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  Most popular articles (Since October 17, 2017)

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Recovery and tolerance of the organs at risk during re-irradiation
Suman Das, Kanhu Charan Patro, Ashutosh Mukherji
January-June 2018, 1(1):23-28
In the last few decades, there have been major improvements in diagnosis, staging, and management of cancer which has translated into better disease outcomes and longer survival rates and with better quality of life. This improvement in the quality of life is by better normal tissue sparing caused by the increasing use of newer techniques and technologies, especially in surgery and radiotherapy. Along with higher survival, there is now greater acknowledgment of the need to treat local recurrences and hence the increased use of re-irradiation. Better technology such as intensity modulated radiotherapy translates into better sparing of normal tissue, but at the same time, late toxicity is still of concern. Factors such as residual late damage, total dose, fraction size, technique, type of tissue, and time interval to re-irradiation still guide prescription of the re-irradiation dose. Knowledge of long-term recovery of organ at risk is hence of importance in re-irradiation. This review article has emphasized on the recovery and tolerance of organs at risk such as Spinal cord, Brainstem, and Brain. This is important in prescribing doses for the target volume for re-irradiation and in setting constraints for surrounding critical organs during the planning process.
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BRCA1 and BRCA2 mutations in ovarian cancer
Anurag Mehta
January-June 2018, 1(1):1-4
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Craniospinal irradiation by rapid Arc® technique in supine position: A dosimetric and clinical analysis
Vijayaprabhu Neelakandan, S Sherly Christy, Ashutosh Mukherji, K Sathyanarayana Reddy
January-June 2018, 1(1):16-22
Introduction: In craniospinal irradiation (CSI), prone position has been commonly used but, in some patients, especially pediatric cases where anesthesia is needed prone position may not help. In planning CSI by supine technique, beam geometry and field matching have to be considered, and immobilization is essential to ensure reproducibility of treatment. Materials and Methods: Data of four patients (3 with medulloblastoma and 1 with lymphoma) treated between March 2012 and October 2013 were included in this retrospective dosimetric study and analyzed. Patients were evaluated for dose coverage, organs at risks (OARs) sparing, number of monitor units, and daily table position shifts. Results: All patients underwent CSI by volumetric-modulated arc therapy (VMAT) technique in supine position. All four cases developed Grade 1 skin changes, and only one case developed a Grade 2 change at the end of radiotherapy; also both pediatric cases developed Grades 2 and 3 anemia and leukopenia toward their 4th week of treatment onward. The Rapid Arc®-CSI plans were able to generate dose distributions with high planning target volume (PTV) conformity and homogeneity and with sparing of OAR. The cumulative conformity index for all patients was 0.986, and homogeneity index was 0.1007. The mean PTV doses were within 108% with V110% of <12%, and V107% was 20%. On the evaluation of patient setup errors, a maximal shift of 3 mm in longitudinal direction was noted. At 3 years, all medulloblastoma cases except 1 were in remission. One adult patient with medulloblastoma had multiple spinal metastases at 1 year. Conclusions: Treatment of patients in supine position is reproducible and easily maintained with minimal acute reactions. VMAT technique helps avoid junctions, field-matching, and benefits with image guidance for precise dose delivery, conformity, and OAR sparing.
