Dayanand Sharma

Evaluation of outcome and prognostic factors in extraosseous Ewing sarcoma

Data on extraosseous Ewing sarcoma (EES) with uniform chemotherapy protocol are minimal. We aimed to examine this aspect in our patients, identify prognostic factors and compare the same with osseous Ewing sarcoma.

Normal tissue complication probability of fibrosis in radiotherapy of breast cancer: accelerated partial breast irradiation vs conventional external-beam radiotherapy.

AIMS Radiotherapy forms an integral part of breast-conserving treatment in early-stage breast cancer. Subcutaneous fibrosis of the treated breast is an important late effect in whole-breast irradiation. The aim of this study was to compare the normal tissue complication probability (NTCP) for radiation-induced fibrosis in treated breast using accelerated partial-breast irradiation (APBI) vs conventional treatment. MATERIALS AND METHODS Ten postoperative early-stage breast cancer patients (T1N0M0) were included in this dosimetric analysis. APBI treatment was planned using conformal radiotherapy technique and conventional treatment plans included two tangential portals. All the APBI treatment plans were made with five non-coplanar beams with 6 MV photons. The prescription dose was 38 Gy in 10 fractions for the APBI treatments and 50 Gy in 25 fractions, followed by a boost dose of 16 Gy in 8 fractions, for the conventional treatments. We used Lymans relative-seriality model and the breast fibrosis NTCP model fitting parameters for the study. RESULTS The equivalent uniform dose (EUD) was 30.09 Gy and 50.79 Gy in APBI and conventional treatment, respectively. The mean NTCP values for ipsilateral breast fibrosis in APBI and conventional treatment were 0.51 and 25.66%, respectively. Using the paired t-test, a statistically significant difference was seen in the breast fibrosis NTCP values for APBI vs conventional treatment (P < 0.001). CONCLUSIONS APBI reduces the ipsilateral breast fibrosis compared to conventional whole-breast treatment in early-stage breast cancer.

Breaking bad news issues: A survey among radiation oncologists

Introduction: Discussion of bad news and resuscitation in terminal cancer is an important but difficult and often neglected issue in day-to-day oncology practice. Materials and Methods: We interviewed 35 radiation oncologists using an indigenous 15-item questionnaire on their beliefs about breaking bad news and resuscitation to terminal cancer patients. Results: Most responders had an oncology experience of three to seven years (20/35). Thirty-two were comfortable discussing cancer diagnosis, prognosis and life expectancy-related issues. A similar number believed all cancer-related information should be disclosed, while only four believed in imparting all information in one visit. All agreed that disclosing sensitive information did not affect survival. When requested by relatives to withhold truth from patients, 11 said they would not comply, 22 agreed to tell the truth only if asked and two agreed to avoid difficult questions. Twenty responders denied having been adequately trained in breaking bad news and were keen on dedicated classes or sessions in this area of practice. Most (33/35) believed that Indian patients were keen on knowing their diagnosis and prognosis. Although all agreed to the importance of discussing resuscitation, only 17 believed patients should be involved. Majority (20/35) agreed that the issue needs to be discussed while the patient was conscious. Patients with unsalvageable disease were deemed unsuitable for aggressive resuscitation by 30 responders while the rest believed it should be offered to all. Most (21/35) admitted to feeling depressed after breaking bad news though only seven felt disclosure was more stressful than untruthful statements. Only four knew of a law regarding resuscitation in cancer. Conclusion: Observing the widely varied beliefs and practices for disclosing bad news, it is recommended that such training be a regular part of medicine curriculum, especially in the Oncology setting.

Radiation induced heart disease: Pathogenesis, management and review literature.

Radiation therapy (RT) is a very important part of multimodality cancer therapy. Addition of RT improves survival in many cancers, but there are some accompaniments of radiation. One of them is radiation induced heart disease (RIHD). RT for mediastinal lymphoma, breast, lung and oesophageal cancer is associated with the development of RIHD. The problem can be intensified with the addition of chemotherapy. Therapeutic modalities for RIHD are the same as in the non-irradiated population. However, surgery may be difficult in the irradiated patients. The long latent period is the reason why RIHD is not extensively studied. Survival of cancer patients has improved over past few decades, so RIHD is a growing concern especially in younger patients. In this review article, we have discussed the pathogenesis, clinical manifestation and management of RIHD along with impact of chemotherapeutic agents.

