Clinical profile and outcomes in cervical cancer: An audit from a tertiary cancer center.

Background: Carcinoma cervix contributes to a major proportion of cancer treatment in tertiary oncology centers. The outcomes are dependent on multiple factors. We conducted an audit to establish the pattern of treatment practiced for carcinoma cervix at the institute and suggest changes thereof to improve the quality of care. Methodology: A retrospective observational study of 306 diagnosed cases of carcinoma cervix was carried out for the year 2010. Data was collected with regards to diagnosis, treatment, and follow-up. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20. Results: Out of 306 cases, 102 (33.33%) patients received only radiation therapy and 204 (66.66%) patients received concurrent chemotherapy. The most common chemotherapy used was weekly cisplatin 99 (48.52%), followed by weekly carboplatin 60 (29.41%) and three weekly cisplatin 45 (22.05%). Disease-free survival (DFS) at 5 years was 36.6% with patients of overall treatment time (OTT) of <8 weeks and >8 weeks showing DFS of 41.8% and 34% (P = 0.149), respectively. Overall survival (OS) was 34%. Concurrent chemoradiation improved overall survival by a median of 8 months (P = 0.035). There was a trend towards improved survival with three weekly cisplatin regimen, however, insignificant. Stage correlated with improved overall survival significantly with stage I and II showing 40% and stage III and IV showing 32% (P < 0.05) OS. Acute toxicity (grade I-III) was higher in the concurrent chemoradiation group (P < 0.05). Conclusion: This audit was a first of its kind in the institute and threw light on the treatment and survival trends. It also revealed the number of patients lost to follow-up and prompted us to review the reasons for it. It has laid the foundation for future audits and recognized the importance of electronic medical records in the maintenance of data.

Estimation of dose-volume parameters of female urethra as organ-at-risk during interstitial brachytherapy in gynecological malignancies.

PURPOSE: Interstitial brachytherapy (ISBT) is often used as post-external beam radiotherapy (EBRT) to treat locally advanced gynecological malignancies. Female urethra is in close proximity to the target during ISBT. However, it has not been evaluated as an organ-at-risk (OAR). Overlapping symptoms caused by radiation-induced bladder toxicity vs. urethral toxicity make it difficult to identify and report urethral toxicities separately. This was a retrospective study to estimate dose-volume parameters of female urethra during high-dose-rate ISBT. MATERIAL AND METHODS: Data of 24 patients with gynecological malignancies treated by ISBT were selected. Urethra and periurethral regions were retrospectively contoured. Mean volume, Dmax, Dmean, D2cc, D1cc, D0.5cc, D0.2cc, and D0.1cc were documented. Unpaired t-test was used for comparison of means. RESULTS: 20/24 Ca. cervix, 1/24 Ca. vagina, and 3/24 Ca. vaginal vault received 6-6.5 Gy in 4 ISBT fractions. Mean urethral length was 3.54 ±0.55 cm. Mean doses received by urethra per BT fraction were Dmax = 4.23 ±1.32 Gy, Dmean = 2.71 ±1.01 Gy, D0.2cc = 3.31 ±1.07, and D0.1cc = 3.54 ±1.09 Gy. Comparison of total BT 2 Gy equivalent dose (EQD2) with 4 fractions for urethra between patients with (9/24) and without anterior vaginal wall (15/24) involvement included Dmean = 18.79 ±7.49 Gy vs. 11.14 ±6.15 Gy*, D1cc = 10.90 ±10.03 Gy vs. 4.54 ±3.93 Gy*, D0.5cc = 19.50 ±8.69 Gy vs. 11.97 ±6.54 Gy*, D0.2cc = 23.78 ±8.94 Gy vs. 15.51 ±7.39 Gy*, and D0.1cc = 25.88 ±9.37 Gy vs. 17.39 ±8.03 Gy*, respectively (*p < 0.05). CONCLUSIONS: Female urethra receives significant doses during ISBT for gynecological malignancies, especially when the anterior vaginal wall is within the target volume. Reporting doses to urethra would enable to develop clinical correlation and dose-volume constraints for urethra as organ-at-risk in future.