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Risk stratification in early-stage estrogen receptor+/HER2-breast cancer patients: Comparative analysis of cost-effective methods
Chandra Prakash, Aparna Gunda, Arun Kumar Attuluri, Lekshmi Madhav, Charusheila Ramkumar, Chetana Basavaraj, Nirupama Naidu, Manjiri M Bakre
January-June 2018, 1(1):5-15
Context: Treatment decisions in early-stage hormone receptor-positive breast cancer patients are dependent on the potential risk of cancer recurrence. Multiple expensive gene expression based or cost-effective methods are used to assess the risk in conjunction with traditional prognostic determinants – age, tumor parameters – size, node, grade, and gold standard biomarkers-estrogen receptor, progesterone receptor (PR), and Human epidermal growth factor receptor 2. Aim: The aim of this study is to compare the performance of multiple economic methods, namely, (1) Ki67; (2) immunohistochemistry 4 (IHC4)-multi-biomarker test; (3) Luminal A/B subtyping (4) PREDICT-an online tool. Settings and Design: IHC was performed as per standard protocol on a retrospective cohort of 401 patients. The Kaplan–Meier analysis and Cox proportional-hazards model were used. Results: The results confirmed that lymph node status is the most useful prognostic indicator among the traditional clinicopathological parameters. IHC4 had a hazard ratio (HR) of 2.847 and separated the low-, intermediate- and high-risk groups significantly (P = 0.0248). Luminal subtyping (HR = 2.530) also stratified the two risk groups significantly (P = 0.0321), but had HR lesser than IHC4. Ki67 and PREDICT could not separate the cohort into low- and high-risk groups with statistical significance. All tools compared separated the low-, intermediate- and high-risk groups with a maximum of 7% difference in metastasis-free survival significantly less compared to Oncotype Dx, which separates with 28% difference in survival. Conclusions: IHC4 is a significant predictor of prognosis among the four tools tested. However, multiple limitations of IHC4 tool about validation and lack of standardized protocols for IHC create a need for a robust, accurate, and cost-effective risk assessment tool.
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Approach towards re-irradiation of common cancers
Anis Bandyopadhyay, Kanhu Charan Patro, Poulami Basu, Kaushik Roy
January-June 2018, 1(1):29-34
Reirradiation, in combination with systemic therapy or biologicals, in recent years, has become a popular option for locally recurrent cancers and for infield second malignancies in cases where surgical salvage is not feasible. However before embarking onto such a course of second radiation a systematic approach is needed to avoid undesirable consequences and to gain meaningful advantage in terms of survival and local control. An decision making approach for common cancers where re-irradiation is commonly used like the head and neck cancers, the gliomas and in cases of gynecological cancers has been discussed. Proper selection of the cases and the choosing the intention for re-irradiation is probably most important initial step. Care of the details of the initials course of radiation like the dose fractionation schedule, volume irradiated, dose to the Organs at risk along with patient's present general condition is of utmost importance. Issues like dose memory, threshold time interval, maximum effective cumulative dose etc are still areas of research and their importance in each individual site needs to ascertain in future. Finally, the aim is to have a perceived benefit over the potential of harm in a successful course re-irradiation.
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Radiobiology of re-irradiations
B Nanditha Sesikeran, Sayan Paul, Kanhu Charan Patro, Manoj K Gupta
January-June 2018, 1(1):35-39
The treatment options for recurrent tumors are limited. Re irradiation is being increasingly considered as an option, in view of the advances in treatment techniques, particularly the ability to document doses, overlay plans, intensity modulation, and image guidance. preclinical and clinical studies has been to estimate the total cumulative doses (EQD2) also termed as normalized total dose (NTD) that can be delivered to various tissues. In this review article reirradiation radiobiology of different tissues and dose fractionation have been discussed.
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Late recurrence and metastasis in a case of acinic cell carcinoma of parotid
Nikhila K Radhakrishna, Kannan Periasamy, Ashutosh Mukherji, Bhawana A Badhe
January-June 2018, 1(1):51-53
Acinic cell carcinoma (ACC) of the salivary glands is a low grade malignancy which can present with late recurrences and distant metastasis. Being relatively resistant to chemotherapy, managing metastatic ACC is a clinical challenge, especially considering the long duration of survival of these patients. A 33-year-old female presented with recurrent ACC of the left parotid, eighteen years after initial presentation; with incidentally detected asymptomatic lung metastases. She remained stable after six cycles of triple agent chemotherapy and continues to be clinically asymptomatic at nine months post chemotherapy. We hereby, report this case to highlight the late recurrence and metastatic pattern of ACC and the benefit of achieving stable disease with triple agent chemotherapy. Further clinical studies on other anticancer agents are required to achieve better treatment outcomes.