Radiofrequency ablation of hepatic metastasis: Results of treatment in forty patients

AIM To evaluate the local control of hepatic metastasis with radiofrequency ablation treatment. MATERIALS AND METHODS We did a retrospective analysis in 40 patients treated with radiofrequency ablation for hepatic metastasis. The tumors ablated included up to two metastatic liver lesions, with primaries in breast, gastrointestinal tract, cervix, etc. Radiofrequency ablation was performed under general anesthesia in all cases, using ultrasound guidance. Radionics Cool-Tip RF System was used to deliver the treatment. RESULTS The median age of patients treated was 49 years. There were 13 female and 27 male patients. The median tumor size ablated was 1.5 cm (0.75-4.0 cm). A total of 52 radiofrequency ablation cycles were delivered. Successful ablation was achieved in all patients with hepatic metastasis less than 3 cm in size. Pain was the most common complication seen (75%). One patients developed skin burns. At 2-year follow-up 7.5% of patients had locally recurrent disease. CONCLUSIONS Radiofrequency ablation is a minimally invasive treatment modality. It can be useful in a select group of patients with solitary liver metastasis of less than 3 cm size.

A prospective study evaluating surgery and chemo radiation in muscle invasive bladder cancer

AIM The aim of our study was to compare the two standard treatment approaches in muscle invasive carcinoma of urinary bladder--radical cystectomy and chemo radiation. MATERIALS AND METHODS Transitional cell carcinoma (TCC) of bladder of stages, T2 to T4, N0/N1/N2 and M0 were included in the study. Patients were allotted to two arms of the study. Arm A consisted of radical cystectomy. Adjuvant CMV chemotherapy was given for T3/T4 or Node positive disease only. Arm B received 2 cycles of neoadjuvant CMV chemo therapy followed by concurrent chemo radiation. RESULTS Forty-four patients were recruited into the study. Thirty patients in the surgical arm and 13 patients in the chemo radiation arm. The actuarial two-year survival rate in surgical arm is 56% while in chemo radiation arm it is 54%. There was no statistically significant difference in disease-free survival also between the two groups. CONCLUSION Chemo radiation yielded equivalent survival results with radical cystectomy. So it is worth giving preference to chemo radiation that will give a better quality of life for the patient.

Outcomes and Prognostic Factors for Ewing-Family Tumors of the Extremities

BACKGROUND There are few published studies describing the clinical results of patients uniformly treated for a Ewing-family tumor of an extremity. METHODS We performed a review of patients who had received uniform treatment consisting of neoadjuvant chemotherapy, surgery and/or radiation therapy as local treatment, and then adjuvant chemotherapy from June 2003 to November 2011 at a single institution. RESULTS There were 158 patients included in the study. The median age was fifteen years. Sixty-nine (44%) of the patients had metastatic disease at presentation. Fifty-seven patients underwent surgery, and forty-one received radical radiation therapy following neoadjuvant chemotherapy. After a median of 24.3 months (range, 1.6 to ninety-seven months) of follow-up, the five-year event-free survival, overall survival, and local control rates (and standard error) were 24.1% ± 4.3%, 43.5% ± 6%, and 55% ± 6.8%, respectively, for the entire cohort and 36.4% ± 6.2%, 57.6% ± 7.4%, and 58.2% ± 7.9%, respectively, for patients without metastases. In the multivariate analysis, metastases predicted inferior event-free survival (p = 0.02) and overall survival (p = 0.03) rates in the entire cohort, whereas radical radiation therapy predicted an inferior local control rate in the entire cohort (p = 0.001) and in patients without metastases (p = 0.04). In the group with localized disease, there was no difference between the patients who received radical radiation therapy and those who underwent surgery with regard to tumor diameter (p = 0.8) or post-neoadjuvant chemotherapy response (p = 0.1). A white blood cell count (WBC) of >11 × 109/L predicted inferior event-free survival (p = 0.005) and local control (p = 0.02) rates for patients without metastases. CONCLUSIONS To our knowledge, this is the largest study on extremity Ewing-family tumors treated with uniform chemotherapy and either surgical resection or radical radiation therapy in Asia. All possible efforts should be made to resect a primary tumor after neoadjuvant chemotherapy, as radical radiation therapy alone results in a poor local control rate despite a good post-neoadjuvant chemotherapy response. Patients without metastases but with a high WBC had inferior event-free survival and local control rates and may require more aggressive therapy. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcome of combined modality treatment including neoadjuvant chemotherapy of 128 cases of locally advanced breast cancer: Data from a tertiary cancer center in northern India

