Puneet Kumar Bagri

Cancer related fatigue: A ubiquitous problem yet so under reported, under recognized and under treated

Background: Cancer related fatigue (CRF) is a problem that is highly under reported, under recognized and thus, under treated. About 80% of patients receiving chemotherapy/radiotherapy experience CRF, making it the most common side effect of cancer treatment. Functional assessment of chronic illness therapy fatigue (FACIT-F) version-4 is a 13 item questionnaire that has been used to measure the level of fatigue of cancer patients during their daily activities over the past 7 days. Materials and Methods: 92 patients of age 18 years and above attending the oncology Out Patient Department (OPD) of a regional cancer center were recruited in this study and were given FACIT-F questionnaire. The relevant sociodemographic parameters were obtained from the medical records of the patients. The internal consistency of the 13 items was measured using the Cronbach′s alpha. Results: The Cronbach alpha coefficient for FACIT-F scale in our study was found to be 0.74. Kendall′s coefficient of concordance was estimated to be 0.080. The correlation between Eastern Cooperative Oncology Group (ECOG) performance status and mean score of FACIT-F was studied, Pearson correlation coefficient was estimated to be 0.271 (P = 0.009). Conclusions: FACIT-F is a brief, simple, easy to administer and patient friendly tool to measure the fatigue in last 7 days. CRF should be given adequate attention from the beginning of the treatment to improve the quality of life of cancer patients.

Scattered radiation to gonads: role of testicular shielding for para-aortic and homolateral illiac nodal radiotherapy.

BACKGROUND Scattered radiation to organs at risk deserves great attention during radiotherapy especially when the concern is about fertility. Minimizing the delivery of scattered radiation to the gonads while treating abdominal nodes or pelvic fields in male patients requires adequate shielding of the testes to preserve testicular functions. We constructed a testicular shield with cerrobend for the purpose of treatment of seminoma of testis stage I and IIA disease. MATERIALS & METHODS An outer shell of coconut of required dimensions was taken as a base over which cerrobend was poured to obtain two semi-spherical half testicular shields. Five patients of seminoma early stage (stage I and IIA) were treated with this testicular shield. RESULTS The estimated total dose received by the testis by scatter radiation after completion of the treatment was 0.115Gy (0.28%) of total mid-plane dose of 40Gy delivered by inverted Y field. At a distance of 8cm from the inferior field border the 2cm thick cerrobend testicular shield provided a shielding factor of 3.2/0.3=10.33. CONCLUSIONS With proper testicular shielding, doses as low as 0.28% of the prescribed dose can be achieved. This low dose is believed to maintain the fertility of the patient.

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.

Astroblastoma of cerebrum: A rare case report and review of literature.

Astroblastoma is a rare neuroepithelial primary brain tumor of uncertain origin. They form 0.45-2.8% of all the neuroglial tumors. This tumor is usually localized in the cerebral hemisphere of young adults and children. The authors report a case of low-grade astroblastoma in a 16-year-old male and review the relevant literature. The patient presented with 2 months history of progressive headache with projectile vomiting for last 2 months. He underwent gross total resection of the lesion through right temporo-occipital craniotomy. Since tumor showed no evidence of high-grade lesion, adjuvant radiotherapy was not planned. However, the patient developed recurrence of the tumor after 12 months. Localized three-dimensional conformal radiotherapy was planned. In patients harboring anaplastic astroblastoma, gross-total resection and adjuvant therapy after the initial surgery seems to be the best choice. They can be easily misdiagnosed as they are rarely encountered in clinical practice and share common radiological and histopathologic appearance with other glial neoplasms.

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.

Comparison of single versus multiple fractions for palliative treatment of painful bone metastasis: First study from north west India

Background: Bone metastasis is a usual cause of pain in advanced cancer. Conventional radiation schedules require larger hospital stay and thus are not suitable for patients with poor general condition. This prospective observational study aims to compare the pain-relieving efficacy of different radiation fractionation schedules, i.e., 8 Gy administered in a single fraction versus 30 Gy administered in 10 fractions. Materials and Methods: Two hundred and fifty consecutive patients of bone metastasis were evaluated for the study, with 63 patients being excluded due to non-fulfillment of the inclusion criteria. The response to radiotherapy leading to pain relief as per the Visual Analog Scale was recorded at the end of treatment, 8 days, 15 days and 1 month during the follow-up visits. Results: Sixty-two percent of the patients received a single fraction while the remaining received 10 fractions. In the 10-fraction group, overall response was present in 60% of the patients. Stable pain was present in 23% of the patients while 9% patients had progressive pain. At 1 month of completion of treatment, 9% patients were lost to follow-up. In the single-fraction arm, overall response was seen in 58%, stable pain in 27% and progressive pain in 7% of the patients. Six percent of the patients were lost to follow-up. Conclusions: Single-fraction treatment for bony metastasis is as effective as multiple fractions to relieve bony pain and provides treatment convenience to both the patient and the caregiver.

