Quality of life assessment in testicular non-seminomatous germ cell tumour survivors

PURPOSE

Patients with Germ cell tumours (GCT) are at risk of long-term toxicities due to multimodality therapy. It is debatable whether there is an impact on the quality of life(QoL) of GCT survivors.

METHODS

A case-control study was conducted at a tertiary care centre in India, using the EORTC QLQ C30 questionnaire, to compare the QoL between GCT survivors(disease free > 2 years) and healthy matched controls. A multivariate regression model was used to identify factors affecting QoL.

RESULTS

A total of 55 cases and 100 controls were recruited. Cases had a median age of 32 years (interquartile range, IQR 28-40 years), ECOG PS of 0-1(75%), advanced stage III (58%), chemotherapy (94%) and 66% were > 5 years from diagnosis. The median age of controls: 35 years (IQR 28-43 years). A statistically significant difference was seen for emotional (85.8 ± 14.2 vs 91.7 ± 10.4, p 0.005), social(83.0 ± 22.0 vs 95.2 ± 9.6, p < 0.001) and global scales (80.4 ± 21.1 vs 91.3 ± 9.7, p < 0.001). Cases had more nausea and vomiting(3.3 ± 7.4 vs 1.0 ± 3.9, p 0.015), pain(13.9 ± 13.9 vs 4.8 ± 9.8, p < 0.001), dyspnea(7.9 + 14.3 vs 2.7 ± 9.1, p 0.007), and appetite loss(6.7 ± 14.9 vs 1.9 ± 7.9, p 0.016) and greater financial toxicity(31.5 ± 32.3 vs 9.0 ± 16.3, p < 0.001). Adjusting for age, performance status, BMI, stage, chemotherapy, RPLND, recurrent disease, and time since diagnosis, no predictive variables were significant.

CONCLUSION

There is a detrimental impact of history of GCT in long term survivors of GCT.

Clinical Profile and Predictors of Survival in Carcinoma Penis Patients

BACKGROUND

Carcinoma penis is a rare neoplasm, and the literature is scarce on long-term survival and its predictors. The aim of the study was to determine the clinical profile and management patterns, identify predictors of survival, and the impact of education and rural/urban dwelling on survival.

METHODS

Patients with a histological diagnosis of carcinoma penis from January 2015 to December 2019 were included in the study. Demographics, clinical profile, education status, primary residence address, and outcomes were obtained from the case records. Distance from the treatment centre was obtained from the postal code. The primary objectives were to assess relapse-free survival (RFS) and overall survival (OS). The secondary objectives were to identify the predictors of RFS and OS and to determine the clinical profile and treatment patterns in patients with carcinoma penis in India. Time-to-event was calculated by Kaplan-Meir analysis and survival was compared by the log-rank test. Univariate and multivariable Cox regression analyses were used to find independent predictors of relapse and mortality. Logistic regression analyses to examine the associations of rural residence, education status, and distance from the treatment centre with the relapse adjusting for measured confounding variables.

RESULTS

Case records of 102 patients treated during the above period were retrieved. The median age was 55.5 (interquartile range [IQR] 42-65 years). Ulcero-proliferative growth (65%), pain (57%), and dysuria (36%) were the most common presenting features. Clinical examination or imaging revealed inguinal lymphadenopathy in 70.6% of patients, however, only 42% of these lesions were pathologically involved. A total of 58.8% of patients were from rural areas, 46.9% had no formal education, and 50.9% had a primary residence ≥100 km from the hospital. Patients with lower education and rural households had higher TNM stages and nodal involvement. Median RFS and OS were 57.6 months (15.8 months to not reached) and 83.9 months (32.5 months to not reached), respectively. On univariate analysis tumor stage, involvement of lymph nodes, T stage, performance status, and albumin was predictive for relapse and survival. However, on multivariate analysis, the stage remained the only predictor of RFS and nodal involvement, and metastatic disease was a predictor of OS. Education status, rural habitation, and distance from the treatment centre were not predictors for relapse or survival.

CONCLUSIONS

Patients with carcinoma have locally advanced disease at presentation. Rural dwellings and lower education were associated with the advanced stage but did not have a significant bearing on the survival outcomes. The stage at diagnosis and nodal involvement is the most important predictor of RFS and OS.

Differential effect of body mass index (BMI) on outcomes of patients treated with docetaxel in prostate cancer - An exploratory analysis

OBJECTIVE

There are contradictory data on differential effect of docetaxel based on BMI in patients with breast and prostate cancer. We performed an exploratory analysis to determine if the benefit of docetaxel in patients with metastatic castration-resistant prostate cancer (mCRPC) is modified by BMI.

METHODS

We performed a post hoc analysis of the data retrieved from the ENTHUSE M1C study. BMI (kg/m²) was categorized as: 18.5 to <25 as lean; 25 to <30 as overweight; and ≥30 as obese. Cox regression models were constructed to determine the impact of BMI on progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 466 patients were eligible for the current analysis. The median PFS was 7.3, 7.7 and 8.4 months (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.81 to 1.06; P = 0.261) in lean, overweight and obese patients. The median OS was 16.6, 20.1 and 21.4 months (HR, 0.75; 95% CI, 0.63 to 0.89; P = 0.002) for lean, overweight and obese patients. After adjusting for baseline and tumor characteristics, there was no association of BMI with PFS (overweight, HR, 0.89; 95% CI, 0.71 to 1.13; P = 0.353; obese, HR, 0.86; 95% CI, 0.66 to 1.13; P = 0.277) while overweight (HR, 0.68; 95% CI, 0.51 to 0.89; P = 0.006) and obese (HR, 0.59; 95% CI, 0.41 to 0.83; P = 0.003) patients had significantly better OS compared with lean patients.

