Saptarshi Ghosh

Chemoradiotherapy in a Case of Malignant Syringocystadenocarcinoma Papilliferum of Vulva with Locoregional Failure.

Introduction. Syringocystadenocarcinoma papilliferum (SCACP) is an extremely rare malignant adnexal tumor, which arises from syringocystadenoma papilliferum. To date, less than 30 cases of malignant SCACP have been reported, of which locoregional metastases were found in only four cases. Case Report. A 57-year-old female patient who presented to our Oncology Department with a recurrent malignant SCACP of the left labia along with right inguinal lymphadenopathy. Pathological examination confirmed the diagnosis of malignant SCACP with right inguinal lymph node metastases. Due to the fixity of the right inguinal nodes, neoadjuvant chemotherapy was administered with Cisplatin and 5-Fluorouracil for four cycles, following which the primary tumor and the contralateral inguinal nodes regressed completely. Then definitive chemoradiation was delivered with five cycles of weekly Cisplatin and external beam pelvic irradiation up to a dose of 59.4 Gy. Patient is disease-free 11 months after treatment. Discussion. We here report the fifth case of malignant SCACP with locoregional metastases. This is the first case of malignant SCACP which has been treated with neoadjuvant chemotherapy followed by concurrent chemoradiation. Although surgery has been used most commonly, chemoradiation may also have a role in the treatment of malignant SCACP, especially in cases of locoregional metastases.

Squamous Cell Carcinoma Developing in a Cutaneous Lichen Planus Lesion: A Rare Case

Lichen planus is a benign disorder characterized by an itchy, noninfectious skin rash. Though lichen planus is a common papulosquamous disorder affecting about 1-2% of the population, neoplastic transformation of cutaneous lichen planus lesions occurs very rarely and should be borne in mind while treating nonhealing longstanding lesions of lichen planus. Studies suggest an estimated 0.3–3% risk of malignancy in patients with oral lichen planus, however, cutaneous lichen planus does not carry an increased risk of malignant degeneration. We present a case of a 36-year-old male with a 10-year-long history of hypertrophic lichen planus who presented with a nonhealing ulcer in the left popliteal fossa. The patient underwent wide local excision with superficial skin grafting. Postoperative histopathological examination revealed verrucous squamous cell carcinoma complicating lichen planus. In view of underlying structure involvement, adjuvant radiation therapy was given. This case is being reported to emphasize the infrequent possibility of development of malignancy in cutaneous lichen planus, especially if it presents as a longstanding, nonhealing, itchy lesion with patchy areas of depigmentation in the lower limbs.

Osseous Metastases in Gynaecological Epithelial Malignancies: A Retrospective Institutional Study and Review of Literature.

INTRODUCTION Osseous metastasis in gynaecological epithelial tumours is an extremely rare phenomenon occurring in less than 1% of these cancers. AIM To analyse the clinical characteristics and prognosis in patients with gynaecological epithelial cancers with bone metastases. MATERIALS AND METHODS This was a single institutional retrospective study done with the data available from January 2008 to January 2015. Out of 1686 patients with epithelial gynaecological malignancies there were a total 18 (1.07%) patients with osseous metastasis. Clinico-pathologic characteristics were tabulated in Microsoft Excel 2013 and data were analysed using SPSS software Version 21. A p-value< 0.05 was taken to be statistically significant. Survival analysis was done by using Kaplan-Meier method and log-rank test was used to find out the difference in survivals. RESULTS Out of the 18 gynaecological epithelial cancer patients with bone metastases, 12 had cervical cancer, three had ovarian cancer, two had endometrial carcinoma and one patient had vulvar malignancy. Twelve patients had squamous cell histology, while the rest had adenocarcinoma. The mean interval from primary diagnosis of cancer to the detection of bone metastases was 31.9 months (range, 1 - 60 months). Solitary bone lesion was present in seven patients. The most common site of bone metastasis was lumbar vertebra. Extra-osseous metastasis was present in 12 patients. The mean follow-up period was 8.3 months. During the follow-up period 12 out of the 18 patients died. There was significant difference in survival (p = 0.005) between patients with solitary bone metastasis and patients with multiple osseous metastases. Near significant survival difference (p = 0.056) was also noted in patients with extra-osseous metastases when compared to the patients without. Improved survival was also found in patients with controlled local disease (p = 0.003) when compared to patients with local failure. CONCLUSION Bone metastasis in gynaecological epithelial malignancies is a rare phenomenon, but with grave prognosis. Multiple sites of bone involvement, recurrence at the primary tumour site and presence of other non-osseous metastases are poor prognostic indicators. Treatment in these patients should be tailored according to the patients need.

Routine use of ultrasound guided tandem placement in intracavitary brachytherapy for the treatment of cervical cancer - a South Indian institutional experience.