Addition of magnetic resonance imaging to computed tomography-based three-dimensional conformal radiotherapy planning for postoperative treatment of astrocytomas: Changes in tumor volume and isocenter shift

Introduction: Postoperative radiotherapy is the current gold standard treatment in astrocytomas. Computed tomography (CT)-based radiotherapy planning leads to either missing of the tumor volume or underdosing. The aim of this prospective study was to study the changes in tumor volume on addition of magnetic resonance imaging (MRI) to CT-based three-dimensional radiotherapy treatment planning of astrocytomas. Materials and Methods: Twenty-five consecutive patients of astrocytoma (WHO grades I-IV) for postoperative three-dimensional conformal radiotherapy were included in this prospective study. Postoperative tumor volumes were contoured on CT-based images and recontoured on CT-MRI images after automated MRI co-registration on treatment planning system Eclipse 8.9.15 as per ICRU-50 report. Tumor volumes were compared with each other. Result: The MRI-based mean and median tumor volume was 24.24 cc ± 13.489 and 18.72 cc (range 5.6-46.48 cc), respectively, while for CT it was 19.4 cc ± 11.218 and 16.24 cc (range: 5.1-38.72 cc), respectively. The mean and median isocenter shift between CT and MRI was 4.05 mm and 4.39 mm (range 0.92-6.32 mm), respectively. There is a linear relationship between MRI and CT volume with a good correlation coefficient of R2 = 0.989, and MRI-based tumor volume was 1.208 times as compared to CT volume. Statistical analysis using paired sample t-test for the difference in CT and MRI tumor volume was highly significant (P < 0.001). Conclusion: Addition of MRI to the CT-based three-dimensional radiation treatment planning reduces the chances of geographical miss or tumor under dosing. Thus, MRI should be an integral part of three-dimensional planning of astrocytomas.

Malignant phyllodes tumor with chondro and osteosarcomatous differentiation and secondaries in lungs

Phyllodes tumor is a rare breast tumor, with neoplastic epithelial and stromal components for 10 cm in size and firm in consistency. She underwent left mastectomy. The histopathology revealed a malignant phyllodes tumor with sarcomatous stromal overgrowth and heterogeneous chondro and osteosarcomatous differentiation. At 2 months after surgery, she reported to us with secondaries in bilateral lungs. We planned palliative chemotherapy in view of good general condition of the patient and lung metastasis. Chemotherapy included ifosfamide, adriamycin and cisplatin as per standard regimen every 3 weekly. After three cycles, her lung metastasis cleared completely. It was planned to continue same chemotherapy for six cycles.

Kikuchi-Fujimoto disease: A diagnostic and therapeutic challenge

Kikuchi-Fujimoto disease (KFD) is a rare, benign, self-limiting disorder that generally presents with cervical lymphadenopathy. Recognition and early diagnosis of this condition is very critical as it can be easily mistaken for tuberculosis, lymphoma or systemic lupus erythematosus. It predominantly affects young adults (mean age 20-30 years), with a slight preponderance in females. There have been very rare reports of KFD in childhood or elderly. We report case of a 9-year-old female child who presented with fever and cervical lymphadenopathy. Examination of other systems and laboratory investigations were normal. Biopsy of the cervical node showed features suggestive of histiocytic necrotizing lymphadenitis (KFD). CD20, CD3 and CD68 stained positive while CD15 and CD30 were negative, thus confirming the diagnosis. The child was treated with steroids and complete remission occurred in few weeks. Although the incidence of KFD is rare, clinicians should be aware of this condition as early recognition and diagnosis of the disease will minimize unnecessary investigations and cytotoxic treatments.

Recurrent epithelioid sarcoma of wrist: A case report and review of literature

Epithelioid sarcoma is a rare variety of soft tissue sarcoma that affects young adults mostly involves forearm and hand. It mainly presents as a painless slow growing mass, but can present as multifocal lesions. It has a high rate of recurrence and metastasis. A 35-year-old male presented to our department in November 2013 with a painful ulcer with bloody discharge in the medial side of left wrist. The patient gave a history of swelling with serous discharge from 11 years. Local excision was done 6 times from 2003 to 2011. The patient also gave a history of falling on an outstretched hand and swelling at same site in July 2013, this time again wide local excision was done. The histopathology report was suggestive of high-grade osteogenic sarcoma. Immunohistochemistry (IHC) showed expression of cytokeratin, epithelial membrane antigen, CD34 and CA-125; tumor cells had lost INI-1 expression. IHC confirmed the diagnosis of epithelioid sarcoma of left wrist. Contrast-enhanced computed tomography thorax was suggestive of lung metastasis. Thus, doxorubicin based chemotherapy was planned.