Metronomic Chemotherapy After Palliative Radiotherapy In Rare Soft Tissue Sarcomas; An Insight Into Radiation Therapy And The Immune Response

Introduction/Objective

Soft tissue sarcomas (STSs) account for less than 1% of the overall human burden of malignant tumors. The intent of treatment in metastatic STSs is palliative and prognosis is dismal. This study aims to evaluate the role of low dose radiotherapy and low dose oral metronomic therapy in heavily pretreated metastatic infrequent STSs.

Methods

This research was conducted in a prospective observational manner in a tertiary care center. A total of 16 cases met the inclusion criteria for enrollment in the study group. The diagnosis of all subtypes of STS was confirmed by histopathology and immunohistochemistry or cytogenetic studies. All the enrolled patients with metastatic STSs who were treated with surgery and two lines of chemotherapy were initially treated with low dose radiotherapy of twenty Gy in five fractions or thirty Gy in ten fractions according to ECOG performance status of the patient.

Results

Out of 16 patients, seven patients (43.75%) were treated with 20Gy, 5# and 9 patients (56.25%) were treated with 30Gy, 10 # radiotherapy (RT). Out of 16 patients, four were of malignant fibrohistiocytic sarcoma, three were angiosarcoma, three were malignant phylloides tumor of the breast, and two were fibrosarcoma. One patient from each of the following subtypes inflammatory myofiroblastic tumor, leiomyosarcoma, synovial sarcoma, and dermato fibrosarcoma protuberance. Out of 16 patients, seven (43.75%) had a partial response (PR), nine (56.25%) had stable disease (SD) at 3 months and all the patients had stable disease (SD) at 6 months of evaluation. All the patients had enjoyed a better quality of life as compared to their life during injectable chemotherapy.

Conclusion

Targeted low dose radiation and metronomic chemotherapy lead to quantifiable antiangiogenic effects, immune effects in the local tumor microenvironment, and influences circulating immune mediators and anti- angiogenesis that could potentially help eradicate disease both within and outside the radiation treatment field.

Painless lump over the forehead which turned painful: an unusual presentation of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies and is known to most often present with symptomatology pertaining to local hepatic disease. Although HCC is known to metastasize to lungs, abdominal lymph nodes, adrenal glands and the vertebral column, it is rather rare to come across patients with skull metastasis. The manifestation of a solitary frontal bone metastasis leading to a painless lump over the forehead as the initial presenting feature of HCC is highly unusual. This case report pertains to a 40-year-old male patient who had initially observed a painless lump over his forehead that was gradually increasing in size over a span of 3 months. He sought medical attention when, after several months, the “painless lump” suddenly became painful. Investigations revealed the involvement of both the outer and the inner table of the frontal bone, and a biopsy revealed the histopathology to be that of HCC. On further investigation, he was found to have systemic disseminated disease involving both the left and right lungs and vertebrae and treatment was initiated with sorafenib. Despite an initial partial response, the patient subsequently succumbed to hepatic failure. This case report illustrates the fact that HCC can silently progress, and even lead to dissemination and distant metastases before becoming clinically evident.