Ashok Kalwar

Comparative analysis of cisplatin-induced nephrotoxicity in head and neck cancer and carcinoma cervix during concurrent chemoradiotherapy

Background: Cisplatin is widely used as radio sensitizer in head and neck cancer (HNC) and carcinoma cervix (CaCx). This study aims to see comparative nephrotoxicity of cisplatin in HNC and in CaCx without obstructive uropathy treated by concurrent chemoradiotherapy (CCRT). Materials and Methods: Fifty patients of HNC and 50 patients of CaCx stage II/III without obstructive uropathy were included in this study. Cisplatin 50 mg intravenous weekly was given before EBRT with adequate hydration and premedication in both groups. Before chemotherapy; blood urea, serum creatinine, and glomerular filtration rate (GFR) were measured. GFR was measured using 99mTc diethylene triamine pentacaetic acid (DTPA) renogram study. Results: At the end of 4th week, blood urea level 41-45 mg% was in 40 and 4% in HNC and CaCx, respectively (P = 0.018). At the end of 3rd and 4th week, blood urea level >45 mg% was 10 and 6% in HNC cases, respectively. At the end of 4th week, serum creatinine level 1.1-1.5 mg% was 50 and 8% in HNC and CaCx, respectively (P = 0.047). Serum creatinine level >1.5 mg% was 6, 8, and 22% in HNC at the end of 2nd, 3rd, and 4th week, respectively. GFR <80 ml/min at the end of 4th week was 14% in HNC and only 2% in CaCx. GFR <100ml/min was significant at the end of 4th week (P = 0.04). Univariate analysis showed significant relation between reduced oral fluid intake and reduced GFR (P < 0.001). Conclusion: In HNC, during concurrent chemoradiation, as the 3rd-4th week is reached, oral mucosal reactions increase and affect oral intake which further add to the cisplatin-induced nephrotoxicity. In CaCx without obstructive uropathy, renal function impairment is less severe as oral intake of water and liquid is not much impaired.

Allele Frequency of ABO Blood Group Antigen and the Risk of Esophageal Cancer

Background. ABO blood group and risk of squamous cell carcinoma of esophagus have been reported by many studies, but there is no discipline that had provided association with the genotype and gene frequency by population statics. Methods. We conducted a case-control study on 480 patients with squamous cell carcinoma of the esophagus and 480 noncancer patients. ABO blood group was determined by presence of antigen with the help of monoclonal antibody. Chi-square test and odds ratio (OR) with 95% confidence intervals (CIs) were calculated by statistical methods, and gene frequencies were calculated by Hardy-Weinberg model. Results. We observed significant associations between ABO genotype and squamous cell carcinoma of esophagus. OR (95% CIs) was 1.69 (1.31–2.19) for presence of B antigen allele relative to its absence (P < 0.0001); in female subgroup OR (95% CIs) observed at 1.84 (1.27–2.65) was statistically significant (P = 0.001). SCC of esophagus shows significant difference in comparison to general population; blood group B is found to be higher in incidence (P = 0.0001). Increased risk of cancer was observed with absence of Rh antigen (P = 0.0001). Relatively increased gene frequency of q[B] allele is observed more significantly in female cancer patients (P = 0.003). Conclusion. Statistically significant association between squamous cell carcinoma of the esophagus and ABO and Rh genotype is identified by this study. Sex and anatomical site of cancer also present with statistically significant relative association. However, larger randomised trials are required to establish the hypothesis.

Giant cell variant of malignant fibrous histiocytoma of male breast: A rare case report

Malignant fibrous histiocytoma (MFH) is the most common form of soft tissue sarcoma during middle and late adulthood in the deep connective tissue of the extremities, abdominal cavity, and retroperitoneum. However, primary breast sarcoma is a rare disease entity, comprising less than 1% of all breast malignancies. MFH of the male breast is very rare. We present a case of MFH of giant cell variant of the right breast in a 50-year-old male who presented with a painless lump. Following cytological investigation, simple mastectomy was performed. Immunohistochemical staining confirmed the diagnosis.

