Primary malignant tumors of the trachea - the Tata Memorial Hospital experience

OBJECTIVE

Primary tumors of the trachea are extremely rare. Treatment methods vary considerably and few studies have sought to provide adequate guidelines. This study reviews the records of patients treated for tracheal cancer at the Tata Memorial Hospital (TMH), Mumbai, India.

SUBJECTS AND METHODS

Fifteen patients with primary tracheal malignancies were identified in the TMH database during the period from 1983 to 2000. They were predominantly males (87%) belonging to an older age-group (67% above 40 years). Common presenting symptoms were cough, hoarseness, hemoptysis and indications of airway obstruction. Squamous cell carcinoma was the commonest histologic subtype (40%) followed by adenoid cystic carcinoma (27%). Ten patients received radical treatment. One patient underwent surgery (resection and anastomosis) and received postoperative radiotherapy. Another was explored but was found to be unresectable and was 1 of 2 patients treated with chemotherapy and radiotherapy. Laser resections and radiotherapy were used in 2 patients while 4 patients were managed with radiotherapy alone. One patient was treated elsewhere. The majority of patients (8/9) were treated with locoregional fields and doses ranging from 40 to 60 Gy (median 50 Gy). Two patients also received intraluminal brachytherapy, 1 as part of initial treatment and another for recurrence.

RESULTS

Only 5 patients treated at TMH (5/9) achieved local control of their disease. Follow-up times ranged from 1 month to 134 months, median of 38 months. Distant metastases were identified in 4 patients (bone n = 1 and lung n = 3). Median survival was 38 months. Overall survival at 5 years was 37% by Kaplan-Meier method, but this figure should be treated with caution since only 6 patients had a follow-up of more than 2 years.

CONCLUSION

Tracheal cancer is a rare malignancy. Radiation therapy is a reasonably effective modality for unresectable disease.

Transperineal low-dose rate iridium-192 interstitial brachytherapy in cervical carcinoma stage IIB

PURPOSE

To assess local control, survival and complications in patients with cervical carcinoma Stage IIB treated radically with transperineal Iridium-192 low-dose rate interstitial brachytherapy following external beam radiotherapy.

PATIENTS AND METHODS

65 women (age 25-70 years, mean 47 years) with cervical carcinoma Stage IIB were initially treated with external beam radiotherapy on a telecobalt or 6 MV linear accelerator to a dose of 50 Gy delivered in 5-6 weeks. After 2-3 weeks of completing external radiation, patients received interstitial brachytherapy with Iridium-192 (activity 0.5-1 mCi/cm) using a Syed-Neblett perineal template. The median dose delivered to the implant volume was 24 Gy (range 20-32 Gy) delivered at an average dose rate of 0.70 Gy/h (range 0.40-1.20 Gy/h). A point defined at 1.5 cm lateral to the central uterine tandem at the level of os was taken as a representative for assessing the dose to the cervix. Mean doses delivered by interstitial brachytherapy to point A, cervix, point B and rectum were 38 Gy, 34 Gy, 16 Gy and 16 Gy, respectively.

RESULTS

At a median follow-up of 53 months, the actuarial disease free survival and overall survival for 65 patients at both 5 and 10 years was 64% and 44%, respectively. Response to radiotherapy was a strong predictor of local control with 82% of patients continuing to have pelvic control after initial complete response. Overall, nine (14%) patients had persistent disease, ten (15%) developed a central recurrence after initial control and three patients developed distant metastasis on follow-up. No patient had any immediate treatment-related complication. Late toxicity included grade I-II rectal reactions in five patients and grade IV bladder complication (vesico-vaginal fistula) in two patients. 5 years after treatment, one patient developed intestinal obstruction, which was relieved after conservative management. Two patients developed vaginal stenosis. The 5- and 10-year disease free survival was 48% in patients aged less than 45 years as compared to 80% in patients of more than 45 years (p = 0.009). Dose to the cervical point was a prognostic indicator with 5- and 10-year disease free survival of 47% in patients who received < 35 Gy in comparison to 80% in patients who had > 35 Gy (p = 0.03). There was no difference in local control and survival in patients with minimal and moderate parametrial involvement. Bulky disease (> 4 cm) at presentation and a longer gap between external radiation and brachytherapy showed a trend towards inferior local control.

CONCLUSIONS

Interstitial brachytherapy after external beam irradiation in patients with cervical carcinoma Stage IIB results in acceptable local control, survival and complication rates. Increased dose to the cervical disease results in improved local control and survival and should therefore be considered while optimizing brachytherapy treatment plans. Comparison of the results with those of standard intracavitary therapy remains to be proven in a randomized trial.

