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Langerhans cell histiocytosis (LCH) is a disorder of clonal proliferation of dendritic cell mainly occurring in children. Spine involvement is rare. This usually presents with pain and torticollis when neck is involved. Histopathology with immunohistochemistry is confirmatory. Local curative therapy with excision or curettage is used for localized disease. Radiotherapy is usually reserved for selected cases. Systemic chemotherapy is the treatment of choice for widespread systemic disease. In this article, we present an unusual presentation of atlantoaxial LCH with mastoid involvement resulting in hearing loss as the first symptom and quadruparesis in a middle aged male patient, which was also associated with soft-tissue mass at the nape of the neck and deafness. The patient was treated with radical radiotherapy, which provided excellent response to the disease. Involvement of atlantoaxial joint and temporal bone associated with soft-tissue mass neck and deafness in a middle-aged man is an extremely rare clinical situation. [ABSTRACT FROM AUTHOR]

The primary objective of this study was to evaluate the applicability of World Health Organization (WHO), Southwest Oncology Group (SWOG) and Response Evaluation Criteria in Solid Tumours (RECIST) guidelines when evaluating the response of cytotoxic agents in solid tumours. Patients with a solid tumour who were planned for standard chemotherapy, were aged more than 18 years and had an anticipated life expectancy of at least 12 weeks were included in the study. Patients received chemotherapy using standard protocols and were required to have a pre-treatment evaluation of tumour burden on CT. Subsequent response assessment was performed every two cycles. Each patient was evaluated by all three criteria (WHO, SWOG and RECIST) to check the applicability of a specific criterion during routine clinical practice. In total, 80 patients were included in the study. Out of these, the response criteria displayed discordance in 17 (21%) patients. Of these 17 patients, RECIST criteria were not applicable for 6 patients owing to the small lesion size. The present study shows that a particular guideline may be useful in establishing uniformity of evaluation in a desired study population but may not be the best for that population during routine clinical practice. It also indicates that each of the guidelines has its own applicability and that no guideline can outweigh the other during routine clinical practice. [ABSTRACT FROM AUTHOR]

This study examined the pathological complete response (pCR) rate and safety of sequential gemcitabine-based combinations in breast cancer. We also examined gene expression profiles from tumour biopsies to identify biomarkers predictive of response. Indian women with large or locally advanced breast cancer received 4 cycles of gemcitabine 1200 mg m(-2) plus doxorubicin 60 mg m(-2) (Gem+Dox), then 4 cycles of gemcitabine 1000 mg m(-2) plus cisplatin 70 mg m(-2) (Gem+Cis), and surgery. Three alternate dosing sequences were used during cycle 1 to examine dynamic changes in molecular profiles. Of 65 women treated, 13 (24.5% of 53 patients with surgery) had a pCR and 22 (33.8%) had a complete clinical response. Patients administered Gem d1, 8 and Dox d2 in cycle 1 (20 of 65) reported more toxicities, with G3/4 neutropenic infection/febrile neutropenia (7 of 20) as the most common cycle-1 event. Four drug-related deaths occurred. In 46 of 65 patients, 10-fold cross validated supervised analyses identified gene expression patterns that predicted with >or=73% accuracy (1) clinical complete response after eight cycles, (2) overall clinical complete response, and (3) pCR. This regimen shows strong activity. Patients receiving Gem d1, 8 and Dox d2 experienced unacceptable toxicity, whereas patients on other sequences had manageable safety profiles. Gene expression patterns may predict benefit from gemcitabine-containing neoadjuvant therapy. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the local control of hepatic metastasis with radiofrequency ablation treatment. Materials and Methods: We did a retrospective analysis in 40 patients treated with radiofrequency ablation for hepatic metastasis. The tumors ablated included up to two metastatic liver lesions, with primaries in breast, gastrointestinal tract, cervix, etc. Radiofrequency ablation was performed under general anesthesia in all cases, using ultrasound guidance. Radionics Cool-Tip RF System was used to deliver the treatment. Results: The median age of patients treated was 49 years. There were 13 female and 27 male patients. The median tumor size ablated was 1.5 cm (0.75-4.0 cm). A total of 52 radiofrequency ablation cycles were delivered. Successful ablation was achieved in all patients with hepatic metastasis less than 3 cm in size. Pain was the most common complication seen (75%). One patients developed skin burns. At 2-year follow-up 7.5% of patients had locally recurrent disease. Conclusions: Radiofrequency ablation is a minimally invasive treatment modality. It can be useful in a select group of patients with solitary liver metastasis of less than 3 cm size. [ABSTRACT FROM AUTHOR]

Aim: The aim of our study was to compare the two standard treatment approaches in muscle invasive carcinoma of urinary bladder--radical cystectomy and chemo radiation.Materials and Methods: Transitional cell carcinoma (TCC) of bladder of stages, T2 to T4, N0/N1/N2 and M0 were included in the study. Patients were allotted to two arms of the study. Arm A consisted of radical cystectomy. Adjuvant CMV chemotherapy was given for T3/T4 or Node positive disease only. Arm B received 2 cycles of neoadjuvant CMV chemo therapy followed by concurrent chemo radiation.Results: Forty-four patients were recruited into the study. Thirty patients in the surgical arm and 13 patients in the chemo radiation arm. The actuarial two-year survival rate in surgical arm is 56% while in chemo radiation arm it is 54%. There was no statistically significant difference in disease-free survival also between the two groups.Conclusion: Chemo radiation yielded equivalent survival results with radical cystectomy. So it is worth giving preference to chemo radiation that will give a better quality of life for the patient. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the local control of hepatic metastasis with radiofrequency ablation treatment. Materials and Methods: We did a retrospective analysis in 40 patients treated with radiofrequency ablation for hepatic metastasis. The tumors ablated included up to two metastatic liver lesions, with primaries in breast, gastrointestinal tract, cervix, etc. Radiofrequency ablation was performed under general anesthesia in all cases, using ultrasound guidance. Radionics Cool-Tip RF System was used to deliver the treatment. Results: The median age of patients treated was 49 years. There were 13 female and 27 male patients. The median tumor size ablated was 1 .5 cm (0.75-4.0 cm). A total of 52 radiofrequency ablation cycles were delivered. Successful ablation was achieved in all patients with hepatic metastasis less than 3 cm in size. Pain was the most common complication seen (75%). One patients developed skin burns. At 2-year follow-up 7.5% of patients had locally recurrent disease. . Conclusions: Radiofrequency ablation is a minimally invasive treatment modality. It can be useful in a select group of patients with solitary liver metastasis of less than 3 cm size. [ABSTRACT FROM AUTHOR]