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Response to osimertinib in EGF816-resistant T790M-mutated lung cancer
James C Kuo, Natasha B Leighl
January-June 2018, 1(1):43-45
A 75-year-old male with metastatic adenocarcinoma of the lung that harbored an epidermal growth factor receptor (EGFR) mutation had disease control for 16 months with EGF816, an investigational, third-generation EGFR tyrosine kinase inhibitor (TKI), in a phase I clinical trial. On disease progression, his treatment was switched to an earlier third-generation EGFR TKI, osimertinib. A rapid response occurred but was short-lived for only 10 weeks, before a rapid progression ensued. The mechanism of sequential resistance to EGF816, and subsequently, osimertinib in this male was indeterminant because of the absence of baseline genomic profiling of the tumor. Repeated molecular profiling demonstrated persistent EGFR mutations and a possibly emergent TP53 G266E mutation. This case highlighted the importance of serial biopsies for genomic analysis to understand emergent TKI resistance. As non-cross resistance may be present among the various EGFR TKI, the potential in the sequential approach in targeted therapy should be explored.
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Re-irradiation in central nervous system tumors
Sayan Paul, B Nanditha Sesikeran, Kanhu Charan Patro, Kausik Bhattacharya, Vijay Anand Reddy Palkonda
January-June 2018, 1(1):40-42
Radiotherapy (RT) in relapsed brain tumors has been used sparingly because of the risk of toxicity, particularly white matter necrosis. However, evidence from preclinical animal models and increasing data from clinical series show that brain and spinal cord have marked repair potential, and re irradiation should be considered a valid option in selected patients. The choice of technique and dose fractionation for re irradiation depends on tumor characteristics (volume and location), previous RT dose and volume, and patient characteristics (age and performance status). For small volume tumors in noneloquent areas, single fraction SRS and brachytherapy may be good options. For small and intermediate volume tumors in eloquent areas, FSRT or hypofractionated RT may be used. For large volume recurrences, requiring partial brain irradiation, conventional fractionation is safer and offers palliation with minimal risk of radiation induced toxicitie.
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Redefining hypocalcemia for surgeons
Karthik K Prasad, Debanshu Bhaduri, Manish S Bhatia
January-June 2018, 1(1):46-47
Hypocalcemia is a well-known complication of parathyroidectomy. Although biochemical hypocalcemia denotes serum levels of total calcium below the lower limit of the reference range, symptoms of hypocalcemia occur even with normal/high calcium levels in postparathyroidectomy patients. Understanding the pathophysiology of hypocalcemia, rather than just treating the biochemical parameters, is more important in the management of these patients.
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Tracheobronchial aspergillosis: A rare case report
Kumar Doshi, Ramakant K Deshpande, Sameer Pathan, Prriya B Eshpuniyani
January-June 2018, 1(1):48-50
Invasive pulmonary aspergillosis (IPA) is a life-threatening disease seen more commonly in critically ill patients and immunocompromised individuals. Tracheobronchial aspergillosis (TBA) is a variant of IPA which mimics bronchopneumonia usually but can present with acute respiratory distress. Clinical suspicion of the diagnosis and prompt treatment is lifesaving for TBA. Here, we present a rare case report of a patient of unresectable tracheobronchial mucoepidermoid carcinoma who presented with acute respiratory distress and responded to prompt action and antifungals.
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Lynch syndrome—It’s time we start detecting it
Anurag Mehta, Garima Gupta
July-December 2018, 1(2):55-60
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Innovativeness in breast cancer: The prime example of anti-HER2 agents
Yasar Ahmed, Jonathan Lee, Ahmed Yousif
July-December 2018, 1(2):80-83
Since the identification of HER2 in breast cancer pathogenesis and the introduction of the first drugs targeting this receptor, the humanized monoclonal antibody trastuzumab and the tyrosine kinase inhibitor lapatinib, many advances have been made in the treatment of HER2-positive breast cancer that have led to a progressive improvement in the outcome of patients with early and advanced breast cancer. One of the major achievements is the development of dual HER2 blockade strategies. Evidence from the neoadjuvant and metastatic setting suggests that by combining trastuzumab with other anti-HER2 drugs such as lapatinib or the humanized monoclonal antibody pertuzumab, the efficacy of treatment may be further improved.