CONCLUSIONS

There was no effect of BMI on PFS in patients with mCRPC receiving docetaxel. Interestingly, overweight and obese patients had a longer OS compared with lean patients, which is in contradiction to a recent study in breast cancer; and warrants further investigation.

Rosette Forming Glioneural Tumor Treated with Conformal Radiation

Rosette forming glioneural tumors (RGNT) are a rare type of low-grade brain tumor included in 2007 in WHO classification. Given the benign nature of the disease, a complete surgical excision has been considered optimum. However, a handful of cases have reported the locally aggressive nature of RGNT. In addition, radiation may also be considered for a tumor located in areas where surgical excision is difficult. We present a similar case, where surgical risk was weighed against resection and we treated the patient with conformal radiation.

Ga-68 PSMA PET/CT in recurrent high-grade gliomas: evaluating PSMA expression in vivo

PURPOSE

We planned this prospective study to evaluate PSMA expression in recurrent high-grade gliomas (rHGG), including anaplastic astrocytoma and glioblastoma using Glu-NH-CO-NH-Lys-(Ahx)-[Ga-68 (HBED-CC)]- (Ga-68 PSMA) positron emission tomography (PET), with its theranostic potential in mind.

METHODS

This was a prospective study enrolling patients with clinical and MRI evidence of rHGG on follow-up. Three treated cases of HGG with RN on MRI were also included as negative controls. Abnormal tracer accumulation in the brain parenchyma, more than the contralateral hemisphere was interpreted as positive study. For semiquantitative analysis, a 3D spherical region of interest (ROI) was drawn around the site of the abnormal Ga-68 PSMA uptake, and the ratio of SUVmax of tumor (T) to SUVmax of the contralateral corresponding area (TBR) was calculated. Each patients' PSMA brain PET was fused to the corresponding MRI and reviewed for concordance.

RESULTS

Thirty patients were included in the study, a total of 49 lesions were detected on MRI, and fused PET/MR images showed increased Ga-68 PSMA uptake in all these lesions. Multifocal lesions were better appreciated on fused PET-MR images, and concordance between MRI and PET was 100 % for patient and lesion-wise detection. Recurrent glioma lesions showed SUVmax and SUVmean values (median and IQR) 6.0 (4.4-8.2) and 3.3 (2.8-3.7), respectively. Lesions labeled as radiation necrosis on MRI did not show tracer accumulation.

CONCLUSION

Ga-68 PSMA has potential utility for evaluating recurrence in HGG and its potential for theranostics would encourage its use in the evaluation of these patients.

Glioblastoma with Primitive Neuroectodermal Component Treated with Adjuvant Radiotherapy and Temozolomide: A Pooled Analysis of 23 Patients

Aim

Glioblastoma (GBM) is one of the most aggressive neoplasms of the central nervous system with dismal survival. In recent years, different variants of GBM have been described in the literature. GBM with areas of neuroectodermal differentiation (GBM-PNET) is a relatively new entity in GBM. Presence of the neuroectodermal component increases the propensity of systemic dissemination as with other intracranial primitive neuroectodermal tumors (PNET). The optimal treatment for these patients remains a controversy, with authors reporting local radiotherapy to craniospinal irradiation and chemotherapy. We intend to analyze the pattern of care for GBM with neuroectodermal component.

Materials and Methods

We retrieved data of four patients with GBM-PNET treated in our institute; data were also retrieved from published series to derive treatment and outcome results.

Results

In this series, we report the outcome of a series of four patients of GBM-PNET treated with adjuvant radiotherapy and temozolomide. All but one patient underwent gross total resection of the tumor. Adjuvant hypofractionated radiation with concurrent and adjuvant temozolomide was used in all cases. The median follow-up was 12.9 months in the present series. One patient experienced local recurrence 18 months after the treatment. A review of published literature on GBM-PNET was done; studies with details of patient outcome were used for an independent analysis. Twenty-three patients were identified, and the pooled analysis revealed a median progression free and overall survival of 10 and 25, months respectively. Extent of surgery, local radiation vs. craniospinal irradiation, and age at presentation had no impact on the survival.

Conclusion

GBM PNET is a new entity with only few cases reported so far. Clinical behavior and treatment outcome of these tumors are not different from conventional GBM. However, these patients are at higher risk of CSF dissemination. Hence, an individualized treatment approach is best suited.

An audit of over 1000 breast cancer patients from a tertiary care center of Northern India

BACKGROUND

Breast cancer is the commonest cancer among women. India along with United States and China collectively account for one third of the global burden. The present study reports the clinico-epidemiological data of our patient population. This may help in better understanding of the disease in our population and also form ground for conducting further breast cancer research in India.

METHODS

The study was conducted at an apex teaching and medical research institution in India from September 2013 to April 2015 as a retrospective review of prospectively collected data of breast cancer patients. The socio-demographic characteristics, reproductive risk factors, clinical presentation, TNM staging and histopathological characteristics for breast cancer in these patients were recorded. The data was recorded on an Xcel spreadsheet and analyzed using IBM SPSS 21.