Xenobiotic metabolic enzymes CYP1A1 and GSTM1 are known to increase the risk of head and neck cancer. However, their role in the development of oral potentially malignant disorders (OPMDs) in the Indian population is uncertain. This study aimed to investigate the CYP1A1 and GSTM1 gene polymorphism in the urban population of the state of Delhi as well as to investigate the risk of disease progression. Genotype analysis via polymerase chain reaction was conducted in 1169 cases and 1046 controls with regard to GSTM1 and CYP1A1 (ile-val) genes. The oral lesions were biopsied for histopathological diagnosis. Follow-up of the subjects was done at 6-month intervals and the status of the lesions was recorded as static, progressed, or regressed. Descriptive analysis was done with a p-value ≤ 0.05 and odds ratio with a 95% confidence interval being considered for a measure of association. Subjects who consumed both tobacco and alcohol and developed OPMD lesions were 8.2 times more likely to harbour CYP1A1 Val/Val genotype (p = 0.047; OR = 8.224; 95% CI = 1.024–66.037). The highest progression rate and lowest regression rate were found for the CYP1A1 Val/Val genotype in our sample. The CYP1A1 Val/Val genotype may be associated with an increased risk of development of OPMDs amongst consumers of both tobacco and alcohol. Real-time activity-based sensing of isoforms of the CYP1A1 enzyme in living systems is needed to validate the same. [ABSTRACT FROM AUTHOR]

A response by G. K. Rath to a letter to the editor about their article "Radiofrequency ablation in liver metastasis" in the previous issue is presented.

The aim of this study was to evaluate the breast dose heterogeneity in CT-based radiotherapy treatment planning and to correlate with breast parameters. Also, the number of slices required for treatment planning in breast cancer by tangential field technique has been assessed by comparing the treatment plans according to International Commission on Radiation Units and Measurement (ICRU) 50 guidelines (1993) for single-slice, three-slice, and multi-slice (3D) planning. Sixty women who underwent isocentric tangential field breast radiotherapy were included in this study. The plans were optimized and analyzed with dose volume histograms. Sixty-three percent of the single-slice plans and 26.7% of the three-slice plans showed poor dose homogeneity as compared to the 3D plans. Dose inhomogeneity correlated better with breast volume (r² = 0.43) than the chest wall separation (r² = 0.37) and breast area product (r² = 0.36). Similarly, breast volume correlated better with breast area product (r² = 0.80) than with chest wall separation (r² = 0.56). Breast volume can be approximated to breast area product from the relation, breast volume = [(breast area product x 8.85) - 120.05]. The results of this study showed that most of the cases require 3D planning for breast cancer. It also showed that patients with large breast are prone to have more dose inhomogeneity with standard tangential field radiotherapy. In centers where 3D planning is not possible due to lack of facilities or workload, three slices-based planning can be performed to approximate the dosimetric advantage of 3D planning. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate technetium labeled l -methionine for imaging recurrent brain tumors. Material and Methods: Brain SPECT with 99m Tc- l -methionine was performed to evaluate tumor viability in 42 patients with primary brain tumor. Findings of SPECT were correlated with radiological and histopathological findings as reference. Results: 99m Tc- l -methionine showed localized increased uptake in 40 patients with tumor recurrence, whereas 2 patients with post-radiation gliosis did not show tracer accumulation. A low differential uptake rate (DUR) 2.43±0.74 and methionine retention (MR) index 0.93±0.03 was seen in cases of post-radiation gliosis. A high DUR (36.20±10.31) and MR index (4.87±2.37) was seen in cases of recurrent tumor. Mean DUR in high-grade tumors (44.01±8.46) was significantly higher ( P <0.001) than in low-grade tumors (30.42±7.38), and mean MR index in high-grade tumors (7.03±2.05) was significantly higher than in low-grade tumors (3.27±0.82) ( P <0.001). Conclusion: 99m Tc- l -methionine can be used as a SPECT tracer to differentiate tumor recurrence from post-radiation gliosis. [ABSTRACT FROM AUTHOR]

Blood−brain barrier imaging of brain tumours is fast attracting interest now that it has been demonstrated that disruption of the blood−brain barrier is essential for uptake of all tumour-seeking agents. The aim of the present study was to differentiate recurrent tumour from post-radiation gliosis using 99mtechnetium-glucoheptonate (99mTc-GHA) as a tumour-seeking agent. Brain single photon emission computed tomography (SPECT) with 99mTc-GHA was performed in 73 patients with primary malignant brain tumours after radiotherapy, and the results were correlated with the clinical behaviour of the disease on follow up. The SPECT was suggestive of recurrent tumour in 55 patients. The clinical course was consistent with recurrence in 51 of the 55 patients. The clinical course was consistent with radiation necrosis in the remaining 21 patients, which included 17 patients with a negative SPECT and four patients with a positive SPECT study. Mean GHA index in recurrent tumour and post-radiation gliosis was 7.04 ± 4.35 and 1.88 ± 1.70, respectively ( P = 0.0001). Mean GHA index in high-grade and low-grade glioma was 7.78 ± 4.73 and 3.15 ± 2.44, respectively ( P = 0.001). 99mTechnetium-glucoheptonate brain SPECT is a sensitive and reliable diagnostic modality to differentiate recurrent tumour from post-radiation gliosis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Brain Single Photon Emission Computerised Tomography (SPECT) has been established as a potentially useful tool for the assessment of recurrent brain tumours. Though brain SPECT is exquisitely sensitive in detecting viable tumour tissue in the supratentorial region, its efficacy has not been evaluated till date in case of infratentorial posterior fossa tumours. AIM OF THE STUDY: To evaluate the diagnostic utility of brain SPECT in differentiating recurrence of tumour from post-radiation gliosis in the posterior fossa of the brain. SUBJECTS AND METHODS: Twenty-one patients with primary malignant posterior fossa brain tumour were evaluated by brain SPECT with Tc99m-Tetrofosmin as the tumour-seeking agent. Clinical behaviour of the tumour observed for a minimum period of one year after the SPECT study was taken as the gold standard. STATISTICAL ANALYSIS: The Chi-square test has been used to note the significance of the association between the clinical outcome and the SPECT finding. In addition, the sensitivity and specificity of brain SPECT were also calculated. RESULT: Brain SPECT in 4 patients revealed increased tracer concentration over the primary tumour bed, which was consistent with recurrent tumour. The clinical course was consistent with tumour recurrence in 13 of the 21 patients, which included 3 patients with positive SPECT study and 10 patients with negative SPECT study. Brain SPECT revealed recurrent tumour in 4 patients whereas clinical follow-up suggested recurrence in 13 patients. The clinical course was consistent with radiation necrosis in the remaining 8 patients. In 1 brain SPECT positive patient the clinical course was consistent with post-radiation gliosis. CONCLUSION: This study demonstrates that brain SPECT is not a sensitive diagnostic modality to differentiate recurrent tumour from post-radiation gliosis in the posterior fossa of the brain. [ABSTRACT FROM AUTHOR]