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A comparative study of ropivacaine and bupivacaine with fentanyl for postoperative patient-controlled epidural analgesia after major abdominal oncosurgery
Anita Kulkarni, Anudita Gupta, Shagun B Shah, Ajay K Bhargava
July-December 2018, 1(2):66-72
Aim: To compare the analgesic efficacy of epidural ropivacaine–fentanyl with bupivacaine–fentanyl combination administered by patient-controlled epidural analgesia (PCEA) technique for postoperative pain relief after major abdominal oncosurgery. Materials and Methods: A prospective, randomized, interventional, parallel group, active control study was conducted on 60 patients with American Society of Anesthesiologists physical status I–III. Random allocation was carried out into two groups of 30 patients each. Intraoperatively, after administering a loading dose (10mL of 0.5% bupivacaine) in both the groups, continuous infusions of 0.1% bupivacaine plus fentanyl (2 µg/mL) (Group BF) or 0.1% ropivacaine plus fentanyl (2 µg/mL) (Group RF) were started at the rate of 5mL/h. Postoperatively, same drug concentrations were administered via PCEA pump at 4mL/h as a baseline infusion (bolus dose, 3mL; lockout interval, 15min). Visual analog scale (VAS) score at rest and on coughing was recorded at specific time points. Rescue analgesia was administered as per protocol. Results: VAS scores at rest and on coughing were higher in Group BF as compared to Group RF. Group RF had less drug consumption, required fewer PCEA boluses, and had minimal motor blockade as compared to Group BF. Conclusion: Good analgesic efficacy with lower drug consumption makes Group RF well suited for postoperative PCEA with hemodynamic stability and minimal motor blockade.
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Influencing factors while prescribing androgen deprivation therapy for carcinoma prostate in clinical practice: When literature is not enough!
Kuldeep Sharma, Subodh C Pande, Kamal Verma, Sandeep Goel
July-December 2018, 1(2):73-79
Objective: Androgen deprivation therapy (ADT) is an integral part of prostate cancer management but its clinical use remains controversial. Materials and Methods: We retrospectively analyzed 91 patients with prostate cancer treated between 2007 and 2014 to determine the factors that influenced our physician’s decisions regarding ADT prescription. Results: Of the 55 radically treated cases, the mean age was found to be 67 years with comorbidities present in 67% cases. Overall, 26% patients were symptomatic at presentation with 0%, 19%, and 81% cases in low-, intermediate-, and high-risk (HR) category, respectively. When divided into two groups, ADT (41 cases) and NADT (non-ADT, 14 cases), more HR cases (80% vs. 20%, P = 0.05) and all patients with positive nodes fell in ADT group (P = 0.05). Patients in ADT group had a significantly higher mean initial prostate-specific antigen (iPSA) than that of NADT group (54.2 vs. 13.9ng/mL; P = 0.02). Treatment outcomes and toxicities remained comparable between the two groups. Overall, 74% patients obtained response to primary treatment (75.6% in ADT and 71.4% in NADT) with 10 patients experiencing disease progression during follow-up (FU). Mean progression-free survival was 43 and 32 months in ADT and NADT group, respectively (P = 0.24). Median FU was 54.9 and 35.5 months in ADT and NADT group, respectively (P = 0.29). At last FU, 91% patients were alive (88% in ADT and 100% in NADT) with 67% in disease-free status. Conclusion: Prognostic risk grouping, node positivity, and high iPSA emerged as significant factors that influenced decisions regarding ADT prescription. Other factors such as age, comorbidities, symptoms, Gleason score, and T-stage were found to be insignificant.
