Head and neck cancer forms the major chunk of cancer patients in developing country like India. About 2/3rd of the patients present in locally advanced stage in which the cure rates are low. Concomitant chemoradiation with platinum compounds is the standard treatment for such patients as it offers organ and function preservation with better quality of life. MACH-NC update (2009) shows that concomitant chemoradiation provides an absolute survival benefit of 6.5% at 5 years. Many chemotherapeutic agents including 5-FU, taxanes and biologically targeted therapy have been investigated in an effort to maximize the locoregional and survival in locally advanced head and neck cancer. Oral chemotherapeutic agent gives the ease of self medication on daily basis without the need for hospital admission and intravenous infusion. Theoretically daily administration of oral chemotherapy agent mimics the continous infusion of a parenteral agent. Since infusional 5-FU along with Radical RT has achieved a complete response rate of 68% for 5-FU arm versus 56% for placebo arm (p=0.04) with the overall median survival of 33 months for 5-FU versus 25 months for placebo arm, Capecitabine (analog of 5-FU) in low doses have been used in concomitant setting for locally advanced head and neck cancer. Overall response rate observed has been 33-89% with manageable toxicity and near total patient compliance. The maximally tolerated dose to be given daily during radiation therapy is 500 mg/m2 b.i.d. Lower dose doses of 250-350 mg/m2 have also been used in concomitant with lesser toxicity and greater...
PALLIATIVE CHEMORADIOTHERAPY VERSUS RADIOTHERAPY ALONE FOR MANAGEMENT OF LOCALLY ADVANCED HEAD & NECK CARCINOMA PATIENTS WITH POOR PERFORMANCE STATUS
Introduction: Palliative external beam radiotherapy (EBRT) and chemotherapy is commonly practiced for management of locally advanced head & neck carcinoma (LAHNC) patients with poor performance status. This study compares EBRT alone and EBRT along with low dose Gemcitabine. Method: Study was conducted in Department of Radiotherapy, PGIMS Rohtak, in 2008-09; on histopathologically proven, untreated 60 cases of LAHNC, having KPS 60-70. Patients were randomly assigned either control group (n=30), given EBRT alone as 20Gy/5Fr/5days or study group (n=30), given EBRT as 20Gy/ 5Fr/ 5days and Gemcitabine 200 mg/m2 i.v. 2 hour prior to radiotherapy on day 1. Mean age was 53 years (26-84 years). Male:female ratio was 5:1. Most common primary site was base of tongue followed by larynx. Major symptoms were pain, difficulty in swallowing and altered voice. Patients were staged as per AJCC 2002; 2/3rd were stage IVA and 1/3rd were IVB. Despite randomization, there was no significant difference between two groups in age, sex, primary site, stage, and performance status. The side effects were graded as per RTOG criteria. Results: Objective response, 3 months post-treatment, in the chemoradiotherapy and radiotherapy alone group respectively was: CR 7% vs 0%; PR 30% vs 33%; stable disease 56% vs 46% and progressive disease 7% vs 20%. Subjective response, similarly was better in study group through out; even significantly better in dysphagia at 3 months follow up. Acute skin reactions were: Grade I- 73% vs 47% at 2 weeks and 60% vs 40% at 1 month respectively. Acute mucosal reactions were: Grade I- 30% vs 17%, Grade II- 43% vs 17% respectively. No hematological and grade III/IV skin or mucosal reactions observed. Differences in reactions were not statistically significant. Conclusion: In management of LAHNC patients with poor performance status, addition of low dose Gemcitabine to palliative radiotherapy gives better disease control and symptomatic relief without unmanageable side...
Cancer cells have a multitude of mechanisms to avoid and suppress immunity. Normal cells when exposed to chemical carcinogens, irradiation and certain viruses get transformed to cancer cells which can grow indefinitely. These cells have decreased requirements for growth factors; do not undergo apoptosis resulting in malignancy. The tumor cells have various antigens which are responsible for the generation of immune responses towards that particular tumor. There are two types of tumor antigens; tumors specific transplantation antigens (TSTAs) and tumor associated transplantation antigens (TATAs). The TSTAs are specific to tumor, result from mutations which alter the cellular proteins while TATAs may be proteins present in or during some stages of fetal development but not expressed or expressed at low levels in normal adult cells. Adoptive T-cell therapy involves the ex vivo cultivation of T cells with activity against a specific target cancer antigen to increase the frequency of these T cells to achieve therapeutic levels and then infuse them back into the patient. Oncolytic viruses selectively infect, replicate in, and kill tumor cells with no or limited impact on normal tissues which means that tumor cells have surface receptors to bind the virus. Monoclonal antibodies (mAbs) are immunoglobulins derived from a single clone of B cells, act by targeting an antigen which acts a ligand of receptor involved in signal transduction within the...
ABSTRACT Aim of the Study: To review and suggest treatment approach for rare diseases Leiomyosarcoma of testis. Material and Method: Here, we have reviewed management of Primary Leiomyosarcoma of the testis by search of case reports in PubMed Central, Embase, Cochrane, and Web of Science Central database. We have classified the obtained information as per Oxford Centre for Evidence Based Medicine (OCEBM) level of evidence, and National Comprehensive Cancer Network (NCCN) Categories of Evidence and Consensus. Here, current treatment scenario for sarcoma and its outcome will be discussed for a new case of low grade primary leiomyosarcoma of testis that was confirmed with Immuno-histochemistry after high inguinal orchidectomy, for painless testicular mass. Systematic review, line listing of old reported cases and treatment evidences were analysed by reviewing various international databases. Results: Leiomyosarcoma is a very rare disease, and only few cases have been reported on online databases. It is usually reported among elderly men following irradiation or long-term anabolic steroid use. Intensive search reveals lack of definitive guidelines for management of leiomyosarcoma because available evidence is level V as per OCEBM and level C as per NCCN. Conclusion: Even though early diagnosis and treatment by high inguinal orchidectomy improves survival and decreases risk of recurrence of leiomyosarcoma, there is need of research and definitive chemotherapy guidelines, similar to sarcoma of other site of the...