Primary spinal glioblastoma multiforme (GBM) is a rare entity, which is invariably associated with poor outcome. Standard treatment is surgery followed by post-operative radiotherapy. Due to paucity of cases role of chemotherapy is investigational. We intend to report two cases of primary spinal GBM treated with radiation and adjuvant temozolomide. [ABSTRACT FROM AUTHOR]

Breast cancer with multiple parenchymal brain metastases carries an extremely poor outcome. Cranial radiotherapy improves survival by only a few months and the role of systemic therapy is marginal and largely unexplored. We report a patient with recurrent carcinoma of breast presenting with multiple bilateral cervical nodes and brain metastases manifesting as a right hemiparesis and facial nerve palsy, who was treated with palliative whole brain irradiation and letrozole. At the follow up at 20 months, neurological function had fully recovered, and both cerebral and extracerebral lesions had completely resolved, with calcification of the cerebral lesions. This report suggests that letrozole has beneficial effects both in extracranial and intracranial disease in hormone responsive metastatic breast cancer. [ABSTRACT FROM AUTHOR]

Sweat gland carcinoma is a rare skin tumor. The tumor has propensity to spread to lymph nodes and distant metastases has been reported. Their exact incidence in the Indian setting is not known. Aspects related to treatment are also not clearly defined. Though surgery forms the initial treatment approach, adjuvant treatment has not been properly explored. We report here a case of sweat gland carcinoma with bilateral lung metastases. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented focusing on adenocarcinoma of the gall bladder presenting with a cutaneous metastasis.

Background: For inoperable non-small cell lung cancer combined chemotherapy and radiotherapy plays an important role as a therapeutic modality. The aim of the present study was to analyze neoadjuvant chemotherapy related acute toxicity in locally advanced lung cancer (stage IIIA and IIIB) in Indian patients using Cisplatin and Etoposide combination chemotherapy.Material and Methods: Forty patients of locally advanced Non small cell lung cancer received three cycles neoadjuvant chemotherapy using Injection Cisplatin and Etoposide. The patients were taken for Radical radiotherapy to a dose of 60 Gray over 30 fractions in conventional fractionation after completing chemotherapy. Chemotherapy associated toxicity was assessed using common toxicity criteria (CTC v2.0)Results: Forty patients were available for final evaluation. Median age of presentation of patients was fifty-six years. Thirteen patients had Non small cell lung cancer stage IIIA while twenty-seven patients had Stage IIIB disease. Anemia was the most common hematological toxicity observed (seen in 81% of patients). Nausea and vomiting were the most common non-hematological toxicity seen. Sensory neuropathy was seen in 38% of patients. 88% patients developed alopecia. Seven patients developed febrile neutropenias.Conclusion: Neo-adjuvant chemotherapy using Cisplatin and Etoposide continues to be a basic regimen in the Indian set up despite availability of higher molecules, since it is cost effective, well tolerated and therapeutically effective. Blood transfusions, growth factors and supportive care can be used effectively to over come toxicity associated with this regimen. [ABSTRACT FROM AUTHOR]

Context and Aim: The prognosis of primary gliosarcoma (PGS) remains dismal with current treatment modalities. We analyzed the outcome of PGS patients treated with concurrent and adjuvant temozolomide (TMZ).Settings and Design: Retrospective single institutional analysis.Materials and Methods: We retrospectively evaluated 27 patients of PGS treated with radiotherapy (RT) and TMZ during 2007-2012.Statistical Analysis Used: Overall survival (OS) was estimated by the use of Kaplan Meier method and toxicities were evaluate using common terminology criteria for adverse events version 2.0 (National Cancer Institute, USA).Results: Median age at presentation and Karnofsky performance status was 45 years and 90 respectively and male: female ratio was 20:7. Patients received adjuvant RT to a total dose of 60 Gy at 2 Gy/fraction. All patients except 5 received adjuvant TMZ to a median number of 6 cycles. Grade 2 and 3 hematological toxicity was seen in 8% and 4% of patients respectively during concurrent RT. During adjuvant chemotherapy, 13.6% had Grade 3 thrombocytopenia and 9.5% had Grade 3 neutropenia. Median OS was 16.7 months (1 year and 2 year actuarial OS was 70.8% and 32.6% respectively). Adjuvant TMZ was associated with a better survival (median survival 21.21 vs. 11.93 months; P = 0.0046) on univariate analysis and also on multivariate analysis (hazard ratio 1.82, 95% confidence interval: 1.503-25.58; P = 0.012).Conclusions: The results of our study, largest series of patients with PGS treated with concurrent and adjuvant TMZ shows an impressive survival with acceptable toxicity. We suggest TMZ be included in the "standard of care" for this tumor. [ABSTRACT FROM AUTHOR]

