Predictors of toxicity after neoadjuvant chemoradiotherapy for locally advanced gall bladder cancer

Background: The present study evaluated the correlation of hepatobiliary toxicity and radiation dose received in patients undergoing neoadjuvant chemoradiotherapy (NACRT) for locally advanced unresectable gall bladder cancers (LAGBC). Methods: Twenty-six patients with LAGBC, treated with NACRT (55–57 Gy/25 fractions/5 weeks and weekly gemcitabine 300 mg/m2) within a phase II study, were included. Whenever feasible, surgery was performed after NACRT. Acute and late hepatobiliary toxicity was recorded. Treatment scans were retrieved to delineate central porto-hepatobiliary system (CPHBS), resected liver surface, segment IV B and V, and duodenum. The doses received by these structures were recorded and correlated with toxicity. Results: Of 26 patients, 20 (77%) had partial or complete response and 12 (46%) had R0 resection. At the median follow-up of 38 months, overall survival was 38%. Eight (30%) patients had post-treatment toxicity, of which most common was biliary toxicity (30%). A correlation was observed between the biliary leak and V45Gy CPHBS >50 cm3 (P = 0.070). Higher toxicity was observed in those with metallic stents (P = 0.072). Conclusion: The incidence of the biliary leak was 46%. CPHBS dose was found to correlate with biliary leaks. Restricting V45Gy CPHBS <50 cm3 and using plastic stent may facilitate a reduction in hepatobiliary toxicity in patients undergoing NACRT and surgery.

Management of colon cancer at a tertiary referral center in India - Patterns of presentation, treatment, and survival outcomes

AIM: To define the patterns of disease presentation, treatment strategies, and outcomes for patients with colon cancer at a tertiary referral center in India over 1 year period. MATERIALS AND METHODS: This is a retrospective analysis of a prospectively maintained database. All consecutive patients with proven or suspected colonic adenocarcinoma between July 2013 and July 2014 were evaluated in a dedicated analysed multidisciplinary clinic at the Tata Memorial Hospital, Mumbai. The demography, treatment plan, pathology, stage, and survival data were examined. RESULTS: The median age of presentation was 49 years with 60.1% male patients. In total, 151 cases (57.4%) underwent treatment with curative intent consisting of surgery with adjuvant chemotherapy as indicated. The rest were offered either palliative chemotherapy (36.9%) or best supportive care (5.7%). Approximately, 70% patients had advanced stage disease (Stage III/IV) at presentation and 41.8% presented with metastatic disease with the liver being the most common site of disease dissemination. With a median follow-up of 29 months, the estimated 3-year disease free survival for patients treated with curative intent was 67.1%. The median progression free survival was 12.3 months for patients treated with palliative intent. The estimated 3-year overall survival was 89.7%, 65.5%, and 22.8% for Stage I/II, Stage III, and Stage IV, respectively. CONCLUSION: Indian patients with colon cancer, at a tertiary referral center, tend to present at more advanced stages of the disease as compared to the West. However, curative treatment with surgery and chemotherapy offers similar survival outcomes when compared stage for stage

A comparative analysis of quality of life after postoperative intensity-modulated radiotherapy or three-dimensional conformal radiotherapy for cervical cancer

AIMS: The aim of this study is to compare the quality of life (QOL) between adjuvant three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) for cervical cancer. MATERIALS AND METHODS: QOL assessment was done at the baseline and then longitudinally after completing (chemo) radiation. All patients completed EORTC QLQ-C30 and EORTC QLQ Cx-24 modules. Independent-sample t-test was used to compare the mean scores between the two groups. Analysis of variance was used to compare differences in QOL measures over the six time points (baseline, post-RT, 3, 6, 9, and 12 months after treatment) and between treatment groups (3DCRT vs. IMRT). Linear mixed model was also performed to account for attrition. RESULTS: Overall, 64 patients (image-guided IMRT, n = 40 and 3DCRT, n = 24) completed QOL assessment. The median age and follow-up period were 48 years and 15.5 months, respectively. General QOL domains such as emotional (at 12 months, P = 0.04) and social (at 3 months, P = 0.02 and 12 months, P = 0.03) were better with IMRT. Pain (12 months, P = 0.03); fatigue (12 months, P = 0.05); nausea and vomiting (12 months, P = 0.03); insomnia (post-RT, P = 0.05 and 12 months, P = 0.03); appetite loss (post-RT and 12 months, P = 0.04); and diarrhea (6 months, P = 0.02 and 12 months, P = 0.003) scores were significantly better with IMRT. On linear mixed model analysis, there was a significant interaction between treatment cohort and assessment intervals for physical, emotional, and social functioning, appetite loss, diarrhea, lymphedema, and menopausal symptom scores were significantly better with IMRT. CONCLUSIONS: Treatment technique (IMRT vs. 3DCRT) impacts early QOL in undergoing adjuvant radiation for cervical cancer.