UNVEILING THE MYSTERIOUS WORLD OF SALIVARY DUCT CARCINOMA OF THE PAROTID GLAND- A RARE CASE REPORT AND REVIEW OF THE LITERATURE.
Among many variants of salivary gland tumors, salivary duct carcinoma (SDC) of the parotid gland is a highly aggressive and rare malignant tumor which ranks among those with the worst prognosis and a significant mortality. These tumors got their name based on its microscopic resemblance and being analogous to similar schemes in the ductal carcinoma of the breast. The characteristic microscopic features of salivary duct carcinoma are composed of comedo necrosis, a cribriform and papillary pattern of intraductal growth and aggressive infiltration to adjacent structures. Majority of cases are typically treated with radical parotidectomy with or without neck dissection followed by adjuvant radiotherapy. We present a case of a 60 year old male patient who presented with progressive facial paralysis and right parotid swelling. FNAC was positive for malignancy. PET-CT showed a lesion in right superficial lobe of parotid with bilateral neck nodes. Patient underwent right total parotidectomy with right radical neck dissection and left modified neck dissection. Facial nerve was preserved. Microscopic examination reported it as a salivary duct carcinoma, positive for Her2/neu antibody with lymph node metastasis (22/23). Patient received adjuvant radiotherapy and 12 cycles of Transtuzumab. There were no recurrences or metastases within 12 months of...
Gestational trophoblastic diseases include hydatidiform moles and gestational trophoblastic neoplasia i.e. invasive mole, choriocarcinoma, placental site trophoblastic tumor and epitheloid trophoblastic tumor. Incidence from India has been reported up to 2.4/ 1000 pregnancies, 2.5/ 1000 deliveries and 2.6/ 1000 live births. The standard protocols for management exist and are evolving fast. Though all gestational trophoblastic diseases are not malignant, still these need to be managed intensively, because of their potentially life threatening complications and common occurrence in fertility age group females. The better aspect is that; if timely and standard interventions are made; these are highly curable conditions, even with preservation of reproductive...
Desmoid tumor is a slow growing neoplasm with aggressive infiltration of adjacent tissue with very rare metastatic potential. We report a 35 years old female patient with desmoid tumor of the anterior abdominal wall who underwent primary resection followed by mesh pasty. Patient had a past history of abdominal surgery in form of caesarean section, and after 5 years of surgery, she presented with a lump over right hypochondrium since last one year. Patient was assessed before surgery by clinical evaluation, abdominal ultrasound, computerized axial tomography scanning (CT scan), magnetic resonance imaging (MRI), and histopathology and immunohistochemistry report.Patient was operated with wide local excision of rectus abdominis muscle mass with meshplasty under general anaesthesia. After all, histology in this case revealed a desmoid tumor with negative β-Catenin report of operated tissue. In view of the negative surgical margins, patient has been put on regular follow...
INCIDENTALLY DETECTED TRANSITIONAL CELL CARCINOMA IN A NONFUNCTIONING KIDNEY: SHOULD WE RELY ON RADIOLOGY?
Abstract: Primary transitional cell carcinoma (TCC) of the renal pelvis is a relatively rare disease and incidentally detected in a non-functioning kidney is much rarer. Herein, we report a case of incidentally detected histopathologically proven case of primary TCC of renal pelvis in a nonfunctioning kidney associated with staghorn calculus.
IMPACT OF CHRONOMODULATED RADIOTHERAPY ON ACUTE SKIN TOXICITY IN CHEST WALL IRRADIATED BREAST CANCER PATIENTS – A SINGLE INSTITUTION ANALYSIS.
Abstract: We explored the possible association between the timing of delivery of radiation and the grade of skin reaction that develops in breast cancer patients receiving chest wall irradiation as adjuvant treatment after modified radical mastectomy. Invasive breast cancer patients, registered during the period of January 2013 – December 2014, who had undergone modified radical mastectomy followed by chest wall irradiation, were eligible for inclusion to the study. All the patients received chest wall external beam radiotherapy (EBRT) to a dose of 50 Gy in 25 fractions, one fraction a day, five days a week, delivered as tangential opposed pair, from a Cobalt 60 teletherapy source. Patients were stratified based on whether they received EBRT in the morning (between 8 am – 11 am) or in the evening between (5 pm – 8 pm). The clinicopathological characteristics of patients in both the arms were relatively well balanced. The incidence of higher grade of skin reaction (grade 3 or 4) was 22.5 % compared to 35.7 % in the morning and evening arms respectively, which was statistically significant (p = 0.039). The time to development of Grade 3 or 4 toxicity was 4.44 weeks compared to 4.11 weeks in the morning and evening arms respectively, suggesting that higher toxicity developed earlier in the patients receiving EBRT in the evening, though not statistically significant (p =...
A RETROSPECTIVE ANALYSIS OF PALLIATIVE SURGICAL PROCEDURES FOR ADVANCED MALIGNANCIES IN A PRIVATE TERTIARY CANCER CARE CENTER.
Palliative surgery is an important, yet understudied aspect of palliative care. The present article emphasizes the diversity of palliative surgical procedures performed at a private tertiary cancer care center in India and the need of the multidisciplinary approach towards it. Though the overall morbidity and mortality is high, a significant number of cancer patients are alleviated from their symptoms and have a better quality of life, even in those with an anticipated short...