Evaluation of dosimetric impact of inter-application and intra-application variations in fractionated high-dose-rate intra-cavitary brachytherapy of cervical cancer.

PURPOSE: To evaluate feasibility and safety of execution of optimized intra-cavitary brachytherapy (ICBT) plan of first fraction in subsequent fractions in high-volume, low-resource centers. MATERIAL AND METHODS: This non-randomized prospective study included 30 cervical cancer patients, who underwent 4 fractions of high-dose-rate (HDR)-ICBT in 2 applications, one week apart, 2 fractions per application delivered on two consecutive days. Computed tomography (CT) simulation was done before each fraction, organs at risk (OARs) were contoured on all sets of CT images. Optimized plans were generated for each set of CT images and executed for the treatment. Test treatment plans were retrospectively generated by applying first treatment fraction's dwell times adjusted for decay, and dwell positions of the applicator for subsequent treatment fractions paired t-test was performed to analyze D2cc dose variations of OARs among the paired sets of plans. RESULTS: Comparison between the plans showed daily plans provided lower D2cc to OARs than test plans. In intra-application plan comparison, there was a significant dose reduction to 2 cc sigmoid (p = 0.021) and bladder (p = 0.007) in daily plan. Mean D2cc of optimized and unoptimized plans were 361.35 ±114.01 and 411.70 ±152.73 for sigmoid, and 511.23 ±85.47 cGy and 553.57 ±111.23 cGy for bladder, respectively. In inter-application, D2cc rectum and sigmoid demonstrated a statistically significant dose variation (p = 0.002) and (p = 0.007), with mean D2cc rectum of optimized and unoptimized plans being 401.06 ±83.53 cGy and 452.46 ±123.97 cGy, and of 2 cc sigmoid 340.84 ±117.90 cGy and 387.79 ±141.36 cGy, respectively. CONCLUSIONS: Fractionated HDR brachytherapy amounts to significant variation in OAR doses if re-simulation and re-plan is not performed for every fraction and ICBT application. Therefore, plan of the day with optimization of the doses to target and OARs must be followed for each fraction.

Spectrum of metastatic neoplasms of the brain: A clinicopathological study in a tertiary care cancer centre.

BACKGROUND: While brain metastases (BM) are the most common causes of neurologic disorders in patients with known systemic malignancies, they can often be the initial manifestations of an undetected primary elsewhere. BM are major causes of morbidity and mortality in cancer patients. AIMS: We describe a mixed population (data from both retrospective and prospective collection) having a BM from a solid tumor. We report the percentage distribution of the most frequent types of BM, confirming the data published in the literature. This paper may play a role in presenting the Southeast Asian reality compared with the Western countries. SETTING: A tertiary-care cancer centre. MATERIALS AND METHODS: Data for 4 years were retrieved from the records of the Department of Pathology of our institute. Hematolymphoid and meningeal tumors were excluded. Hematoxylin and eosin (H and E) stained slides were reviewed, and in cases with an unknown primary, immunohistochemistry (IHC) was advised. The panel of markers was chosen based on the histomorphology on H and E sections. IHC was done in cases with an unknown primary where paraffin blocks were available. RESULTS: Lung cancer was found to be the most common primary malignancy (n = 30; 48.4%) followed by breast cancer (n = 13; 21%), colorectal cancer (n = 6; 9.6%), and skin cancer (melanoma) [n = 3; 4.8%]. CONCLUSION: The incidence of BM from lung and breast cancer was similar to that seen in the Western studies. However, BM from colorectal cancer and melanoma show a higher and lower incidence, respectively, in comparison with the Western literature.

Tackling a recurrent pinealoblastoma.

Pineoblastomas are rare, malignant, pineal region lesions that account for <0.1% of all intracranial tumors and can metastasize along the neuroaxis. Pineoblastomas are more common in children than in adults and adults account for <10% of patients. The management of pinealoblastoma is multimodality approach, surgery followed with radiation and chemotherapy. In view of aggressive nature few centres use high dose chemotherapy with autologus stem cell transplant in newly diagnosed cases but in recurrent setting the literature is very sparse. The present case represents the management of pinealoblastoma in the recurrent setting with reirradiation and adjuvant carmustine chemotherapy wherein the management guidelines are not definitive.

