Raj Kumar Nirban

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.

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.

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.

Ibrutinib: A comprehensive review of a promising drug

Ibrutinib is a recent Food and Drug Administration-approved drug for the treatment of lymphoid malignancies: mantle cell lymphoma and chronic lymphocytic leukemia (CLL). It is a Brutons tyrosine kinase (BTK) inhibitor which increases the apoptotic susceptibility of malignant lymphocytes and also causes tissue redistribution of lymphocytes. Strong biological rationale makes BTK an ideal target for therapy of CLL and other B-cell malignancies. We are presenting a comprehensive review of this promising drug, highlighting its metabolism, safety profile, trials, and approved uses.

Ototoxicity following Vinblastine chemotherapy in a patient of Hodgkin's Lymphoma

Sudden hearing loss is a well-known complication of certain chemotherapeutic agents. However, vinblastine has seldom been implicated causing ototoxicity. We report a case of sudden bilateral hearing loss in a 36-year-old male patient of Mixed cellularity Hodgkin′s lymphoma following standard adriamycin, bleomycin, vinblastine, and dacarbazine chemotherapy.

Sociodemographic parameters of Esophageal Cancer in northwest India: A regional cancer center experience of 10 years

Background: Despite various advances in the treatment of Esophageal Cancer (EC), being one of the least responsive tumors to cancer therapy, the overall prognosis remains poor. Therefore, it is significant to understand various sociodemographic factors associated with EC to find out various schemes for primary prevention of the disease. Materials and Methods: This is a retrospective analysis of medical records of the EC patients registered in the regional cancer center of northwest India from January 2003 to December 2012. The site of the disease and the histology were also recorded in addition to the various sociodemographic parameters. Results: Out of 55,742 patients registered in our hospital; 3,667 were diagnosed to have EC. Male:female ratio was 1.15:1. The mean age was 54.6 ± 11.74 years; 66.15% of the patients were illiterate and 48.6% belonged to the low socioeconomic status. Smoking and alcohol consumption were identified as risk factors in 48 and 25.6% of the patients, respectively. Conclusions: The etiology in majority of the patients is linked to tobacco and alcohol, thus, modification of life style with limiting the use of addictions may be an effective strategy in the prevention of this dreaded and mostly incurable disease.

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 Sociodemographic Parameters of Patients Admitted in a Newly Established Palliative Care Center in a Regional Cancer Institute of North-West India.

Background: After 4 months of the establishment of palliative care center (PCC) in our institute, we present an audit of the sociodemographic parameters of admitted patients. Such an audit can help to recognize the lacuna in the management and thus help to identify the specific requirements of cancer patients that might be overlooked in a busy cancer center. Materials and Methods: A total of 234 patients were admitted in our PCC since its inception in October 2013. The study design was retrospective, collecting the data from the medical records of the patients. The descriptive statistics of all these data were calculated in terms of frequencies and percentage of categorical variables. Results: Out of 234 patients admitted in PCC, 156 (66%) were male. The median age of the patients was 54 years. A total of 44% patients had primary malignancy of head and neck, 14% of cervical, 17% of lung cancer, 6% of breast, and 5% of colon, respectively. Metastatic disease was present in 76% of the patients admitted in the PCC. Liver was the most common (46%) metastatic site. Total 13 symptoms were identified with mean number of symptoms per patient at admission in PCC being 5.17. Conclusions: Palliative care services are an indispensable part of a tertiary regional cancer care center. The oncologists should be made aware of the requirement of better relief of pain and other distressing symptoms to provide better quality of life to the patients suffering from advanced cancer.