Background and Objective: Neurocytoma (NC) is a rare benign neuronal tumor. A complete excision remains curative for most of these tumors, but atypical histology and extra-ventricular location often necessitates adjuvant therapy. We intended to explore the clinico-pathological features and treatment outcome in patients of NC in our institute.Materials and Methods: Medical records were reviewed and data collected on NC over a 6-year period (2006-2012) from the departmental archives. Disease free survival (DFS) was analyzed by Kaplan-Meier method.Results: A total of 18 patients met the study criteria. Fourteen patients had intra-ventricular neurocytoma (IVNC), right lateral ventricle being the most common site of origin. Gross total resection and near total resection were achieved in eight cases each whereas tumor decompression and biopsy could be done in two cases. On post-operative histopathological examination, eight patients were found to have atypical NC while 10 patients had typical NC. All patients underwent adjuvant radiation. The median dose of post-operative radiation was 56 Gy. All patients were alive at their final follow-up. One patient had both clinical and radiological evidence of local relapse. In the evaluable patients (n = 18), after a median follow-up of 35 months the DFS rate at 2 years and 3 years are 100% and 83% respectively.Conclusion: Use of adjuvant radiation to a total dose of 56 Gy enhances the local control and achieves superior survival in patients of NC. Use of 3D conformal planning techniques may help us to achieve better therapeutic ratio in patients with NC. [ABSTRACT FROM AUTHOR]

Background: The significant impact of postoperative radiotherapy (PORT) on cardiac morbidity in patients of early breast cancer (EBC) undergoing breast-conserving surgery has been shown in different studies. The present study was conducted to assess the impact of surgery and the side of involvement on radiation dose to left anterior descending artery (LAD) and Left circumflex coronary artery (LCx).Materials and Methods: Totally, 58 patients of EBC were randomly chosen for this dosimetric study and planned with tangential field technique without intensity modulation (IM). Heart, LAD, and LCx (n = 55) were contoured. Dose volume histograms were analyzed to determine the Dmax (maximum dose) and Dmean (mean dose) of LAD and LCx. Student's t-test was used for comparative analysis of the means.Results: The mean Dmax of LAD for left (L) EBC was 3.17 Gray (Gy) while for right (R) EBC it was 0.86 Gy (P = 0.007; 95% C.I, 1.14-3.48). The mean Dmean of LAD for L-EBC and R-EBC were 1.97 Gy and 0.79 Gy, respectively (P = 0.029; 95% C.I, 0.77-1.60). The mean-Dmax of LCx for patients with L-EBC (2.9 Gy; range: 1.2-4.35 Gy) was statistically higher than that for R-EBC (1.3 Gy; range: 0.7-3.2 Gy) (P = 0.045). The mean-Dmean of LCx for L-EBC (2.1 Gy; range: 0.6-3.6 Gy) was also significantly higher than that of L-EBC (0.9 Gy; range: 0.7-2.1 Gy) (P = 0.03). There was no significant impact of the pattern of surgery on LAD dose, but significance was noted for LCx dose parameters (P = 0.04 and 0.08 for m-Dmax and m-Dmean of LCx).Conclusion: This pilot dosimetric study confirms the assumption that patients with left-sided EBC are at higher risk of developing long-term cardiac morbidity when treated with PORT due to increased dose to LAD. [ABSTRACT FROM AUTHOR]

Objective: Evaluation of utility of fluorine-18 fludeoxy-glucose (18F,-FDG) positron emission tomography/CT (PET/CT) for restaging patients with primary malignant germ cell tumours (GCTs). Methods: Data of 92 patients (age, 31.94 ±10.1 years; male/ female, 86/6) with histopatholpgically confirmed malignant GCTs (gonadal, 88; mediastinal, 4; seminomatous, 47 and non-seminomatdus, 45) who underwent 18F-FDG PET/CT for, restaging (suspected recurrence/post-therapy evaluation) were retrospectively analysed, Two experienced nuclear medicine physicians reviewed the PET/CT images in consensus, qualitatively and semi-quantitatively [maximum standardized, uptake value (SUVmax)]. Histopathology (if available), and clinical/imaging/biochemical follow-up (minimum of 6 months) were employed as the reference standard. Results: 18F:FDG PET/CT was interpreted as positive in 59 and negative in 33 patients. Local disease was seen in 5, nodal disease in 50 and distant metastasis in 22 patients. PET/CT was true positive in 49, false positive in 10, true negative in 30 and false negative in 3 patients. 18F-FDG PET/CT showed sensitivity, specificity,, positive predictive value, negative predictive value and accuracy of 94.2%, 75.0%, 83.0%, 90.9% and 85.8% overall; 90.0%, 74.0%; 72.0%, 90.9% and 80.8% in seminomatous GCT; and 96,8%, 76.9%, 91.1%, 90.9% and 91.1% in non-seminomatous GCT, respectively. Difference in PET/CT accuracy for seminomatous and non-seminomatous GCTs was not significant (p = 0.263). PET/CT demonstrated disease in 13 patients with negative/equivocal conventional imaging findings and in 9 patients with normal tumour markers. No site- or histology-based difference, Was seen in SUVmax. Conclusion: 18F-FDG PET/CT demonstrates high diagnostic accuracy for restaging patients with malignant GCTs. It has comparable diagnostic performance in both seminomatous and: non-seminomatous malignant GCTs. Advances in knowledge: The present article demonstrates high diagnostic accuracy 18F-FDG PET/CT for restaging both seminomatous and non-seminomatous malignant GCTs in a large patient population. [ABSTRACT FROM AUTHOR]

BACKGROUND: Malignant tumors of the trachea are rare. A multimodality treatment approach is often necessary. Outcomes of radical non-surgical approaches are sparse. Radiation combined with sequential or concurrent chemotherapy is an important treatment option. MATERIALS AND METHODS: We present an analysis of outcomes using modern radiotherapy and chemotherapy for tracheal tumors. RESULTS: Radiation dose escalation using modern techniques is of benefit for these tumors. The results with chemotherapy are encouraging. CONCLUSIONS: Radiation plays a distinct role and should be a part of treatment for these tumors. The role of chemotherapy needs to be studied further. [ABSTRACT FROM AUTHOR]