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Reirradiation in breast malignancies
Venkata Krishna Reddy Pilaka, Kanhu C Patro, Partha S Bhattacharyya, Chitta R Kundu, Madhuri Palla, Rajesh Balakrishnan
July-December 2018, 1(2):84-88
Ipsilateral breast or chest wall recurrence remains one the most common site of disease recurrence and significantly increases the morbidity and mortality. The current standard of care for ipsilateral breast tumour recurrence has been mastectomy. However, various recent studies showed that there is feasibility of repeat breast conservation surgery with reirradiation. Reirradiation in breast cancer is complicated approach. Many physicians are reluctant to reirradiate breast with restricted data available. This paper will review the current literature on reirradiation for locally recurrent breast cancer
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Intensified versus non-intensified induction therapy with cytarabine and daunorubicin for patients with newly diagnosed acute myeloid leukemia
Mehrzad Mirzania, Sayyed Reza Safaee Nodehi, Ramezan Ali Sharifian, Farhad Shahi, Amir Hosein Emami, Mohsen Esfandbod, Gholam Reza Togeh, Sahar Tavakoli
July-December 2018, 1(2):61-65
Background: The purpose of this study was to compare the efficacy and adverse effects of intensified dose of daunorubicin (DNR) and cytarabine (Ara-C) versus their standard dose in induction therapy for patients with newly diagnosed acute myeloid leukemia (AML). Materials and Methods: In a retrospective review, patients with AML in Hematology and Oncology Department of Imam Khomeini Hospital, Tehran, Iran, who underwent induction therapy with standard dose of Ara-C and DNR (100mg/m2 for 7 days and 45mg/m2 for 3 days, respectively) were compared in terms of overall survival (OS) rate, disease-free survival (DFS) rate, and treatment-related complications with those who underwent double-intensified induction (i.e., Ara-C, 200mg/m2 for 7 days and DNR, 60mg/m2 for 3 days). Results: Among 123 patients, the standard-dose regimen was used for 49 patients, and 74 patients received the dose-intensified regimen. The rate of 2-year DFS, 2-year recurrence rate of the disease, and treatment-related mortality improved significantly in the latter group (P < 0.05). However, between the two groups, OS rate, bone marrow blast cell percentage 14 days after treatment, the number of antibiotics received, fungal infection rate, and the need for bone marrow transplants did not significantly differ. On the other hand, the risk of heart failure significantly increased in the dose-intensified group (P < 0.05). Conclusion: Treatment of AML using combined dose-intensified induction significantly improved DFS rate and decreased the disease-recurrence rate but did not significantly improve OS rate, and more side effects were encountered.
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Prolonged survival with anti-epidermal growth factor receptor therapy in head and neck squamous cell carcinoma: A case series
Pratik Patil, Vineet G Gupta, Ranga R Rangaraju, Waseem Abbas, Peush Bajpai
July-December 2018, 1(2):97-100
Head and neck cancer (HNC) is the sixth most common cancer worldwide, with approximately 650,000 patients newly diagnosed annually. In the late 1990s, surgery followed by postoperative radiotherapy (RT) or RT alone was the standard therapeutic modality for locoregionally advanced head and neck squamous cell carcinoma (LA-HNSCC). As chemotherapeutic agents were identified to have additional effects when combined with RT, chemoradiotherapy has become the standard treatment over the last decade for patients with LA-HNSCC who were not candidates for surgery. Despite the heterogeneity of both tumor location and genetic aberrations, 90% of HNCs are histologically squamous cell carcinomas. Hereby, we present a case series of patients with HNSCC who were benefited with anti-epidermal growth factor receptor therapy with a prolonged survival.
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Cancer prostate metastasis to testis: A rare encounter
Kshitij Raghuvanshi, Hrishikesh Deshmukh, Abid Raval, Devendra Kumar Jain
July-December 2018, 1(2):94-96
Carcinoma of prostate rarely metastasizes to the testis. It is the most common primary cancers among all the solid malignancies contributing the majority of testicular metastases. Here, we report such type of rare case in a 64-year-old man who presented with a history of severe lower urinary tract symptoms and progressively increasing swelling of the right testis. The case was subsequently diagnosed as a prostate cancer with testicular metastasis.
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“So near, yet so far”: Palliative care services remain elusive in India
Sudip Bhattacharya, Sukhpreet Singh, Amarjeet Singh
July-December 2018, 1(2):101-102
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Clinical pearls in pediatric anesthetic considerations for peripheral blood stem cell transplant and lacunae in our current knowledge
Shagun B Shah, Ajay K Bhargava, Sangeeta Bhagat, Dinesh Bhurani, Narendra Agrawal
July-December 2018, 1(2):89-93
Clinical introduction of peripheral blood stem cell transplant (PBSCT) has replaced bone marrow as a stem cell source in 99% autologous and 75% allogeneic transplantation cases. Incompliant pediatric donors require general anesthesia for PBSCT. Whether the CD34-positive (CD34+) stem cell yield from PBSC donor is affected by age, weight, and sex of donor and type/duration of anesthesia is not very clear from the current literature. These factors may have significant clinical implications as is evident from the poor yield (0.11 million/kg CD34+ cells) on the second day of stem cell harvest from our 2-year-old donor.
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