Primary extranodal mucosa associated lymphoid tissue (MALT) lymphoma of the prostate

Low-grade B-cell mucosa associated lymphoid tissue (MALT) lymphoma can rarely present primarily in extranodal sites other than stomach, which is the most common site for it. Until now only four cases of primary prostatic MALTomas have been described in the literature and we report the fifth. We describe a case of primary prostatic MALToma in a 67-year-old man and the diagnosis was made on the trans-urethral resection specimen of the prostate. As the disease was limited to prostate (stage IEA), the patient was treated with external beam radiation therapy to a total dose of 4400cGy in 22 fractions. The patient achieved completed remission and has remained free of disease in the following 36 months.

Radiation therapy in T1-T2 glottic carcinoma: influence of various treatment parameters on local control/complications

PURPOSE

To evaluate the influence of various treatment parameters on local control as well as complications in T1 and T2 glottic carcinomas.

METHODS AND MATERIALS

Between 1975 and 1989, 676 patients with early glottic carcinoma (460 T1 and 216 T2) received curative radiation with three different treatment regimens, as follows: Regimen 1-50 Gy/15 Fr/3 weeks (3.33 Gy/daily) for 192 patients; Regimen 2-60-62.5 Gy/24-25 Fr/5 weeks (2.5 Gy/daily) for 352 patients; and Regimen 3-55-60 Gy/25-30 Fr/5-6 weeks (2-2.25 Gy/daily) for 132 patients.

RESULTS

The local control at 10 years was 82% and 57% for T1 and T2 lesions respectively (p = 0.0). For the T1N0M0 group, field size had significant impact on local control with both univariate (p = 0.05) and multivariate (p = 0.03) analysis. For T2N0M0, group field size (p = 0.03) as well as registration year (p = 0.016) were significant in univariate analysis whereas only field size remained significant on multivariate analysis. Persistent radiation edema was noted in 146 (22%) patients and was significantly worse with larger field size (p = 0.000) but not related to different treatment regimens.

CONCLUSION

The shorter fractionation schedule had comparable local control, without increased complications in comparison to the protracted schedule and is best suited for a busy department.

Primary carcinoma of the vagina: Tata Memorial Hospital experience

PURPOSE

Carcinoma of the vagina is a rare gynecological malignancy comprising approximately 2% of all the gynecological malignancies. We have analyzed the treatment outcome of the patients treated at the Tata Memorial Hospital from January 1984 to December 1993.

METHODS AND MATERIALS

In this 10-year period, 134 patients of primary vaginal cancers were registered at our hospital. Of these, 75 patients received complete treatment and are analyzed.

RESULTS

Disease-free survival (DFS) for the whole group is 50%, and overall survival (OAS) is 60%. Most locoregional recurrences and distant failures are noted in the 2 years following treatment. DFS at 5 years is as follows: Stage I (5 patients), Stage IIA (37 patients), Stage IIB (15 patients), Stage III (14 patients), and Stage IV (4 patients); are 40%, 55%, 60%, 50%, and 25%, respectively. The DFS for patients with complete response (42 patients) to external radiation at 5 years is 68%, with partial response (25 patients) is 35%, and with poor or no response (6 patients) is 18% (p = 0.0000). We observed that brachytherapy was an important part of the treatment, and patients who received brachytherapy (59 patients), either with a vaginal intracavitary applicator (30 patients) or interstitial implant (29 patients) had a DFS of 53% and 56%, respectively, while 15 patients who received external radiation alone had a DFS of 30%. Patients receiving brachytherapy within 4 weeks of external radiation had a DFS of 60% as compared to 30% when the interval was more than 4 weeks.

CONCLUSION

The factors indicating prognosis are: site and extent of involvement, presence of lymph nodes at presentation, technique of brachytherapy, and interval between external radiation and brachytherapy.

Seroepidemiology of Helicobacter pylori infection in India. Comparison of developing and developed countries

Helicobacter pylori (previously Campylobacter pylori) is now accepted as the major cause of type B gastritis and thus what is known about the epidemiology of type B gastritis can reasonably be transferred to H. pylori. We used a specific ELISA for anti-H. pylori IgG to study the prevalence of H. pylori infection in a population of lower socioeconomic class from Hyderabad, India. The results from India were compared to studies from other parts of the world. Two hundred thirty-eight individuals ages 3 to 70 participated. The frequency of H. pylori infection increased with age (P less than 0.01) and was greater than 80% by age 20. H. pylori infection was present in 79% of the population studied; there was no gender-related difference in prevalence of H. pylori infection. IgG antibody against hepatitis A (HAV) was rapidly acquired in Hyderabad; in a subset of 58 children between the ages of 3 and 21 tested, the frequency of anti-HAV was 98.2%. The prevalence of H. pylori infection increases with age in both developed and developing countries. The high age-specific prevalence of H. pylori infection in developing countries is probably a reflection of the lower socioeconomic level of those areas.