RESULTS

The study comprised of 1310 breast cancer patients with males comprising 1.1%. The median age of presentation was 47 years, and menarche 14 years. Most of women were married and multiparous. More than half of the women were postmenopausal at presentation. All patients were symptomatic at presentation with median duration of symptom of 5 months and median lump size of 5 cm. Most common stage at presentation was Stage II and most common histopathology was Invasive ductal carcinoma. 61.9% tumors were hormone receptor positive. Triple negative cancers formed one third of all tumors.

CONCLUSION

Breast cancer in the Indian scenario is a disease of younger woman who lack the characteristic reproductive and demographic risk factors. This calls for a need to study the clinico-demographic risk factors and characteristics of our own population.

Differential effect of body mass index (BMI) on outcomes of patients treated with docetaxel in prostate cancer: An exploratory analysis

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Background: Docetaxel is a lipophilic drugs with a high affinity for adipose tissue resulting in a higher volume of distribution.There are contradictory data with regards to the differential effect of docetaxel based on BMI in breast cancer patients. However, there are no such data in patients with prostate cancer. A We performed an exploratory analysis to determine if the benefit of docetaxel in patients with metastatic castration resistant prostate cancer (mCRPC) is modified by BMI. Methods: This is a post hoc analysis of data retrieved from the phase III ENTHUSE M1C study that assessed the efficacy and safety of additional zibotentan in combination with docetaxel in patients with mCRPC (ClinicalTrials.gov identifier: NCT00617669). BMI (kg/m2) was categorized as: 18.5 to < 25, lean; 25 to < 30, overweight; and ≥ 30, obese. Cox regression models were constructed to determine the impact of BMI on progression-free survival (PFS) and overall survival (OS) after adjusting for baseline characteristics. Results: A total of 466 patients were eligible for current analysis, of whom 34%, 46% and 20% were < 65 years, 65-74 years and > 75 years, respectively. The median total and free baseline PSA were 99.5 (interquartile range [IQR], 33.6 to 237.0) ng/mL and 13.9 (IQR, 5.4 to 37.4) ng/mL, respectively. There were 31% (n = 145), 46% (n = 213) and 23% (n = 108) lean, overweight and obese patients. Visceral metastasis was present in 52% patients, while the number of bone metastases were 1-3 in 15%, 4 in 5%, 5-20 in 58% and ≥ 21 in 23%. The median number of cycles of docetaxel administered were 10 (IQR, 6-10). The median PFS was 7.3, 7.7 and 8.4 months (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.81 to 1.06; P = .26) for lean, overweight and obese patients, respectively. The median OS was 10.3, 10.7 and 12.4 months (HR, 0.75; 95% CI, 0.63 to 0.89; P = .01) for lean, overweight and obese patients, respectively. After adjusting for baseline and tumor related characteristics, there was no association of BMI with PFS (overweight, HR, 0.92; 95% CI, 0.73 to 1.17; P = .50; obese, HR, 0.90; 95% CI, 0.67 to 1.18; P = .42) while overweight (HR, 0.68; 95% CI, 0.52 to 0.91; P = .01) and obese (HR, 0.61; 95% CI, 0.43 to 0.88; P = .01) patients had significantly better OS as compared with lean patients. Conclusions: The differential effect of docetaxel based on BMI was not observed in patients with mCRPC. Interestingly, obese patients had a significantly longer OS, which warrants further investigation.

Associations of education, residence, and travel distance to oncology center on survival outcomes in patients with penile cancer: A tertiary care referral center experience

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Background: Rural residence, educational status & longer travel distance are variably associated with suboptimal cancer treatment and outcomes. There are limited data on impact of these factors on treatment patterns & survival outcomes in penile cancer. Methods: Patients with a histological diagnosis of carcinoma penis during 2015 to 2019 were identified from the database of a large tertiary care center in India. Chart reviews were performed to retrieve demographic, clinicopathological and treatment details. Educational status was categorized as no formal education and any educational attainment, while travel distance was dichotomized at 500 km. Logistic regression analyses were performed to examine the associations with cancer treatments. Relapse free survival (RS) and overall survival (OS) were calculated by plotting Kaplan Meir curves and compared using log rank test. Multivariable Cox regression analysis were used to determine the associations of socioeconomic status and residence on survival outcomes. Results: A total of 100 patients were eligible for the current analysis. The median age was 56 (interquartile [IQR]range, 42-65) years. The median duration of symptoms was 6 (IQR, 4-12) months. Ulcero-proliferative growth (65%) was the most common presenting symptom followed by pain (57%) and dysuria (36%). Most patients had grade 2 tumor (60%), while stage was equally distributed from I-IV. Three-fourths of patients had clinically enlarged inguinal lymph nodes, while, 42 % were pathologically involved. Of all patients, 58% were from rural communities, 44% patient didn’t receive any formal education, and 36% had travelling distance of over 500 km from the hospital. Surgery, radiotherapy, and chemotherapy were administered in 53%, 42% and 24%, respectively. On multivariable logistic regression analysis, lower education, rural residence and longer travel distance were not associated with a lower likelihood of receiving any treatment. At a median follow-up of 50.7 months, median RFS and OS were 59.8 (95% CI, 15.8-NR) and 83.9 (95% CI, 29.2–NR) months, respectively. After adjusting for tumor stage, involvement of lymph nodes, PS, and grade, education status, primary residence (urban vs rural), and distance from the treatment center were not associated with RFS and OS. However, advanced stage was the only factor predictive of worse RFS and OS (Table). Conclusions: Rural residence, educational status and travel time were not associated with treatment administration and survival outcomes in patients with penile cancer treated in a publicly funded tertiary care center in India. [Table: see text]

