per Warren and Gates criteria have included. Various details which have regarded site, age at presentation, sex, synchronous or metachronous, treatment have recorded. RESULTS: Among 41 cases of multiple primary malignancies that have observed, 8 were synchronous (19.51%) and 33 were metachronous (80.49%). Out of 41 patients, 25 (60.98%) were females and 16 (39.02%) were males. The most common sites of primary tumor were head and neck cancers that have followed by gynecological cancers, breast cancer, lung cancer, esophageal cancer, and then the others. Among the second malignancy, the most common site was breast and gastrointestinal tract that have followed by lung and gynecological cancers. Out of the total number of cases with double location, 14 tumors (34.15%) have belonged to the breast, out of which 5 (12.20%) have represented first locations and 7 (17.07%) have been second locations. Both locations have belonged to the breast in 2 patients (4.9%). In 5 cases (12.20%), there were associations of breast-cervix and in 6 cases (14.63%), there were association of lung-head & neck cancers. CONCLUSION: The incidence of multiple primary malignancies has not been rare at all. Screening procedures have especially been useful for the early detection of associated tumors, whereas careful monitoring of patients has treated for primary cancer, and then a good communication between patients and medical care team would certify not only an early detection for secondary tumors, but only finally & subsequently, an appropriate management.