The growing burden of cancer in India: epidemiology and social context.

Cancer can have profound social and economic consequences for people in India, often leading to family impoverishment and societal inequity. Reported age-adjusted incidence rates for cancer are still quite low in the demographically young country. Slightly more than 1 million new cases of cancer are diagnosed every year in a population of 1.2 billion. In age-adjusted terms this represents a combined male and female incidence of about a quarter of that recorded in western Europe. However, an estimated 600,000-700,000 deaths in India were caused by cancer in 2012. In age-standardised terms this figure is close to the mortality burden seen in high-income countries. Such figures are partly indicative of low rates of early-stage detection and poor treatment outcomes. Many cancer cases in India are associated with tobacco use, infections, and other avoidable causes. Social factors, especially inequalities, are major determinants of India's cancer burden, with poorer people more likely to die from cancer before the age of 70 years than those who are more affluent. In this first of three papers, we examine the complex epidemiology of cancer, the future burden, and the dominant sociopolitical themes relating to cancer in India.

Cancer research in India: national priorities, global results.

Over the past 20 years, cancer research in India has grown in size and impact. Clinicians, scientists, and government and state policy makers in India have championed cancer research, from studies to achieve low-tech, large-scale health outcomes to some of the most advanced areas of fundamental cancer science. In this paper, we frame public policy discussions about cancer with use of an in-depth analysis of research publications from India. Cancer research in India is a complex environment that needs to balance public policy across many competing agendas. We identify major needs across these environments such as those for increased research capacity and training and protected time for clinical researchers; for more support from states and enhanced collaborative funding programmes from government; for development of national infrastructures across a range of domains (ie, clinical trials, tissue banking, registries, etc); and for a streamlined and rational regulatory environment. We also discuss improvements that should be made to translate research into improvements in cancer outcomes and public health.

Abscopal effect in a patient with chronic lymphocytic leukemia during radiation therapy: a case report.

Radiotherapy has a significant impact on the local tumor environment and its distant component. Abscopal effect is the bystander effect of radiotherapy observed at a site distant to that irradiated within the same subject. Abscopal effect even though described, is not a common clinical event. We report a documented observation of abscopal effect in a patient of Chronic Lymphocytic Leukemia during radiation therapy.

Molecular constitution of breast but not other reproductive tissues is rich in growth promoting molecules: a possible link to highest incidence of tumor growths.

In the current study we tested if highest incidence of benign as well as cancer growths in breast tissue is due to constitutive molecular composition of this tissue. To delineate the molecular basis, we compared the expression of nine functional gene modules (total 578 genes) that regulate major positive growth and negative inhibitory signals in normal breast with two other reproductive tissues, ovary and uterus. We present data to demonstrate that breast tissues constitutively have very highly elevated levels of several growth promoting molecules and diminished levels of inhibitory molecules which may, in part, contribute for highest incidence of tumor growths in this tissue.

Darier-Roussy Sarcoidosis Mimicking Metastatic Breast Cancer.

Subcutaneous sarcoidosis (also known as 'Darier-Roussy sarcoid') is a cutaneous condition characterized by numerous deep-seated nodules on the trunk and extremities. Coexistence of sarcoidosis and breast cancer are reported in the literature, but there will always be a chance of misdiagnosis. It is very crucial to obtain a tissue diagnosis of suspicious metastatic lesions. We report a case of breast cancer presenting with a subcutaneous sarcoid lesion masquerading as a metastatic lesion. A 50-year-old female patient, who had had cancer of the left breast, was on hormone therapy 2 years after treatment with surgery, radiotherapy and chemotherapy. The patient presented with a sudden onset of a forehead subcutaneous swelling mimicking metastasis which on excision biopsy was proved to be sarcoidosis. In India, sarcoidosis is reported rarely. We have to keep in mind that there is a chance of the metastatic lesions being of sarcoidosis origin or another granulomatous disease. To avoid misdiagnosis, it is better to obtain a tissue diagnosis.