Anesthesia concerns in prostate brachytherapy: An institutional experience

BACKGROUND

Prostate cancer is a common cancer found in men worldwide. Brachytherapy is an established modality used for the treatment of these patients. Although anesthetic management of such patients is challenging but the ideal anesthetic technique has not yet been established. Our study aims to identify the most efficacious anesthetic technique for perioperative management of prostate cancer patients undergoing brachytherapy.

METHODS

Retrospective analysis of ten patients who underwent 16 brachytherapy sessions under combined spinal epidural (CSE) anesthesia between April 2016 and December 2016 was done. The data were collected, tabulated using MS Excel, and statistically analyzed with EPI Info 6 and SPSS-16 statistical software (SPSS Inc. Chicago, USA) to draw relative conclusions.

RESULTS

The median peak sensory dermatome level achieved was T6 and the median maximum motor block achieved was grade 2. The mean (± standard deviation (SD)) time to sensory regression to T10 (range T5-T8) dermatome was found to be 118.00 ± 47.110 (range = 0-238) minutes. Despite the presence of co-morbidities, minor intraoperative complications were observed only in two patients. The postoperative numerical rating scale (NRS) was less than 4 in all patients during the first 24 hours. None of our patients complained of nausea, vomiting, pruritus and respiratory depression. The mean (± SD) patient satisfaction score was 44.40 ± 0.871 (range : 1-5) at the end of 24 hours.

CONCLUSIONS

CSE anesthesia is a safe and effective technique for anesthetic management of patients undergoing prostate brachytherapy.

Health related quality of life analysis among testicular germ cell tumor survivors treated in a tertiary cancer hospital in India

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Background: Testicular Germ Cell Tumor (TGCT) is a highly curable malignancy treated with surgery, radiotherapy and chemotherapy. The available literature has conflicting results on quality of life (QoL) of survivors determined using various tools. There is no Indian data on QoL among TGCT patients. Methods: The study was a prospective case-control study. EORTC QLQ-C30 questionnaire were administered to survivors (last treatment completed at least 2 years back) and healthy age matched controls attending the uro-malignancy clinic of AIIMS between 1st January 2017 to 31st December 2018. The functional, symptom and global QoL scales were scored as per EORTC manual and were compared with each other using student t-test and Mann-Whitney test. The data was analysed with stata v.13.0. Results: The mean scores of all domains of functional scales and global QoL of 114 TGCT survivors were significantly worse than 100 controls except role functioning and cognitive functioning (Table). The symptom scores of cases were significantly worse for each domain except insomnia and constipation (Table). There was no difference in QoL parameters between Seminoma or Non-Seminoma or different stages of GCT. Conclusions: The QoL among TGCT survivors was significantly inferior indicating the long term physical, emotional, social, sexual and financial effects of disease and its treatment on survivors. More robust tools and studies are needed to better define QoL among survivors. ± SD of Functional, symptom and Global QoL Scales) [Table: see text]

Giant cell glioblastoma with spinal and spinal leptomeningeal metastasis in a child: A rare presentation of a rare tumor

Giant cell glioblastoma (GCG) is a rare subtype of classic glioblastoma multiforme with favorable prognosis and little is known about its metastatic potential. We hereby present a unique case of GCG in a 7-year-old child who developed spinal and spinal leptomeningeal metastasis during adjuvant therapy. She succumbed to it in spite of salvage therapy.

Socio-Demographic, Reproductive and Clinical Profile of Women Diagnosed with Advanced Cervical Cancer in a Tertiary Care Institute of Delhi

INTRODUCTION

Cervical cancer is one of the leading cancers among Indian women with estimated 123,000 new cases and 67,477 deaths in 2012. Cervical cancer is a multi-etiological disease. Factors such as low socioeconomic status, tobacco use, sexual and reproductive factors, HIV and other sexually transmitted diseases and long-term oral contraceptive use have been suggested as determinants. Assessment of socio-demographic profile and reproductive history gives a better picture of the determinants of cervical carcinoma in low-resource settings.

METHODS

This hospital-based cross-sectional study was undertaken at a tertiary healthcare institute at New Delhi, India. Sixty-seven newly diagnosed women with advanced cervical cancer (stage 2B-4B), who were undertaking radio- and/or chemotherapy, were included to assess their socio-demographic, reproductive and clinical profile.