AIMS AND OBJECTIVES: Extracorporeal irradiation (ECI) is relatively a rare method used in the management of malignant bone tumors (MBT). It consists of en-bloc removal of the tumor bearing bone segment, removal of the tumor from the bone, irradiation, and re-implantation back in the body. We report our preliminary experience of using ECI for management of MBT. MATERIALS AND METHODS: From year 2009 to 2010, 14 patients with primary MBT were enrolled into this study. The eligibility criteria included histopathological proof of malignancy, no evidence of distant metastases, and suitability for limb preservation therapy. Surgery was performed about 4 weeks after completion of neoadjuvant chemotherapy. The affected bone segment was resected, irradiated extracorporeally with a dose of 50 Gy and reimplanted. Local control, complications and short-term survival were studied. Functional outcome was assessed by Musculoskeletal Tumor Society (MSTS) scoring system. RESULTS: There were 10 males and four females with median age of 14 years. Histopthologically, nine patients had osteosarcoma (OS) and five had Ewing's sarcoma family of tumors (ESFT). Distribution of primary site was as follows: Femur eight patients, tibia five patients and humerus one patient. At a median follow-up was 22 months, three patients (two OS, one ESFT) had local recurrence. Two patients (14%) developed wound infection in the perioperative period. The 2 year local recurrence free survival was 73% and mean MSTS score was 88. CONCLUSION: Results of our study suggest that ECI is technically feasible in the management of MBT and provides decent local control and short-term survival rates. [ABSTRACT FROM AUTHOR]

Brain metastases constitute one of the most common distant metastases of cancer and are increasingly being detected with better diagnostic tools. The standard of care for solitary brain metastases with the primary disease under control is surgery followed by radiotherapy. Radiotherapy is also the primary modality for the treatment of multiple brain metastases, and improves both the quality of life and survival of patient. Unfortunately, more than half of these treated patients eventually progress leading to a therapeutic dilemma. Another course of radiotherapy is a viable but underutilized option. Reirradiation resolves distressing symptoms and has shown to improve survival with minimal late neurotoxicity. Reirradiation has conventionally been done with whole brain radiotherapy, but now studies with stereotactic radiosurgery have also shown promising results. In this review, we focus on reirradiation as a treatment modality in such patients. We performed a literature search in MEDLINE (www.pubmed.org) with key words brain metastases, reirradiation, whole brain radiotherapy, stereotactic radiosurgery, interstial brachytherapy, and brain. The search was limited to the English literature and human subjects. [ABSTRACT FROM AUTHOR]

This study is aimed to evaluate the impact of static and dynamic intensity modulated radiotherapy (IMRT) delivery techniques planned with Eclipse TPS on the integral dose to the healthy normal tissue surrounding the tumor-bearing area and to the volume receiving doses <5 Gy in patients with carcinoma nasopharynx treated with Simultaneous Integrated Boost IMRT (SIB-IMRT). Ten patients with carcinoma nasopharynx were chosen for this dosimetric study. IMRT plans were generated with 6X using dynamic multileaf collimator (DMLC) and static multileaf collimator (SMLC) with 5, 10 and 15 intensity levels (L). Integral dose, volume receiving 5 Gy, number of monitor units (MU) is compared against DMLC. The mean difference in the MU delivered per fraction between 5, 10 and 15 L SMLC and DMLC was -13.25% (P < 0.001, with paired t test), -11.82% (P < 0.001) and -10.81% (P < 0.001), respectively. The mean difference in the integral dose with 5, 10 and 15 L compared to DMLC was -2.96% (P < 0.001), -2.67% (P = 0.016) and -0.39% (P = 0.430), respectively. However, the difference in low-dose volume (V5Gy) was statistically insignificant with mean difference of 0.60% (P = 0.23), 1.18% (P = 0.017) and 1.70% (P = 0.078), respectively for 5, 10 and 15 L compared to DMLC. Our results show that while choosing the IMRT delivery technique using conventional MLC the concerns about integral dose and volume receiving very low doses such as 5 Gy can be ignored. [ABSTRACT FROM AUTHOR]

Aim: The main objective of this study was to analyze the radiobiological effect of different treatment strategies on high-risk prostate adenocarcinoma. Materials and Methods: Ten cases of high-risk prostate adenocarcinoma were selected for this dosimetric study. Four different treatment strategies used for treating prostate cancer were compared. Conventional four-field box technique covering prostate and nodal volumes followed by three-field conformal boost (3D + 3DCRT), four-field box technique followed by intensity-modulated radiotherapy (IMRT) boost (3D + IMRT), IMRT followed by IMRT boost (IMRT + IMRT), and simultaneous integrated boost IMRT (SIBIMRT) were compared in terms of tumor control probability (TCP) and normal tissue complication probability (NTCP). The dose prescription except for SIBIMRT was 45 Gy in 25 fractions for the prostate and nodal volumes in the initial phase and 27 Gy in 15 fractions for the prostate in the boost phase. For SIBIMRT, equivalent doses were calculated using biologically equivalent dose assuming the α/β ratio of 1.5 Gy with a dose prescription of 60.75 Gy for the gross tumor volume (GTV) and 45 Gy for the clinical target volume in 25 fractions. IMRT plans were made with 15-MV equispaced seven coplanar fields. NTCP was calculated using the Lyman-Kutcher-Burman (LKB) model. Results: An NTCP of 10.7 ± 0.99%, 8.36 ± 0.66%, 6.72 ± 0.85%, and 1.45 ± 0.11% for the bladder and 14.9 ± 0.99%, 14.04 ± 0.66%, 11.38 ± 0.85%, 5.12 ± 0.11% for the rectum was seen with 3D + 3DCRT, 3D + IMRT, IMRT + IMRT, and SIBIMRT respectively. Conclusions: SIBIMRT had the least NTCP over all other strategies with a reduced treatment time (3 weeks less). It should be the technique of choice for dose escalation in prostate carcinoma. [ABSTRACT FROM AUTHOR]