Analysis of patterns of palliative radiotherapy in north west India: A regional cancer center experience

Background: Palliative radiotherapy (PRT) is the eventual requirement in 30-50% of all cancer patients. PRT is primarily aimed to relieve pain and prevent/treat collapse or fracture in case of bone metastasis, to reduce edema in patients with cranial metastasis, and to control distressing symptoms of rapid primary growth. An audit of PRT planned in a busy cancer center can help in the characterization of the requirements of the patients and the formulation of institutional policies. Materials and Methods: In total, 516 patients who received PRT in our regional cancer center from January 2012 to December 2012 and whose complete records were available for analysis were selected for this retrospective study. Medical records and radiotherapy files were analyzed to obtain data such as sociodemographic parameters, prescription of PRT, and follow up. Descriptive statistics were evaluated in terms of frequencies and percentages to allow comparisons. Results: Of the 516 patients, 73% patients were male; the median age of the patients receiving PRT was 62 years (range 13-83 years). About 48% (n = 248) patients received PRT at the primary site while rest (52%) were given PRT at the metastatic site. The most common indication of PRT was pain (56.8% cases), followed by cytostatic PRT (19.8%) and raised ICT (12.4%). The median dose prescribed was 30 Gy (range 8-36 Gy) delivered in 1-12 fractions over the duration of 1-18 days. The overall response rate was about 43% at 2 weeks of completion of PRT; the median follow-up of the patients was 154 days (range 9-256 days). The long-term symptom relief at median follow up was 8%. Conclusions: Good clinical judgment and expertise is required in prescribing correct fractionation schedule to achieve effective symptom palliation with lowest possible cost and inconvenience to the patients and relatives. Hypofractionated radiotherapy is a feasible treatment option in patients with advanced incurable disease to achieve effective palliation.

Metronomic therapy with oral 6-mercaptopurine in elderly acute myeloid leukemia: A prospective pilot study.

Introduction: Acute myeloid leukemia (AML) in elderly patients differs biologically from that in younger patients and is known to have unfavorable chromosomal rearrangements, higher resistance, and lower tolerance to chemotherapy. In such circumstances, instead of giving full-blown chemotherapy, palliative metronomic chemotherapy (MCT) could be a treatment option. Patients and Methods: We performed a prospective pilot study of old AML patients (age >60 years) not amenable to curative treatment. Thirty-two patients were enrolled into the study and were treated with daily oral 6-mercaptopurine 75 mg/m 2 . The following inclusion criteria were used: age >60 years, nonpromyelocytic AML, the absence of uncontrolled comorbidities, and patient not amenable to curative treatment. Overall survival (OS) was calculated using Kaplan-Meier method and Cox regression analysis were used to calculate the hazards ratio of significant factors. Results: The median age of the patients was 69 years (range: 61-86 years) with male: female ratio of 2.5:1. About 59.4% of patients had Eastern Cooperative Oncology Group performance status of 2 while rest had the status of 3. The median OS was 6 months (95% confidence interval [CI]: 4.4-7.6). Males had median OS of 7 months (95% CI: 5.4-8.6) versus females with OS of 3 months (95% CI: 1.5-4.4; P = 0.008). There was no survival difference on the basis of baseline hemoglobin or French-American-British class. There were no Grade 4 toxicities and no episode of febrile neutropenia. Conclusions: MCT with oral 6-mercaptopurine is an attractive treatment option in elderly AML patients who are not amenable to curative therapy with minimal toxicities.

Analysis of outcomes and prognostic factors of acute lymphoblastic leukemia patients treated by MCP841 protocol: A regional cancer center experience

Background: A dramatic improvement in the survival of acute lymphoblastic leukemia (ALL) patients in the last three decades has been observed. MCP 841 protocol is an old but effective tool with tolerable toxicities. The objective of this study was to estimate the relapse-free survival of ALL patients treated uniformly with MCP 841 protocol on the basis of various prognostic factors. Materials and Methods: The study design was retrospective and it was conducted in a regional cancer center of Northwest India. Three hundred and ten ALL patients who underwent treatment with MCP 841 protocol and regular follow-up for up to 5 years were selected for this study. Relapse-free survival was calculated by Kaplan–Meier analysis and Cox regression analysis was used to calculate the hazards ratio (HR) using Statistical Package for the Social Sciences (SPSS) software for windows version 20.0. Results: Fifty-four percent patients were <15 years of age and 69% were males. 53.2% patients were in remission at the end of 5 years of starting the treatment. Relapse-free survival at 5 years by Kaplan–Meir analysis for B-cell ALL was 62% [HR 0.67 {95% confidence interval (CI) 0.47-0.95}] with patients with unknown lineage taken as reference] while for T cell it was 28% [HR 1.41 (95% CI 1.19-1.63), P 0.001]. Patients with total leukocyte count (TLC) <1 lakh/cmm at presentation, relapse-free survival was 68% and those with TLC >1 lakh/cmm had 41% survival [HR 2.14 (1.76-2.48) with, P < 0.001]. Conclusion: MCP 841 protocol is a useful tool for the treatment of ALL in children when more aggressive protocols can not be used.