RESULTS

The mean age of women at the time of detection of cervical cancer was 52.28 ± 11.29 years (range 30-75 years). More than 60 % of patients were illiterate and belonged to middle socioeconomic status. Thirty-nine percentage of the study subjects had their first sexual experience before 15 years of age. Nearly 54 % women had 5 or more pregnancies. Nearly 73 % of women had all deliveries at home. Majority (69 %) of women had symptoms suggestive of reproductive tract infection. Among them, unusual discharge from vagina (73.13 %) followed by bleeding after menopause (55.10 %) and pain in abdomen (44.77 %) were the most common presenting complaints. Pallor was present in nearly two-third (63.93 %) study subjects. More than half (56.72 %) study subjects had moderate anemia, and 7.46 % had severe anemia before treatment. Mean hemoglobin level of the study subjects was 10.35 ± 1.72 gm% before treatment and 9.69 ± 1.29 gm% after treatment. This difference was statistically significant. Around 97 % of the study subjects had squamous cell carcinoma of the cervix. Majority (53.73 %) of the study subjects were in stage 3B of cervical cancer. Combination of radiotherapy and chemotherapy was the most common (77.67 %) modality of treatment.

CONCLUSIONS AND RECOMMENDATIONS

Illiteracy, low socioeconomic status, early sexual debut, high fertility, home delivery, reproductive tract infections, use of insanitary clothes during menstruation and anemia were observed in majority of women with advanced cancer cervix. Presence of these factors indicates possible risk of cervical cancer and should be kept in mind when women seek health services. Early diagnosis through high risk or opportunistic screening and timely management of cervical cancer needs to be ensured for better outcomes.

Endolymphatic Sac Tumor in von Hippel-Lindau Disease: A Rare Case Report

Endolymphatic sac tumor (ELST) is a rare papillary neoplasm with locally destructive behavior which can occur sporadically or in association with Von Hippel–Lindau (VHL) disease. We herein present a case of ELST associated with VHL disease in a 14-year-old girl and discuss clinico-radiological, immunohistopathologic findings, and management by staged surgery and postoperative radiotherapy to the residual lesion.

Primary pediatric mid-brain lymphoma: Report of a rare pediatric tumor in a rare location

Primary central nervous system lymphoma (PCNSL) is a rare disease in pediatric age group. A thirteen-year-old male child presented with complaints of headache for six months, vomiting and diplopia for three days. Magnetic resonance imaging of the brain showed a single lesion of 1.7 cm × 1.6 cm × 1.6 cm in the mid brain and tectum. He underwent a gross total resection of the tumor. The histopathological evaluation revealed B cell high grade non Hodgkin lymphoma. The patient was treated with High dose methotrexate and cranio spinal radiation. The patient was alive without disease 12 mo after completion of treatment. This case highlights importance of keeping PCNSL as differential in brain stem lesions of pediatric patients also. Radiation and chemotherapy remains the most important treatment for such patients.

Clinical outcome of patients with primary gliosarcoma treated with concomitant and adjuvant temozolomide: A single institutional analysis of 27 cases

CONTEXT AND AIM

The prognosis of primary gliosarcoma (PGS) remains dismal with current treatment modalities. We analyzed the outcome of PGS patients treated with concurrent and adjuvant temozolomide (TMZ).

SETTINGS AND DESIGN

Retrospective single institutional analysis.

MATERIALS AND METHODS

We retrospectively evaluated 27 patients of PGS treated with radiotherapy (RT) and TMZ during 2007-2012.

STATISTICAL ANALYSIS USED

Overall survival (OS) was estimated by the use of Kaplan Meier method and toxicities were evaluate using common terminology criteria for adverse events version 2.0 (National Cancer Institute, USA).

RESULTS

Median age at presentation and Karnofsky performance status was 45 years and 90 respectively and male: female ratio was 20:7. Patients received adjuvant RT to a total dose of 60 Gy at 2 Gy/fraction. All patients except 5 received adjuvant TMZ to a median number of 6 cycles. Grade 2 and 3 hematological toxicity was seen in 8% and 4% of patients respectively during concurrent RT. During adjuvant chemotherapy, 13.6% had Grade 3 thrombocytopenia and 9.5% had Grade 3 neutropenia. Median OS was 16.7 months (1 year and 2 year actuarial OS was 70.8% and 32.6% respectively). Adjuvant TMZ was associated with a better survival (median survival 21.21 vs. 11.93 months; P = 0.0046) on univariate analysis and also on multivariate analysis (hazard ratio 1.82, 95% confidence interval: 1.503-25.58; P = 0.012).

CONCLUSIONS

The results of our study, largest series of patients with PGS treated with concurrent and adjuvant TMZ shows an impressive survival with acceptable toxicity. We suggest TMZ be included in the "standard of care" for this tumor.

Orbital medulloepithelioma in an adult patient: Radiation-induced second neoplasia?

Second cancers in survivors of hereditary retinoblastoma occur much more commonly than in the general population. This can be attributed both to the germline mutation of the RB gene and chemoradiation used for treatment of this paediatric cancer. Medulloepithelioma is an uncommon tumor of neuroectodermal origin, seen largely in the paediatric population and rarely reported in adults. Though the incidence of second malignancies is common in retinoblastoma, medulloepithelioma as a second malignancy in retinoblastoma survivors is rare, with only one case reported so far. Herein, we present a case of a 29-year-old patient presenting with medulloepithelioma of the right orbit, arising in the radiation field of previously treated retinoblastoma. This case was also peculiar in that though the origin of tumor was in the eyeball it had a very aggressive clinical course.

Impact of post-operative radiation on coronary arteries in patients of early breast cancer: A pilot dosimetric study from a tertiary cancer care center from India

BACKGROUND

The significant impact of postoperative radiotherapy (PORT) on cardiac morbidity in patients of early breast cancer (EBC) undergoing breast-conserving surgery has been shown in different studies. The present study was conducted to assess the impact of surgery and the side of involvement on radiation dose to left anterior descending artery (LAD) and Left circumflex coronary artery (LCx).

