Preety Negi

Three Weekly Versus Weekly Cisplatin as Radiosensitizer in Head and Neck Cancer: a Decision Dilemma

Cisplatin-based concurrent chemoradiation plays an undisputed key role as definitive treatment in unresectable patients with locally advanced squamous cell carcinoma head and neck or as an organ preservation strategy. Treatment with 100 mg/m2 3-weekly cisplatin is considered the standard of care but is often associated with several adverse events. The optimum drug schedule of administration remains to be defined and presently, there is insufficient data limiting conclusions about the relative tolerability of one regimen over the other. This review addresses regarding the optimal dose schedule of cisplatin focusing mainly on three-weekly and weekly dose of cisplatin based concurrent chemoradiotherapy in locally advanced head and neck cancer with an emphasis on mucositis, dermatitis, systemic toxicity, compliance, and treatment interruptions. To derive a definitive conclusion, large prospective randomized trials are needed directly comparing standard 3-weekly cisplatin (100 mg/m2) with weekly schedule (30 - 40 mg/m2) of concurrent cisplatin based chemoradiotherapy in locally advanced squamous cell carcinoma head and neck.

Are Biomarkers Predictive of Anthracycline-Induced Cardiac Dysfunction?

BACKGROUND The early detection of anthracycline- induced cardiotoxicity is very important since it might be useful in prevention of cardiac decompensation. This study was designed with the intent of assessing the usefulness of cardiac troponin T (cTnT) and NT- Pro BNP estimation in early prediction of anthracycline induced cardiotoxicity. MATERIALS AND METHODS In this prospective study histologically proven breast cancer patients who were scheduled to receive anthracycline containing combination chemotherapy as a part of multimodality treatment were enrolled. Baseline cardiac evaluation was performed by echocardiography (ECHO) and biomarkers like cardiac troponin T (cTnT) and N terminal- pro brain natriuretic peptide (NT- Pro BNP). All patients underwent cTnT and NT- Pro BNP estimation within 24 hours of each cycle of chemotherapy and were followed up after 6 months of initiation of chemotherapy. Any changes in follow up ECHO were compared to ECHO at baseline and cTnT and NT- Pro BNP levels after each cycle of anthracycline-based chemotherapy. RESULTS Initial data were obtained for 33 patients. Mean change in left ventricular diastolic diameter (LVDD) within 6 months was 0.154± 0 .433 cms (p value=0.049). Seven out of 33 patients had an increase in biomarker cTnT levels (p value=0.5). A significant change in baseline and follow up LVDD was observed in patients with raised cTnT levels (p value=0.026) whereas no change was seen in ejection fraction (EF) and left atrial diameters (LAD) within 6 months of chemotherapy. NT- Pro BNP levels increased in significant number of patients (p value ≤0.0001) but no statistically significant change was observed in the ECHO parameters within 6 months. CONCLUSIONS Functional monitoring is a poorly effective method in early estimation of anthracycline induced cardiac dysfunction. Estimation of biomarkers after chemotherapy may allow stratification of patients in various risk groups, thereby opening window for interventional strategies in order to prevent permanent damage to the myocardium.

Variegated colors of pediatric glioblastoma multiforme: what to expect?

Malignant gliomas account for 35-45% of primary brain tumors; among these glioblastoma multiforme (GBM) is the most common adult brain tumor constituting approximately 85%. Its incidence is quite less in the pediatric population and treatment of these patients is particularly challenging. Exposure to ionizing radiation is the only environmental factor found to have any significant association with GBM. Several genetic alterations associated with GBM in adults have been well documented such as epidermal growth factor receptor amplification, overexpression of mouse double minute 2 homolog also known as E3 ubiquitin-protein ligase, Phosphatase and tensin homolog gene mutation, loss of heterozygosity of chromosome 10p and isocitrate dehydrogenase-1 mutation. However, data on genetic mutations in pediatric GBM is still lacking. Exophytic brain stem gliomas are rare tumors and are usually associated with a poor prognosis. The most effective treatment in achieving long-term survival in such patients, is surgical excision of the tumor and then chemoradiotherapy followed by adjuvant chemotherapy by temozolomide. This schedule is the standard treatment for GBM patients. In view of the rarity of pediatric GBM, we report here a case of pontine GBM in a 5-year-old girl.

Radiation induced cardiotoxicity in left sided breast cancer - Where do we stand?

Breast cancer is the commonest cancer in women, with around a million new cases diagnosed each year worldwide. Adjuvant radiotherapy (RT) is an important component of therapy for many women with early-stage breast cancer. With improving survival rates following breast cancer, patients are increasingly likely to die of other causes. As a result, long-term adverse effects of treatment are of major concern. To determine which treatment is optimal, clinician need to be aware of long-term risks and benefits of adjuvant therapies. An awareness of the potential cardiotoxicity of RT led to the application of improved RT techniques that minimize the irradiation to the heart. Although new techniques, including intensity-modulated RT combined with free breathing gating and helical tomotherapy may further reduce radiation-induced cardiac toxicities, the most important factors in limiting cardiac radiation are associated with the techniques used and the skill of the radiation oncologist.

