Breaking barriers: supporting hematopoietic stem cell transplant program through collaborative radiation therapy service from a physically distant center.

BACKGROUND: Total body irradiation (TBI) for hematopoietic stem cell transplant (HSCT) has certain distinct advantages, such as uniform dose distribution and lack of drug resistance, but it is not widely available in resource-constrained settings. To overcome the limitations of in-house radiotherapy services in hematology centers, we evaluated the feasibility of conducting HSCT programs in coordination with two physically distant centers using a reduced-intensity TBI protocol. METHODS: Thirty-two patients with a median age of 20.5 years were included in the study. Fifteen patients were diagnosed with aplastic anemia, 10 patients with acute myeloid leukemia (AML), 3 patients with acute lymphocytic leukemia (ALL), and 4 patients with other hematological conditions. Conditioning regimens used were fludarabine plus cyclophosphamide in 29 cases, fludarabine-cytarabine ATG in 2 cases, and busulfan plus fludarabine in 1 case. The TBI dose was 3 Gy in 28 cases and 2 Gy in 4 cases. Patients were followed monthly after TBI, and the major toxicities were recorded. RESULTS: The median follow-up was 22 months. The most common acute complication was acute graft-versus-host disease (GVHD), which occurred in 15.6% of patients. The major late complications were chronic GVHD (9.3%), Cytomegalovirus (CMV) infection (34.3%), and CMV-induced secondary graft failure (6.2%). Seventy-five percent of patients were alive, 21.9% were dead, and 1 patient was lost to follow-up. CONCLUSIONS: HSCT based on TBI is feasible even if the center lacks a radiotherapy facility by coordinating with a remote radiotherapy facility. without compromising the patient's outcome.

Ethno-geographic distribution and histopathological classification of nasopharyngeal carcinoma in a single center in Nepal.

INTRODUCTION: Nasopharyngeal carcinoma (NPC) shows geographic and ethnic variation with specific etiopathogenesis. This study characterized the distribution of NPC patients stratified by ethnicity, geography, and histology in a tertiary-level cancer center in Nepal. METHODS: A descriptive retrospective study was designed to analyze NPC cases from different regions among patients visiting the hospital from 2016 to 2021. Demographic and clinical information was obtained from medical records. Ethical approval was granted by the Nepal Health Research Council (NHRC). Data analyses and visualization were carried out with R software. RESULTS: During the six-year period, a total of 65 individuals were diagnosed with NPC, comprising 42 males and 23 females. Patient median age was 43 years (range 11-85 years). A bimodal age distribution of cases was observed with peaks in patients aged 30-39 years and 50-59 years. Of the NPC patients studied, 29 were from Koshi Province, with 7 cases from Ilam district and 6 cases from Morang district. There were 18 patients in Bagmati Province, and Kathmandu district had the highest number of cases within this region, with 8 patients. The highest proportion of cases were observed among patients of Janajati ethnicity (60%), including Rai, Limbu, and Sherpa people. Histologically, undifferentiated non-keratinizing NPC was the most commonly observed subtype, accounting for 43.1% of cases, followed by 20% differentiated non-keratinizing NPC and 4.6% keratinizing NPC across the entire sample population. The majority of patients (75.3%) were diagnosed at an advanced stage (stage III or IV) with none diagnosed at stage I. CONCLUSIONS: In our study, most cases of NPC occurred in patients from provinces in eastern Nepal (Koshi province), and of the Janajati ethnic community. The most common histological subtype was undifferentiated non-keratinizing carcinoma. Further epidemiological studies could address differences in prevalence and the challenge of late presentation of NPC patients in Nepal.

Interstitial brachytherapy for internal mammary node in breast cancer: A case report.

This case study reports the feasibility, safety, and efficacy of interstitial brachytherapy for internal mammary nodal recurrence in a 68-year-old woman with triple-negative breast cancer. The patient had previously undergone mastectomy followed by chemotherapy and radiotherapy. However, an internal mammary node was discovered during a routine follow-up a year later, which was confirmed as metastatic carcinoma by fine needle aspiration, with no other metastatic lesions. The patient underwent interstitial brachytherapy under ultrasound and computed tomography (CT) guidance, with a prescribed dose of 20 Gray in one fraction. Follow-up CT scan imaging over a 2-year period of treatment showed a complete resolution of internal mammary node. Therefore, brachytherapy may be considered a potential treatment option for cases of isolated internal mammary node recurrence in breast cancer.