MATERIALS AND METHODS

Totally, 58 patients of EBC were randomly chosen for this dosimetric study and planned with tangential field technique without intensity modulation (IM). Heart, LAD, and LCx (n = 55) were contoured. Dose volume histograms were analyzed to determine the Dmax (maximum dose) and Dmean (mean dose) of LAD and LCx. Student's t-test was used for comparative analysis of the means.

RESULTS

The mean Dmax of LAD for left (L) EBC was 3.17 Gray (Gy) while for right (R) EBC it was 0.86 Gy (P = 0.007; 95% C.I, 1.14-3.48). The mean Dmean of LAD for L-EBC and R-EBC were 1.97 Gy and 0.79 Gy, respectively (P = 0.029; 95% C.I, 0.77-1.60). The mean-Dmax of LCx for patients with L-EBC (2.9 Gy; range: 1.2-4.35 Gy) was statistically higher than that for R-EBC (1.3 Gy; range: 0.7-3.2 Gy) (P = 0.045). The mean-Dmean of LCx for L-EBC (2.1 Gy; range: 0.6-3.6 Gy) was also significantly higher than that of L-EBC (0.9 Gy; range: 0.7-2.1 Gy) (P = 0.03). There was no significant impact of the pattern of surgery on LAD dose, but significance was noted for LCx dose parameters (P = 0.04 and 0.08 for m-Dmax and m-Dmean of LCx).

CONCLUSION

This pilot dosimetric study confirms the assumption that patients with left-sided EBC are at higher risk of developing long-term cardiac morbidity when treated with PORT due to increased dose to LAD.

Outcomes of Young Patients With Rectal Cancer From a Tertiary Cancer Care Centre in India

BACKGROUND

Carcinoma of the rectum is the fourth most common cancer in the world. The peak age of diagnosis is around the seventh decade. Rectal cancer presenting in those < 35 years old are very peculiar in that they present with adverse histologic features and more advanced stage compared with rectal cancer presenting in older patients.

MATERIALS AND METHODS

We retrospectively evaluated the patient records of young patients with rectal cancer (aged < 35 years) treated in our unit at the All India Institute from 2007 to 2013.

RESULTS

A total of 60 young patients with rectal cancer were registered in our unit during the study period. A family history of cancer was present in 3 patients. The median age at presentation was 27.5 years (range, 15-34 years). The male-to-female ratio was 1.5:1. Of the 60 patients, 52 (86.6%) presented with advanced-stage disease (stage III and IV). Mucinous, signet, papillary, and other poor-risk histologic features were seen in 33 patients (55%). The treatment intention was radical for 50 patients (83.3%). The median follow-up period was 7.3 months. Eighteen patients had documented disease progression. Distant metastasis was the most common type of failure, seen in 14 of 18 patients (77%). The median progression-free survival (PFS) was 1.4 years. The 1- and 3-year PFS rates were 66.5% and 42.0%, respectively. On univariate analysis, the Karnofsky performance status and histologic type were significant prognostic factors for PFS.

CONCLUSION

A greater proportion of poor histologic subtypes was found among young patients with rectal cancer. The high incidence of poor histologic subtypes confers a poor prognosis in these patients.

Invasive lobular carcinoma of the male breast: A rare histology of an uncommon disease

Male breast carcinoma is a rare malignancy comprising less than 1% of all breast cancers. It is a serious disease with most patients presenting in advanced stages. Infiltrating ductal carcinoma is the most common histology while lobular carcinoma represents less than 1% of all these tumors. We report a case of locally advanced lobular carcinoma of breast in a 60 year old male.

Intracranial fibrosarcoma treated with adjuvant radiation and temozolomide: Report of a case and review of all published cases

INTRODUCTION

Fibrosarcoma is a rare brain tumour with 33 cases reported so far. However, there is no clear consensus about the nature of the disease and treatment as well as outcome.

METHODS

A MEDLINE search was carried out using MESH terms like intracranial fibrosarcoma, intraspinal fibrosarcoma, fibrosarcoma meninges and fibrosarcoma brain. A total of 22 case reports and series reporting a total of 33 cases were identified. We here also report a case treated in our institute with adjuvant radiation and concurrent and maintenance temozolomide.

RESULTS

The age of presentation ranged from 2months to 75years (Median=17years). The gender ratio was found to be M:F of 1.75-1. Treatment modalities were described for 17 cases. Surgery was part of treatment in all cases while radiation was a part of treatment in 59% of cases (n=10) and chemotherapy in 29% cases (n=5). Survival data were available only for 8 cases and ranged from 1day to 8years (Median=15.5months).

CONCLUSION

Fibrosarcoma is a rare disease with dismal prognosis. Surgery remains the cornerstone of therapy. Radiation confers long term disease control and survival. Chemotherapy needs to be evaluated for these tumours to improve survival.

Youngest case of third ventricular anaplastic neurocytoma

A 6-year-old child presented to us with on and off headache and vomiting for 4 months. On examination, there was bilateral papilledema with mild intracranial hypertension but with no neurological deficits. Magnetic resonance imaging (MRI) showed third ventricular mass with obstructive hydrocephalus with possibility of glioma. The patient underwent gross tumor excision and histopathology confirmed anaplastic neurocytoma. The postoperative MRI showed residual disease. The patient treated with adjuvant radiotherapy and temozolamide chemotherapy.