Purpose Intracavitary brachytherapy necessitates the insertion of a tandem applicator through the cervical os into the uterine cavity. Blind insertion of the tandem may result in suboptimal tandem placement. This decreases the control of the tumor locally and may result in uterine perforation. Although routine real time ultrasound guided tandem placement has shown better results, it is seldom practised. The aim of this work is to evaluate the role of routine real-time intraoperative trans-abdominal ultrasound guided tandem placement in intracavitary brachytherapy for the treatment of cervical cancer. Material and methods This is a prospective single institutional study conducted from April 2013 to May 2015. A total of 96 patients of locally advanced cervical cancer were treated with routine ultrasound guided brachytherapy amounting to a total of 282 intracavitary applications. Results In 78 of the study patients, the cervical os could be easily identified visually, which was then confirmed with ultrasound guidance. In another 12 patients, though the os could be identified visually, uterine sounding was only possible under ultrasound guidance. In another 4 patients, the cervical os could not be identified visually as the cervix was flushed with vagina and ultrasound guidance was necessary for accurate os identification. In 2 of the study patients, intraoperative ultrasound helped in identifying the patients suitable for interstitial brachytherapy rather than intracavitary brachytherapy. Out of the 96 study patients, the length of the uterine canal changed in 15 patients during the subsequent brachytherapy application. Conclusions This procedure is strongly advocated for proper placement of the tandem applicator and to avoid perforations. It is an accurate, fast, easily available, and cost-effective method. Hence, it can be incorporated in intracavitary applications for cervical cancers even in the developing countries where cost, accessibility, and time are important issues.

Clinico-morphological profile and receptor status in breast cancer patients in a South Indian institution.

BACKGROUND Breast cancer is the most common malignancy in women worldwide and the second most common cancer in females in India. Receptor status may be important for survival. OBJECTIVE To analyse and correlate the clinical and morphological parameters with receptor status in breast carcinoma patients in a tertiary care institution in Southern India. MATERIALS AND METHODS This retrospective study involved 320 patients of breast cancer diagnosed in an oncology hospital over a period of 31/2 years. Data was analysed using SPSS Version 21. RESULTS Some 60.6% patients with breast carcinomas belonged to the age group of 40 to 60 years. The most common histological type was infiltrating ductal carcinoma, not otherwise specified, accounting for 84.4% of patients. On immunohistochemistry, estrogen receptor (ER) and progesterone receptor (PR) were expressed in 56.3% and 53.1% of cases, respectively. CONCLUSIONS Breast cancers in India, a developing country, occur in younger women and tend to be more aggressive with lower rates of ER and PR expression and higher histological tumor grades. Both ER and PR status of the tumors had significant associations with the patient age, pathological TNM stage and histological tumor grade.

Weekly Cisplatin-Based Concurrent Chemoradiotherapy for Treatment of Locally Advanced Head and Neck Cancer: a Single Institution Study

BACKGROUND The organ preservation approach of choice for the treatment of locally advanced head and neck cancers is concurrent chemoradiation with three weekly high doses of cisplatin. Although this is an efficacious treatment policy, it has high acute systemic and mucosal toxicities, which lead to frequent treatment breaks and increased overall treatment time. Hence, the current study was undertaken to evaluate the efficacy of concurrent chemoradiation using 40 mg/m2 weekly cisplatin. MATERIALS AND METHODS This is a single institutional retrospective study including the data of 266 locally advanced head and neck cancer patients who were treated with concurrent chemoradiation using 40 mg/m2 weekly cisplatin from January 2012 to January 2014. A p-value of < 0.05 was taken to be significant statistically for all purposes in the study. RESULTS The mean age of the study patients was 48.8 years. Some 36.1% of the patients had oral cavity primary tumors. The mean overall treatment time was 57.2 days. With a mean follow up of 15.2 months for all study patients and 17.5 months for survivors, 3 year local control, locoregional control and disease free survival were seen in 62.8%, 42.8% and 42.1% of the study patients. Primary tumor site, nodal stage of disease, AJCC stage of the disease and number of cycles of weekly cisplatin demonstrated statistically significant correlations with 3 year local control, locoregional control and disease free survival. CONCLUSIONS Concurrent chemoradiotherapy with moderate dose weekly cisplatin is an efficacious treatment regime for locally advanced head and neck cancers with tolerable toxicity which can be used in developing countries with limited resources.