Background: In upper abdominal malignancies (UAM), due to the presence of multiple inhomogeneous tissues, a wedge-based conformal treatment planning results in high-dose regions inside the target volume. Aim: This study was designed to explore the feasibility of using a field-in-field (FIF) technique in different UAM and its efficacy in reducing the high-dose regions. Materials and Methods: Twelve patients of UAM (which included malignancies of the gastroesophageal junction, stomach, gall bladder, and pancreas) were selected for this study. Computed tomography (CT) scans were performed and three-dimensional conformal wedge plans were generated for all the cases. The same plan was copied with the wedges removed and a FIF plan was generated. The two plans were compared for mean, maximum, and median doses; dose received by 2% (D2) and 98% (D98) of the target volume; volume receiving >107% (V > 107%) and <95% (V < 95%) of the prescribed dose; conformality index (CI); and total monitor units. The doses to critical structures such as liver, kidneys, and spinal cord were also compared. Statistical Analysis: Statistical analysis was performed with SPSS, version 10.0. Results: For all the cases, the FIF technique was better than wedge-based planning in terms of maximum dose, D2, V > 107%, and CI; there was a statistically significant reduction in monitor units. With regard to doses to critical structures, there was marginal dose reduction for the kidneys and spinal cord with FIF as compared to wedge-based planning. Conclusion: The FIF technique can be employed for UAM in place of wedge-based conformal treatment plans. [ABSTRACT FROM AUTHOR]

Abstract: Oral cancer is among the most common cancers in India. Tobacco, its primary risk factor, is widely consumed across the country, in both smoked and smokeless forms. The current study assessed the prevalence of tobacco use and associated oral lesions in a section of the New Delhi population. Population-based cross-sectional survey was used. House visits in urban Delhi within 15 km radius of a tertiary care teaching hospital were conducted. The basic demographic details, tobacco and alcohol history (on a standardized questionnaire) were elicited from 71,022 individuals, followed by an oral examination (inspection and digital palpation) for detecting oral potentially malignant disorders (OPMDs) and oral cancer. Ever tobacco users comprised 22.2% while 16.1% of individuals were current tobacco users; tobacco use was higher among men than women. Bidi was the most commonly used smoked tobacco product (both genders). Regarding smokeless tobacco, gutkha and khaini use was common among men, while the majority of women consumed betel quid with tobacco. Alcohol use was found in 4% of individuals. OPMDs were detected in 3.4% of individuals. Tobacco abuse is very common in our urban community. Community-based oral health education and oral checkup by trained health care workers should be carried out to reduce the burden of tobacco use and ill effects of tobacco. [ABSTRACT FROM AUTHOR]

Aims: Radiotherapy forms an integral part of breast-conserving treatment in early-stage breast cancer. Subcutaneous fibrosis of the treated breast is an important late effect in whole-breast irradiation. The aim of this study was to compare the normal tissue complication probability (NTCP) for radiation-induced fibrosis in treated breast using accelerated partial-breast irradiation (APBI) vs conventional treatment.Materials and Methods: Ten postoperative early-stage breast cancer patients (T1N0M0) were included in this dosimetric analysis. APBI treatment was planned using conformal radiotherapy technique and conventional treatment plans included two tangential portals. All the APBI treatment plans were made with five non-coplanar beams with 6 MV photons. The prescription dose was 38 Gy in 10 fractions for the APBI treatments and 50 Gy in 25 fractions, followed by a boost dose of 16 Gy in 8 fractions, for the conventional treatments. We used Lyman's relative-seriality model and the breast fibrosis NTCP model fitting parameters for the study.Results: The equivalent uniform dose (EUD) was 30.09 Gy and 50.79 Gy in APBI and conventional treatment, respectively. The mean NTCP values for ipsilateral breast fibrosis in APBI and conventional treatment were 0.51 and 25.66%, respectively. Using the paired t-test, a statistically significant difference was seen in the breast fibrosis NTCP values for APBI vs conventional treatment (P < 0.001).Conclusions: APBI reduces the ipsilateral breast fibrosis compared to conventional whole-breast treatment in early-stage breast cancer. [ABSTRACT FROM AUTHOR]

Aims: Radiotherapy forms an integral part of breast-conserving treatment in early-stage breast cancer. Subcutaneous fibrosis of the treated breast is an important late effect in whole-breast irradiation. The aim of this study was to compare the normal tissue complication probability (NTCP) for radiation-induced fibrosis in treated breast using accelerated partial-breast irradiation (APBI) vs conventional treatment. Materials and Methods: Ten postoperative early-stage breast cancer patients (T1N0M0) were included in this dosimetric analysis. APBI treatment was planned using conformal radiotherapy technique and conventional treatment plans included two tangential portals. All the APBI treatment plans were made with five non-coplanar beams with 6 MV photons. The prescription dose was 38 Gy in 10 fractions for the APBI treatments and 50 Gy in 25 fractions, followed by a boost dose of 16 Gy in 8 fractions, for the conventional treatments. We used Lyman's relative-seriality model and the breast fibrosis NTCP model fitting parameters for the study. Results: The equivalent uniform dose (EUD) was 30.09 Gy and 50.79 Gy in APBI and conventional treatment, respectively. The mean NTCP values for ipsilateral breast fibrosis in APBI and conventional treatment were 0.51 and 25.66%, respectively. Using the paired t-test, a statistically significant difference was seen in the breast fibrosis NTCP values for APBI vs conventional treatment (P<0.001). Conclusions: APBI reduces the ipsilateral breast fibrosis compared to conventional whole-breast treatment in early-stage breast cancer. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the local control of hepatic metastasis with radiofrequency ablation treatment.Materials and Methods: We did a retrospective analysis in 40 patients treated with radiofrequency ablation for hepatic metastasis. The tumors ablated included up to two metastatic liver lesions, with primaries in breast, gastrointestinal tract, cervix, etc. Radiofrequency ablation was performed under general anesthesia in all cases, using ultrasound guidance. Radionics Cool-Tip RF System was used to deliver the treatment.Results: The median age of patients treated was 49 years. There were 13 female and 27 male patients. The median tumor size ablated was 1.5 cm (0.75-4.0 cm). A total of 52 radiofrequency ablation cycles were delivered. Successful ablation was achieved in all patients with hepatic metastasis less than 3 cm in size. Pain was the most common complication seen (75%). One patients developed skin burns. At 2-year follow-up 7.5% of patients had locally recurrent disease.Conclusions: Radiofrequency ablation is a minimally invasive treatment modality. It can be useful in a select group of patients with solitary liver metastasis of less than 3 cm size. [ABSTRACT FROM AUTHOR]