A simple technique for cranio-spinal irradiation in pediatric patients

PURPOSE

Field matching poses challenges in craniospinal irradiation (CSI) as it leads either to underdosage or overdosage in the junctional area. A simple technique for CSI in pediatric patients is proposed.

MATERIALS AND METHODS

Computed tomography scans were performed in the prone position. Two lateral cranial fields and a direct posterior spinal field were planned with a common central axis. Half-beam-blocked cranial fields with zero collimator rotation were used for treating the cranium. A half-beam-blocked field defined with jaws was used to treat the spinal column at an extended source-to-surface distance. Before treating the patient, matching of the cranial and spinal field junction along the central axis was verified with an extended dose range film.

RESULTS AND CONCLUSION

The technique described is simple and easy to implement and can be applied to pediatric patients undergoing CSI. This method has the potential to reduce daily setup time and setup errors. This technique is ideally suitable for patients with spinal fields less than 30 cm.

Impact of setup error on integral dose in head and neck cancer treated with intensity modulated radiation therapy

e17056

Background: Intensity modulated radiation therapy (IMRT) has been widely used in the treatment of head and neck cancer and has the potential of escalating the dose with less morbidity. Integral dose is a concern in radiotherapy especially with IMRT as it may lead to an increase in second malignancies. Setup error is another important issue in radiotherapy which affects the final treatment outcome. In this study, the effect of setup error on non-target integral dose (NTID) for head and neck cancer treated with IMRT has been studied. Methods: Twelve patients of carcinoma of nasopharynx treated by IMRT with simultaneous integrated boost technique were included. The dose to the gross tumor volume (PTV70), CTV1 (PTV59.4) and CTV2 (PTV54) were planned for 70 Gy, 59.4 Gy and 54 Gy respectively in 33 fractions. All the patients were planned with nine equally spaced beams. The IMRT plan was generated in Eclipse treatment planning system using sliding window technique. Keeping it as the base plan, the patient setup error was simulated in the treatment planning system for 3 mm, 5 mm and 10 mm by shifting the isocenter in all three dimensions viz. anterior, posterior, superior, inferior, right lateral and left lateral. NTID was calculated from the following relation NTID = (non-target tissue volume X mean non-target tissue dose)/1000. Paired sample t-test was performed to compare NTID for different shifts with no shift (statistical significance: p < 0.05). Results: The mean NTID for no shift was 120.75 ± 22.85 (median: 116.59). The mean NTID with isocenter shift along the anterior direction were 119.87 ± 22.80, 119.24 ± 22.80, 117.97 ± 22.52 for 3 mm, 5 mm and 10 mm respectively. Similarly, the NTID for the posterior shifts were 121.59 ± 22.96, 122.08 ± 23.07 and 123.26 ± 23.34 for 3 mm, 5 mm and 10 mm respectively. The anterior and posterior setup error showed statistically significant difference (p < 0.0001) for NTID compared to no shift whereas lateral, superior and inferior setup errors were found to be statistically insignificant. Conclusions: Setup error is an important issue in radiotherapy. Our study shows that setup error along the posterior direction significantly increases NTID. Hence, the setup error along the posterior direction may increase the risk of second malignances in IMRT.

No significant financial relationships to disclose.

Field-in-field technique for upper abdominal malignancies in clinical radiotherapy

BACKGROUND

In upper abdominal malignancies (UAM), due to the presence of multiple inhomogeneous tissues, a wedge-based conformal treatment planning results in high-dose regions inside the target volume.

AIM

This study was designed to explore the feasibility of using a field-in-field (FIF) technique in different UAM and its efficacy in reducing the high-dose regions.

MATERIALS AND METHODS

Twelve patients of UAM (which included malignancies of the gastroesophageal junction, stomach, gall bladder, and pancreas) were selected for this study. Computed tomography (CT) scans were performed and three-dimensional conformal wedge plans were generated for all the cases. The same plan was copied with the wedges removed and a FIF plan was generated. The two plans were compared for mean, maximum, and median doses; dose received by 2% (D2) and 98% (D98) of the target volume; volume receiving> 107% (V > 107%) and < 95% (V Statistical Analysis: Statistical analysis was performed with SPSS, version 10.0.

RESULTS

For all the cases, the FIF technique was better than wedge-based planning in terms of maximum dose, D2, V > 107%, and CI; there was a statistically significant reduction in monitor units. With regard to doses to critical structures, there was marginal dose reduction for the kidneys and spinal cord with FIF as compared to wedge-based planning.

CONCLUSION

The FIF technique can be employed for UAM in place of wedge-based conformal treatment plans.

A rare case of paraganglioma of the sella with bone metastases

Sellar paragangliomas are very rare lesions with only 11 previous cases described in the literature. We present a further case of sellar paraganglioma. The patient is a 17-year-old man who developed headache, visual blurring, and diplopia. MRI showed a sellar lesion. Trans-nasal trans-sphenoid biopsy showed features of paraganglioma. He was treated by Stereotactic radiotherapy. Four months after treatment he developed bone metastases which was palliated by radiation, zoledronic acid, and chemotherapy. This is the first case of sellar paraganglioma showing metastases to bone.