Hematopoietic Stem Cell Transplantation in Nepal: International Partnership, Implementation Steps, and Clinical Outcomes.

Blood and marrow transplantation (BMT) is rarely available in many low- to middle-income countries (LMICs). In 2012, Civil Service Hospital, a government hospital in Kathmandu, partnered with the University of Illinois at Chicago to consult on the establishment of BMT in their hospital, train staff, and promote educational activities. The implementation of BMT occurred in 3 phases over 4 years and included regular onsite visits, training of personnel in Chicago, continuous remote communication, and co-organization of educational events in Kathmandu. The Nepalese government funded the construction of a state-of-the art BMT unit and stem cell laboratory inside Civil Hospital. Autologous (auto) hematopoietic stem cell transplantation (HSCT) was started in 2016, and allogeneic (allo) HSCT from matched related donors (MRDs) or haploidentical (haplo) donors was initiated in 2017. The cost of transplantation was $5200 for auto-HSCT, $10,000 for MRD HSCT, and $13,300 for haplo HSCT. The major socioeconomic determinants reported by Nepalese BMT providers were the cost of transplantation, loss of revenue of the patient and/or caregiver, and cost of transportation. All patients (n = 66) received peripheral blood stem cell grafts, and all allo-HSCT recipients were given post-transplantation cyclophosphamide as graft-versus-host disease (GVHD) prophylaxis. Among recipients of auto-HSCT (n = 30), with a median follow-up of 1029 days (range, 130 to 1653 days), 87% were alive, and transplantation-related mortality (TRM) was 10%. Among allo-HSCT recipients (n = 36), all patients engrafted, and at a median follow-up of 204 days (range, 12 to 1131 days), 75% of them were alive (MRD, 71%; haplo, 83%), with a TRM of 19%. Only 3 of 36 patients developed acute GVHD grade II-IV. The median overall survival in auto-HSCT recipients was 1610 days and was not reached in allo-HSCT recipients. The long-lasting partnership with University of Illinois at Chicago helped build capacity and allowed the Civil Service Hospital team to establish a BMT program in Nepal that has high quality standards at an affordable cost for the majority of patients.

Intradural extra medullary hemangiopericytoma of dorsal spine.

PURPOSE: Spinal hemangiopericytoma is a rare neoplasm that behaves similar to intracranial hemangiopericytoma, with approximately 60 cases being reported in the literature of which only 10 are located in the intradural extramedullary (IDEM) location. METHODS: We report a rare case of recurrent IDEM hemangiopericytoma of dorsal spine in a 16-year-old boy treated with surgery and adjuvant radiotherapy. RESULTS: Patient is disease free at 5 years posttreatment with residual neurological deficit, but is able to carry out his activities of daily living. CONCLUSION: Gross total resection, if feasible, followed by radiotherapy is the initial treatment of choice as radiotherapy improves recurrence free survival as well as overall survival.

Breaking bad news issues: a survey among radiation oncologists.

INTRODUCTION: Discussion of bad news and resuscitation in terminal cancer is an important but difficult and often neglected issue in day-to-day oncology practice. MATERIALS AND METHODS: We interviewed 35 radiation oncologists using an indigenous 15-item questionnaire on their beliefs about breaking bad news and resuscitation to terminal cancer patients. RESULTS: Most responders had an oncology experience of three to seven years (20/35). Thirty-two were comfortable discussing cancer diagnosis, prognosis and life expectancy-related issues. A similar number believed all cancer-related information should be disclosed, while only four believed in imparting all information in one visit. All agreed that disclosing sensitive information did not affect survival. When requested by relatives to withhold truth from patients, 11 said they would not comply, 22 agreed to tell the truth only if asked and two agreed to avoid difficult questions. Twenty responders denied having been adequately trained in breaking bad news and were keen on dedicated classes or sessions in this area of practice. Most (33/35) believed that Indian patients were keen on knowing their diagnosis and prognosis. Although all agreed to the importance of discussing resuscitation, only 17 believed patients should be involved. Majority (20/35) agreed that the issue needs to be discussed while the patient was conscious. Patients with unsalvageable disease were deemed unsuitable for aggressive resuscitation by 30 responders while the rest believed it should be offered to all. Most (21/35) admitted to feeling depressed after breaking bad news though only seven felt disclosure was more stressful than untruthful statements. Only four knew of a law regarding resuscitation in cancer. CONCLUSION: Observing the widely varied beliefs and practices for disclosing bad news, it is recommended that such training be a regular part of medicine curriculum, especially in the Oncology setting.