Challenges in the management of cancer pain in elderly population: A review

Elderly people are more susceptible to the experience of pain than any other sector of the population. Neoplasia is an important cause of pain in the elderly population. The prevalence of persistent pain in older persons living in a care home setting is estimated at 45-80%, thus highlighting that persistent pain in older people is widespread and problematic in these settings. This article reviews the difficulties in the management of pain in the elderly population and the important differences from other population besides describing the various pain assessment tools, pharmacologic and nondrug management of pain.

Detection of bone metastasis in nasopharyngeal carcinoma by bone scintigraphy: A retrospective study in perspective of limited resource settings

Background: Nasopharyngeal carcinoma (NPC) is an aggressive tumor with a significant proportion of patients presenting with distant metastasis. The skeleton is one of the most common sites of distant failure. This retrospective study was performed to analyze the incidence and patterns of skeletal metastasis in NPC detected by bone scintigraphy in resource-poor settings. Materials and Methods: We analyzed records of 301 NPC patients attending our oncology outpatient department from January 2002 to December 2012. Of these, 33 patients who presented with bony pain underwent bone scan (BS) for suspect of skeletal metastasis. In patients with positive scans, histological diagnosis to confirm metastasis was attempted. Results: Bone metastasis (BM) was found in 19 patients (57.6% of patients undergoing BS, 6.3% of total NPC patients). About 36.8% and 15.8% of BM cases were in the age group 20-29 and 30-39 years, respectively (P = 0.27). 63.1% of metastatic cases were of World Health Organization type-II histology (P = 0.021). Of the patients diagnosed with BM, 52.6% belonged to stage IV at presentation (P = 0.022). Spine was involved in 56% of the positive cases, followed by the pelvis (32%), and ribs (24%). On univariate analysis, histology (P < 0.001), stage at diagnosis (P = 0.007) and age group (P = 0.001) were identified as significant factors affecting BM. However, on multivariate analysis, only stage (P = 0.001) was a significant factor. Conclusion: Bone scintigraphy can be considered in limited resource settings for the evaluation of distant metastasis in the patients of advanced NPC.

Analysis of bone metastasis in head and neck squamous cell carcinoma: Experience of a regional cancer center

Background: Bone metastasis is a rare occurrence in head and neck squamous cell carcinoma (HNSCC). This retrospective study was performed to analyze the frequency and patterns of skeletal metastasis in HNSCC. Materials and Methods : We analyzed records of 8326 HNSCC patients attending our oncology outpatient department from January 2000 to December 2013. All statistical calculations were performed using MedCalc software for windows, version 12.5.0 (Osterd, Belgium). Results : Bone metastasis was found in 25 patients (0.3% of total HNSCC patients, nasopharynx excluded). 10 patients (0.66%) of carcinoma tonsil had skeletal metastasis. The patients of younger age groups had higher frequency of bone metastasis; 1.56% patients of age group 20-29 years while 0.26% patients of 60-69 years age group had skeletal metastasis (P < 0.001). However, no patient of >70 years age was found to have bone metastasis. Most common site of metastasis was spine (56%) followed by pelvis (32%). Isolated involvement of a single bony site was present in 64% of the metastatic cases. Conclusion: Bone metastasis though very rare, should be considered for evaluation in patients of HNSCC especially in younger patients.

Sweet's syndrome in accelerated chronic myelogenous leukemia: A case report and review of literature

Sweets syndrome (acute febrile neutrophilic dermatosis) is a well documented entity in acute leukemia. However, there have been only rare reports of its association with chronic leukemia. We report a case of sweets syndrome in a patient of BCR-ABL positive chronic myelogenous leukemia in accelerated phase for its rare association, classical clinical presentation and dramatic therapeutic response to corticosteroids.