Concurrent Chemoradiation with Weekly Cisplatin for the Treatment of Head and Neck Cancers: an Institutional Study on Acute Toxicity and Response to Treatment

BACKGROUND Concurrent chemoradiation with three weekly high dose cisplatin is the non-surgical standard of care for the treatment of locally advanced head and neck cancers. Although this treatment regime is efficacious, it has high acute toxicity, which leads not only to increased treatment cost, but also to increased overall treatment time. Hence, the current study was undertaken to evaluate the acute toxicity and tumor response in head and neck cancer patients treated with concurrent chemoradiation using 40 mg/m2 weekly cisplatin, which has been our institutional practice. MATERIALS AND METHODS This single institution retrospective study included data for 287 head and neck cancer patients treated with concurrent chemoradiation from 2012 to 2014. RESULTS The mean age of the patients was 48.8 years. The most common site of involvement was oral cavity. Most of the study patients presented with advanced stage disease. The mean overall treatment time was 56.9 days. Some 67.2% had overall complete response to treatment as documented till 90 days from the start of treatment. According to the Radiation Therapy Oncology Group (RTOG) acute radiation morbidity scoring criteria, mucositis was seen in 95.1% of the patients. Dermatitis and emesis were observed in 81.9% and 98.6%, respectively. Regarding haematological toxicity, 48.8% and 29.6% suffered from anaemia and leukopenia, respectively, during treatment. Acute kidney injury was assessed using the Common Terminology Criteria for Adverse Events (CTCAE), and was found in 18.8% of the patients. CONCLUSIONS Concurrent chemoradiotherapy with weekly cisplatin is an effective treatment regime for head and neck cancers with reasonable toxicity which can be used in developing countries, where cost of treatment is so important.

High Dose Rate Brachytherapy in Two 9 Gy Fractions in the Treatment of Locally Advanced Cervical Cancer - a South Indian Institutional Experience.

BACKGROUND Although 3D image based brachytherapy is currently the standard of treatment in cervical cancer, most of the centres in developing countries still practice orthogonal intracavitary brachytherapy due to financial constraints. The quest for optimum dose and fractionation schedule in high dose rate (HDR) intracavitary brachytherapy (ICBT) is still ongoing. While the American Brachytherapy Society recommends four to eight fractions of each less than 7.5 Gy, there are some studies demonstrating similar efficacy and comparable toxicity with higher doses per fraction. OBJECTIVE To assess the treatment efficacy and late complications of HDR ICBT with 9 Gy per fraction in two fractions. MATERIALS AND METHODS This is a prospective institutional study in Southern India carried on from 1st June 2012 to 31st July 2014. In this period, 76 patients of cervical cancer satisfying our inclusion criteria were treated with concurrent chemo-radiation following ICBT with 9 Gy per fraction in two fractions, five to seven days apart. RESULTS The median follow-up period in the study was 24 months (range 10.6 - 31.2 months). The 2 year actuarial local control rate, disease-free survival and overall survival were 88.1%, 84.2% and 81.8% respectively. Although 38.2% patients suffered from late toxicity, only 3 patients had grade III late toxicity. CONCLUSIONS In our experience, HDR brachytherapy with 9 Gy per fraction in two fractions is an effective dose fractionation for the treatment of cervical cancer with acceptable toxicity.

A rare case of a synchronous anaplastic carcinoma thyroid with ductal carcinoma breast.

Dual malignancy was first reported by Billroth in 1889. Incidence of second malignancy in cancer patients is as high as 10%, but synchronous anaplastic thyroid cancer along with breast tumor is a rare entity. We present a case of a 61-year-old female with a synchronous anaplastic carcinoma thyroid with ductal carcinoma breast. The plausible association of breast cancers with thyroid carcinomas should thus be evaluated in larger cohort studies. More importantly, this report is to highlight the unusual synchronous occurrence of anaplastic thyroid cancer with ductal breast cancer and the therapeutic challenges involved in such cases.

Brain Metastases from Solid Tumors: an Institutional Study from South India.

BACKGROUND Brain metastases are the most common intra-cranial neoplasms. The incidence is on a rise due to advanced imaging techniques. AIMS The objective of the study was to analyse the clinical and demographic profile of patients with brain metastases from primary solid tumors. MATERIALS AND METHODS This is a retrospective single institutional study covering 130 consecutive patients with brain metastases from January 2007 to August 2014. RESULTS Some 64.6% of the patients were females. The majority were in the sixth decade of life. The site of the primary tumor was the lungs in 50.8% of the cases. The overall median time from the diagnosis of the primary malignancy to detection of brain metastases was 21.4 months. Survival was found to be significantly improved in patients with solitary brain lesions when compared to patients with multiple brain metastases, and in patients undergoing surgical excision with or without cranial irradiation when compared to whole brain irradiation alone. The majority of the cases belonged to the recursive partitioning analysis class II group. Whole brain radiation therapy was delivered to 79% of the patients. CONCLUSIONS Most of the patients with brain metastases in the study belonged to recursive partitioning analysis classes II or III, and hence had poor prognosis. Most of the patients in the Indian context either do not satisfy the indications for surgical excision or are incapable of bearing the high cost associated with stereotactic radiosurgery. Treatment should be tailored on an individual basis to all these patients.