Simulation of dose to surrounding normal structures in tangential breast radiotherapy due to setup error

Setup error plays a significant role in the final treatment outcome in radiotherapy. The effect of setup error on the planning target volume (PTV) and surrounding critical structures has been studied and the maximum allowed tolerance in setup error with minimal complications to the surrounding critical structure and acceptable tumor control probability is determined. Twelve patients were selected for this study after breast conservation surgery, wherein 8 patients were right-sided and 4 were left-sided breast. Tangential fields were placed on the 3-dimensional-computed tomography (3D-CT) dataset by isocentric technique and the dose to the PTV, ipsilateral lung (IL), contralateral lung (CLL), contralateral breast (CLB), heart, and liver were then computed from dose-volume histograms (DVHs). The planning isocenter was shifted for 3 and 10 mm in all 3 directions (X, Y, Z) to simulate the setup error encountered during treatment. Dosimetric studies were performed for each patient for PTV according to ICRU 50 guidelines: mean doses to PTV, IL, CLL, heart, CLB, liver, and percentage of lung volume that received a dose of 20 Gy or more (V20); percentage of heart volume that received a dose of 30 Gy or more (V30); and volume of liver that received a dose of 50 Gy or more (V50) were calculated for all of the above-mentioned isocenter shifts and compared to the results with zero isocenter shift. Simulation of different isocenter shifts in all 3 directions showed that the isocentric shifts along the posterior direction had a very significant effect on the dose to the heart, IL, CLL, and CLB, which was followed by the lateral direction. The setup error in isocenter should be strictly kept below 3 mm. The study shows that isocenter verification in the case of tangential fields should be performed to reduce future complications to adjacent normal tissues.

Osseous Hodgkin's lymphoma-review of literature and report of an unusual case presenting as a large ulcerofungating sternal mass

Osseous involvement in Hodgkin's lymphoma is uncommon. The most common location is vertebral, primarily in the thoracolumbar region, followed by pelvis, ribs, femur, sternum, clavicle and skull in decreasing incidence. We herein illustrate the salient features of the disease citing a case of a disseminated Hodgkin's lymphoma presenting as a large ulcerofungating sternal mass mimicking chronic tubercular osteomyelitis. The case report highlights the importance of clinical suspicion of unusual presentation of lymphohematopoietic tumors of the bone especially in developing countries, where chronic granulomatous disease is preponderant.

Comparison of computed tomography and magnetic resonance based target volume in brain tumors

PURPOSE

This study was mainly framed to study the difference in tumor volumes as seen on computed tomography (CT) and magnetic resonance (MR) and their significance in planning.

MATERIALS AND METHODS

Twenty-five patients with brain tumor of different diagnoses who underwent stereotactic radiotherapy were included in this study. CT and MR imaging was done for all the patients with 2.5 mm slice thickness. The CT tumor volume and MR tumor volume were measured and compared with each other. The center of mass (CM) of the tumor volume delineated on CT and MR were computed and the shift between the two CMs was determined.

RESULTS

The mean and median volume of the tumor as measured from MR scans was 19.67 cc +/- 13.73 and 16.13 cc (range: 3.25 cc-50.37 cc). Similarly, the mean and median volume of the tumor as measured from CT scans was 15.05 cc +/- 10.13 and 11.63 cc (range: 3.0 cc-36.25 cc) respectively. The mean and median CM shift between CT and MR was 5.47 mm and 5.21 mm respectively.

CONCLUSION

The study demonstrates that MR is an indispensable imaging modality in radiotherapy for planning brain tumors.

Plasmacytoma of bronchus treated by radical radiotherapy--a rare case with four and a half years follow up

Plasmacytoma of the bronchus is a very rare plasma cell neoplasm affecting the bronchus. Here we report a case of plasmacytoma of the bronchus treated by radical radiotherapy in July 2002. The tumor responded very well to treatment and showed a slow but sustained regression in the size over two years. Presently, he has completed four and a half years of follow-up and is free of disease.

A study on contralateral breast surface dose for various tangential field techniques and the impact of set-up error on this dose

The risk of inducing contralateral breast (CLB) cancer in patients undergoing tangential field irradiation for the treatment of breast cancer is a serious concern in radiation oncology. A bilateral breast phantom made of wax attached onto the Alderson Rando phantom was used for studying the CLB dose for techniques using physical wedges, EDWs, IMRT and open fields. The skin dose to the CLB was measured at four different points (3 cm from the medial border of the tangential field (P1), nipple (P3), axilla (P4), midpoint between P3 and P1 (P2)). The highest measured dose occurred at P1 with the 60 degrees physical wedges; it was 15.3% of the dose at isocentre. Similarly, the dose measured at P3 (nipple) with 60 degrees physical wedges was 1.90 times higher than the dose with 60 degrees EDWs. The dose at P1 for IMRT (7.8%) was almost the same as that for the open field (8.7%). The skin dose measured at the nipple was 2.1 - 10.9 % of the isocentre dose. The highest CLB doses were contributed by medial wedged fields. The dose to the CLB can be reduced by using IMRT or avoiding wedging the medial tangential fields. A set-up error in the longitudinal direction has little impact on the CLB dose. Set-up errors > 1 cm in the vertical and lateral directions have significant impact on the CLB dose.