A 55-year-old man with tracheal adenocarcinoma presented with difficulty in breathing and cough with blood-tinged expectoration. As the patient refused surgery, he was treated with definitive radiotherapy to the neck and superior mediastinum to a total dose of 50 Gy (initially 40 Gy by AP/PA portals followed by 10 Gy with a three-field technique). He showed significant symptomatic relief to radiotherapy and defaulted from further treatment. He remained asymptomatic for 7 years, following which he developed sternal metastases and a local tumour recurrence. This case illustrates that long-term clinical remission can be achieved by radiotherapy alone in this rare histological subtype of tracheal carcinoma. [ABSTRACT FROM AUTHOR]

Purpose: To study the role of self-expandable metallic stents in malignant esophageal strictures in terms of patency, improved dysphagia score, and possible associated complications. Material and Methods: Twenty-two patients with inoperable carcinoma of the esophagus underwent stent placement. Four different varieties of covered stents were used. Stenting was performed under fluoroscopic guidance and local pharyngeal anesthesia. During follow-up, patients were examined clinically and radiologically to assess the effectiveness of stents in relieving dysphagia, to check the stent position, patency, and possible complications. Results: Fluoroscopic placement of the stent was successful and well tolerated in all patients without any serious complications. Accurate stent placement was possible in 95% of cases. The mean dysphagia score prior to stenting was 3.5 and poststent 1.2, with an improvement of 2.3 degrees. In two patients with associated fistulas, complete closure was seen after stent insertion. There was poor stent expansion in three patients. Significant tumor overgrowth occurred in two patients, and a second overlapping stent was deployed in one case. Three patients developed food impaction, which needed endoscopic removal of impacted food in two cases. Conclusion: Fluoroscopic placement of self-expandable metallic stents is a safe and effective method of palliating severe dysphagia and fistulas in patients with inoperable esophageal carcinoma. However, complications such as tumor overgrowth and food impaction may require reintervention after stent placement. [ABSTRACT FROM AUTHOR]

Purpose: To document the incidence of skeletal metastases exclusively in advanced cases of retinoblastoma and to rationalize the use of preoperative skeletal scintigraphy in such patients.Material and Methods: Preoperative bone scans of 36 consecutive patients with advanced retinoblastoma who underwent skeletal scintigraphy during 1998 to 2003 were analyzed retrospectively. Bone scans were classified as: Grade 1 (high probability scan for skeletal metastases), Grade 2 (equivocal malignant or benign abnormalities), or Grade 3 (normal or certainly benign lesions).Results: Grade 1 scan was found in 3 (8.33%) patients; bone metastases were confirmed by additional investigations. Grade 2 scan was found in 5 (13.88%) patients; bone metastases were excluded in all by additional investigations. Grade 3 scan was found in the remaining 28 (77.77%) patients. Extraorbital extension of disease was demonstrated by fine needle aspiration of lymph nodes in five patients, which included all three patients with Grade 1 scan. In addition to lymph node metastases, two patients had intracranial extension of the disease; demonstrated by contrast-enhanced magnetic resonance imaging of the head. One patient had liver metastases detected on abdominal ultrasound. None of the patients had skeletal metastases only.Conclusion: Routine preoperative bone scan is not justified in patients with locally advanced retinoblastoma. Bone scan should only be performed in patients with documented extraocular metastatic disease. [ABSTRACT FROM AUTHOR]

Results of the proton magnetic resonance spectroscopy carried out on normal, benign breast disease and locally advanced breast cancer patients are presented. The in-vivo MR spectra of malignant breast tissue of patients (n = 67) suffering from infiltrating ductal carcinoma are dominated by the water resonance, while the spectra of the unaffected contralateral breast tissue of these patients are mainly dominated by resonance arising from lipids which is similar to the spectra of normal breast tissue obtained from volunteers (controls, n = 16). In addition to the water and lipid peaks, in majority of the patients (∼80%) the water suppressed spectra showed a resonance at 3.2 ppm due to choline containing compounds (TCho) before treatment. In patients receiving neoadjuvant chemotherapy, absence/reduction in choline was observed in 89% of the patients. TCho was also observed in 2 of 14 benign lesions. The sensitivity and specificity of in-vivo MRS in detecting TCho in malignant tumours was 78% and 86%, respectively. Observation of TCho before treatment and its disappearance (or reduction) after treatment may be a useful indicator of response of locally advanced breast cancer to neoadjuvant chemotherapy. [ABSTRACT FROM AUTHOR]

Malignant peripheral nerve sheath tumour ( MPNST) is a rare variety of soft tissue sarcoma that originates from Schwann cells or pluripotent cells of neural crest origin. They have historically been difficult tumours to diagnose and treat. Surgery is the mainstay of treatment with a goal to achieve negative margins. Despite aggressive surgery and adjuvant therapy, the prognosis of patients with MPNST remains poor. MPNST arising from penis is a very rare entity; thus, it presents a diagnostic and therapeutic challenge. We present a case of penile MPNST in a 38-year-old man in the absence of neurofibromatosis treated with surgery followed by post-operative radiotherapy to a dose of 60 Gray in 30 fractions and adjuvant chemotherapy with ifosfamide and adriamycin. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the integral dose to carotid vessels in extended field intensity modulated radiotherapy (IMRT) (including the lower neck nodes in IMRT field) and split field IMRT (using separate single anterior field to treat lower neck nodes) in cancer nasopharynx. Materials and Methods: Dosimetric data from 10 patients of carcinoma nasopharynx, undergoing IMRT, were evaluated in this prospective study. The carotid vessels were contoured from sternoclavicular joints upto the base of skull. IMRT plans were generated for all patients with extended field and split field IMRT techniques using nine coplanar beams with 6 MV photons. A dose of 70 Gy to planning target volume (PTV)70Gy, 59.4 Gy to PTV59.4Gy and 54 Gy to PTV54Gy was delivered in 33 fractions. The dose constraints were similar for both the techniques. The integral dose to the carotid arteries was calculated as the mean dose times the volume (mean dose × volume) in units of liter-gray. Results: The mean dose to the carotid vessels in the extended field IMRT was 63.88 ± 0.97 Gy (mean dose ± SD) and it was 64.43 ± 0.73 Gy for the split field technique. The integral dose in the extended field versus split field technique was 0.29 ± 0.0207 and 0.32 ± 0.0213 liter-gray, respectively. The difference was statistically significant (P < 0.013). Conclusions: Extended field IMRT delivers a slightly lower integral dose to carotid arteries in treatment of cancer nasopharynx while maintaining good dose homogeneity to the PTV54Gy and can be preferred over split field radiotherapy. [ABSTRACT FROM AUTHOR]