BACKGROUND Breast cancer is now the most common cancer in many parts of India and the incidence varies from 12 to 31/100,000, and is rising. Locally advanced breast cancer (LABC) accounts for 30-35% of all cases of breast cancers in India. LABC continues to present a challenge and imposes a major health impact in our country. MATERIALS AND METHODS We carried out a analysis of our LABC patients who received neoadjuvant chemotherapy (NACT) at our hospital over a 10-year period, from January 1995 to December 2004. We analyzed the response to NACT, disease-free survival (DFS), and overall survival (OS). RESULTS Patients with stages IIIA, IIIB, and IIIC were included. LABC comprised of 26.24% (609 patients) of new patients. One hundred and twenty-eight (31.1%) patients received NACT. Median age was 48 years and estrogen receptor was positive in 64%. Chemotherapy protocol was an FEC (5-Fluorouracil, Epirubicin, Cyclophosphamide) regimen in the following doses: Cyclophosphamide 600 mg/m2, 5-FU 600 mg/m2, and Epirubicin 75 mg/m2 given every three weeks, six doses, followed by modified radical mastectomy (MRM) and locoregional radiotherapy. The overall response rate (complete response (CR) + partial response (PR)) was 84.4%, clinical CR (cCR) was 13.3% and pathological CR (pCR) was 7.8%. Median DFS and OS were 33 and 101 months, respectively. The disease-free survival (DFS) and overall survival (OS) at five years were 41 and 58%, respectively. CONCLUSIONS This study analyzes the outcome in patients who received NACT, in the largest number of LABC patients from a single center in India, and our results are comparable to the results reported from other centers.

Static versus dynamic intensity-modulated radiotherapy: Profile of integral dose in carcinoma of the nasopharynx

This study is aimed to evaluate the impact of static and dynamic intensity modulated radiotherapy (IMRT) delivery techniques planned with Eclipse TPS on the integral dose to the healthy normal tissue surrounding the tumor-bearing area and to the volume receiving doses < 5 Gy in patients with carcinoma nasopharynx treated with Simultaneous Integrated Boost IMRT (SIB-IMRT). Ten patients with carcinoma nasopharynx were chosen for this dosimetric study. IMRT plans were generated with 6X using dynamic multileaf collimator (DMLC) and static multileaf collimator (SMLC) with 5, 10 and 15 intensity levels (L). Integral dose, volume receiving 5 Gy, number of monitor units (MU) is compared against DMLC. The mean difference in the MU delivered per fraction between 5, 10 and 15 L SMLC and DMLC was −13.25% (P < 0.001, with paired t test), −11.82% (P < 0.001) and −10.81% (P < 0.001), respectively. The mean difference in the integral dose with 5, 10 and 15 L compared to DMLC was −2.96% (P < 0.001), −2.67% (P = 0.016) and −0.39% (P = 0.430), respectively. However, the difference in low-dose volume (V5Gy) was statistically insignificant with mean difference of 0.60% (P = 0.23), 1.18% (P = 0.017) and 1.70% (P = 0.078), respectively for 5, 10 and 15 L compared to DMLC. Our results show that while choosing the IMRT delivery technique using conventional MLC the concerns about integral dose and volume receiving very low doses such as 5 Gy can be ignored.

Sarcomatoid carcinoma of the maxillary sinus: A rare head and neck tumor

Sarcomatoid carcinomas are rare tumors. These tumors have been reported at other sites, but head and neck origin is extremely uncommon. We report here a rare case of sarcomatoid carcinoma involving the maxilla. Only four such cases with maxillary origin have been discussed in English literature earlier. As compared to squamous cell carcinoma of maxilla, this variant is associated with poor prognosis and advanced disease at presentation, as was also seen in our case. There are no standard recommendations for management owing to the rarity of this histology. Surgery and radiotherapy form the mainstays of treatment. Exploration of the role of chemotherapy and novel targeted therapy agents is warranted in order to improve treatment results.