Locally advanced cervical cancer: A study of 5-year outcomes

Background: Cervical cancer is the second most common cancer among Indian women. This present retrospective study was conducted to report patient outcomes with locally advanced cervical cancer treated in the year 2010. Materials and Methods: Case records of cervical cancer patients registered from January 1, 2010, to December 31, 2010 were retrieved. A total of 1200 patients were registered, of which 583 received either definitive or adjuvant radiotherapy (RT). Of these, 345 patients who received complete treatment at our hospital were included for outcome analysis. Descriptive statistics were used to summarize patient- and treatment-related variables, and Kaplan–Meier analysis was performed for survival analysis. Results: The median age was 56 years (range: 33–90). Squamous carcinoma was the most common histology (91.4%) and the majority were FIGO Stage III (45.4%). Median follow-up of the cohort was 44 months (1–85 months). The 5-year disease-free survival (DFS) across stages was 50%. Most important predictor of DFS was FIGO staging (Stage II vs. Stage III: 62% vs. 45%) and use of concurrent chemoradiotherapy (CTRT) l (RT vs. CTRT: 32% vs. 57%, respectively). Patients aged >70 years had a significantly poor DFS at 5 years; however, did not have any effect on survival. Grade 3 or more late toxicity was seen in only 5% of the patients. Conclusion: Five-year DFS of 62% and 45% of Stage II and III patients treated under routine care represents comparable stage-matched results to the rest of the world, respectively.

Clinicopathological spectrum of 19 adenosarcomas of female genital tract, including uncommon clinical associations and immunohistochemical profile, reviewed at a single institution.

Background: Adenosarcomas of the female genital tract have been rarely documented as case series from our continent. Materials and Methods: Over a seven-year period, 19 adenosarcomas were critically reviewed. Results: Nineteen tumors occurred in the age range of 21-65 years (mean: 43), in the endometrium (8), endometrium and cervix (4), cervix (4), and ovary (3). Four cases displayed coexisting leiomyomas; two, adenomyosis; two on background endometriosis; and one in post-treated cervix carcinoma. Histopathologically, the tumors were low grade (10; 52.6%) and high grade (9; 47.3%), the latter with sarcomatous overgrowth (SO) (7/9 cases). Dedifferentiation (8, 42.1%) and conspicuous decidualization (2) were noted. Immunohistochemically, the tumors focally expressed CD10 (4/6), smooth muscle actin (SMA) (3/8), desmin (8/11); diffuse vimentin (7/7), and estrogen receptor/progesterone receptor (ER/PR) (2/4). Ki-67 (6 cases) varied 5-20%. Seventeen patients underwent surgery and four received adjuvant treatment (3/4 high-grade tumors). Five tumors recurred (4 high-grade tumors with SO) and one metastasized. Among 11 patients, five were alive with disease (AWD) (mean: 29.4 months) and six, free of disease (FOD) (mean: 15 months), the latter mostly with low-grade type tumors (83.3% cases). Conclusions: Diverse clinicopathological spectrum was noted within adenosarcomas. Low-grade tumors were less aggressive than high-grade ones, with SO. Immunohistochemically, lower CD10 and ER/PR positivity was noted in high-grade tumors. Surgery formed the mainstay of treatment. Adjuvant treatment was offered in high-grade subtypes, including in tumors with SO.

The European Organization for Research and Treatment of Cancer prostate-specific quality of life module (PR-25) in Hindi and Marathi: translation and pilot testing process.

BACKGROUND: The side effects of various treatments for prostate cancer have a measurable impact on the general as well as disease-related quality of life, which is of pivotal concern as an outcome measure. AIM: Translation and pilot testing of the European Organization for Research and Treatment of Cancer (EORTC) prostate cancer-specific module (PR-25) into Hindi and Marathi. MATERIALS AND METHODS: The translation procedure described by the EORTC was adopted; this comprised two forward translations of the original English questionnaire into Hindi and Marathi each with formation of first intermediary questionnaires and two back translations of the first intermediary questionnaires into English. The first intermediary questionnaires were adapted as the second intermediary questionnaires and pilot tested in ten prostate cancer patients as no modifications were suggested by the back translators. RESULTS: Each patient, after completing the questionnaire, was interviewed by the local project coordinator who questioned them about each item in the second intermediary questionnaire. The patients were asked whether there was any difficulty in answering, confusion while answering, or difficulty in understanding the questions; whether the questions were upsetting; and if the patients themselves would have framed the question in a different way. Based on the suggestions or interpretations of this pilot testing, the necessary changes were incorporated and the final Hindi and Marathi questionnaires were formed. CONCLUSION: Both the translations were submitted to the EORTC for review and have been subsequently approved for clinical studies.

Chest wall metastasis from hepatocellular carcinoma in the absence of a primary: An unusual presentation.

Metastatic hepatocellular carcinoma (HCC) has an aggressive course with a very poor outcome. The common hematogenous metastatic sites are the lungs, bones, and adrenal glands. The chest wall is an extremely rare site of metastasis from HCC. We report a rare presentation in a gentleman, where the chest wall metastasis kept progressing in spite of treatment, without any evidence of a detectable primary.