Bilateral Parotid MALToma: a sure shot for radiation.

TO THE EDITOR: The concept of mucosa-associated lymphoid tissue (MALT) lymphoma was first proposed by Isaacson and Wright in 1983 and is now recognized as a distinct clinical-pathologic disease entity [1]. Between 60% and 70% of patients with MALT lymphomas present with localized (stage I or II) disease involving a non-lymphatic organ. MALT lymphoma arising from the salivary glands is rare; data in the literature are scarce, limited to small series and isolated case reports. Therefore, the characteristics and clinical outcome of this unusual presentation are largely unknown. Extranodal marginal zone lymphoma has a slight female preponderance and usually presents at a localized stage with a low incidence of widespread dissemination, thus requiring local treatment, such as radiation therapy (RT), rather than systemic therapy [2]. In the present case report, we describe a case of MALT lymphoma involving both salivary glands presenting with Sjogrens syndrome and renal tubular acidosis. A 42-year-old woman diagnosed with renal tubular acidosis type II, secondary to Fanconis syndrome, presented with swelling in the left cheek that was not tender but was progressively increasing in size (Fig. 1). Physical examination revealed palpable bilateral swelling in the region of the angle of the mandible measuring 5×5 cm on the left side and 3×3 cm on the right side. The swelling was firm and fixed to the underlying structures. There were no palpable cervical lymph nodes or any other swelling. Ultrasonography revealed a bulky heterogeneous lesion in the left parotid gland measuring approximately 10 mL, suggesting parotitis or a parotid gland abscess. She was given a course of antibiotics for a week but the swelling did not resolve after the treatment. Fine needle aspiration cytology (FNAC) of the swelling showed numerous small-sized lymphoid cells in varying stages of maturation along with histiocytes, indicating a parotid lymph node. Fig. 1 (A) Left parotid swelling measuring 5.8×4.2×4 cm at initial diagnosis. (B) Complete clinical response after radiotherapy. Contrast enhanced magnetic resonance imaging (MRI) of the face and neck revealed complete replacement of the entire left parotid parenchyma by a large, solid lesion involving both the superficial and deep lobes measuring 5.8×4.2×4.0 cm (Fig. 2). A similar lesion was visualized in the right parotid gland measuring 3×2×2 cm with enlarged cervical lymph nodes, which suggested the diagnosis of lymphoma or Warthins tumor. Fig. 2 Contrast enhanced T1- weighted axial and coronal magnetic resonance imaging showing a 5.8×4.2×4 cm lesion replacing the left parotid gland and a 3×2×2 cm lesion in the right parotid gland (A, C). T2-weighted axial and coronal ... A trucut biopsy of the left parotid gland swelling was performed, which revealed a moderate amount of sheets of monotonous lymphoid cells with round irregular nuclei, coarsely clumped chromatin and inconspicuous nuclei with eosinophilic cytoplasm with occasional mitotic figures, resembling monocytoid B cells. Immunohistochemically, the cells were positive for CD20 and Bcl-2, weakly positive for Bcl-6 with a Ki-67 proliferative index of 35%, suggestive of MALT lymphoma (Fig. 3). Fig. 3 (A) Expanded pale looking marginal zone (arrows) surrounding a lymphoid follicle (LF), H&E ×100. (B) Marginal zone cells with round to slightly irregular nuclei and moderate amount of pale cytoplasm, H&E ×400

Detection of subclinical anthracycline induced cardiotoxicity in breast cancer survivors

Aims : To assess the chronic cardiac effects of anthracycline-based chemotherapy regimens on atrial and ventricular diameter, ejection fraction, and valvular abnormalities in relation to cumulative dose in breast cancer patients. Materials and Methods: Breast cancer patients who had received anthracycline-based chemotherapy and radiation therapy were enrolled. All patients had undergone a baseline and follow-up electrocardiogrphy, echocardiography, and clinical cardiac evaluation. Any changes in cardiac parameters were noted. Statistical Analysis Used: Statistical measures used were Chi-square test and independent t-test. Results: A total of 75 breast cancer patients were assessed. Out of these, 56 patients who received cumulative dose of doxorubicin ≥300 mg/m 2 showed increased cardiac dysfunction. Patients with left side breast cancer had greater cardiac abnormalities compared with right side. Conclusion: Cardiac dysfunction was significant with cumulative dose of doxorubicin ≥300 mg/m 2 and also was observed more in left side breast cancer patients.