Cylindric cell carcinomas (transitional cell carcinomas) are a rare and distinct histopathological entity presenting in the head and neck region. They have been known by myriads of nomenclature like cylindric carcinomas, nonkeratinizing sinonasal carcinoma, papillary carcinoma, cylindrical or columnar cell carcinoma, intermediate cell carcinoma, Schneiderian carcinoma, and Ringertz carcinoma. They are considered a variant of nonkeratinizing squamous cell carcinoma. Cylindric carcinomas are usually described in the sinus and nasal cavity and rarely said to involve nasopharynx and larynx. Only passing references have been made for its presentation in oropharynx including tonsils and the base of the tongue. We report here a rare case of transitional cell carcinoma presenting in the base of the tongue. There are no separate treatment recommendations in the literature, and the management is on the lines of treatment of squamous cell carcinoma. We report here a case of cylindric cell carcinoma presenting in the base of the tongue. The patient was staged as having cT2 N3 M0 (Stage IV B) disease. The patient received palliative radiotherapy of 20 Gy in five fractions followed by chemotherapy with injection paclitaxel and carboplatin. A partial response to treatment was achieved at the time of writing this report. [ABSTRACT FROM AUTHOR]

Purpose: Field matching poses challenges in craniospinal irradiation (CSI) as it leads either to underdosage or overdosage in the junctional area. A simple technique for CSI in pediatric patients is proposed. Materials and Methods: Computed tomography scans were performed in the prone position. Two lateral cranial fields and a direct posterior spinal field were planned with a common central axis. Half-beam-blocked cranial fields with zero collimator rotation were used for treating the cranium. A half-beam-blocked field defined with jaws was used to treat the spinal column at an extended sourceto-surface distance. Before treating the patient, matching of the cranial and spinal field junction along the central axis was verified with an extended dose range film. Results and Conclusion: The technique described is simple and easy to implement and can be applied to pediatric patients undergoing CSI. This method has the potential to reduce daily setup time and setup errors. This technique is ideally suitable for patients with spinal fields less than 30 cm. [ABSTRACT FROM AUTHOR]

Background:Spinal cord tumors are rare and fortunately affect only a minority of the population. These tumors are classified based on their anatomic location in relation to the dura mater and spinal cord as epidural, intradural extramedullary or intradural intramedullary. Intradural extramedullary Ewing's sarcoma is extremely rare.Purpose:Here, we are reporting a case of intradural extramedullary Ewing's sarcoma. This is the fourth such case to be reported in English literature.Methods:A 26-year-old gentleman presented to us with low backache and progressive paraparesis from a spinal tumor. Magnetic resonance imaging showed multiple intradural, extramedullary mass lesions extending from the T11 to S2 level. Neither osteolytic nor osteosclerotic changes were seen in the vertebral bodies. Extraskeletal Ewing's sarcoma was diagnosed histopathologically. He was treated by surgery, local radiotherapy and chemotherapy. Two months after treatment, he developed a new skip lesion in the spine at T6–T7 level. The new lesion was treated with local radiotherapy and chemotherapy.Results:Presently, the patient has completed treatment and is clinically doing fine.Conclusion:Intradural extramedullary Ewing's sarcoma is a rare aggressive neoplasm with high propensity for skip metastasis.Spinal Cord (2008) 46, 582–584; doi:10.1038/sc.2008.8; published online 12 February 2008 [ABSTRACT FROM AUTHOR]

Purpose: This study was mainly framed to study the difference in tumor volumes as seen on computed tomography (CT) and magnetic resonance (MR) and their significance in planning.Materials and Methods: Twenty-five patients with brain tumor of different diagnoses who underwent stereotactic radiotherapy were included in this study. CT and MR imaging was done for all the patients with 2.5 mm slice thickness. The CT tumor volume and MR tumor volume were measured and compared with each other. The center of mass (CM) of the tumor volume delineated on CT and MR were computed and the shift between the two CMs was determined.Results: The mean and median volume of the tumor as measured from MR scans was 19.67 cc +/- 13.73 and 16.13 cc (range: 3.25 cc-50.37 cc). Similarly, the mean and median volume of the tumor as measured from CT scans was 15.05 cc +/- 10.13 and 11.63 cc (range: 3.0 cc-36.25 cc) respectively. The mean and median CM shift between CT and MR was 5.47 mm and 5.21 mm respectively.Conclusion: The study demonstrates that MR is an indispensable imaging modality in radiotherapy for planning brain tumors. [ABSTRACT FROM AUTHOR]

BACKGROUND: Radiofrequency ablation (RFA) is a minimally invasive thermal ablation technique. We performed a pilot study of USG guided percutaneous RF ablation of 20 breast tumors less than 3 cm to determine the efficacy and safety of this procedure. METHODS: Nineteen patients with twenty FNAC proven breast tumors underwent RF ablation followed by surgical resection. Sentinel lymph node (SN) biopsy was carried out in 15 patients. Tumor viability after RF ablation was assessed by H and E staining and NADH diaphorase tissue viability staining. Pre and post RF ablation MIBI scan was done in 4 patients. RESULTS: The mean tumor size was 2.3 cm (range 1- 3.5 cm). Histological evaluation with H and E staining revealed mild necrosis in 9, marked necrosis in 8 and complete necrosis in 3 lesions. Complete coagulation necrosis was seen in 19 out of 20 lesions on NADH diaphorase staining. Sentinel node was positive in 5, negative in 9 patients and could not be identified in one patient. Post-RFA MIBI scan showed no radiotracer uptake in two, diminished uptake in one and normal uptake in one patient. Two patients had full thickness skin burn and one had skin puckering at the RF ablation site. SN was identified in 14/ 15 patients (identification rate:93%) and it accurately predicted axillary nodal status in all 14 patients (concordance rate:100%). CONCLUSIONS: RF ablation is promising as a minimally invasive technique in the local treatment of invasive breast cancer with few minor complications and can be performed under GA as a day-care procedure. Post-RF ablation MIBI scan appears to predict the histopathological findings. SN biopsy accurately predicts axillary nodal status following RF ablation of primary breast tumor. [ABSTRACT FROM AUTHOR]