Male breast cancer: A single institute experience.

BACKGROUND: Male breast cancer (MBC) is a rare disease and accounts for 1% of all breast cancers. There is limited data on MBC from India. The aim of our study was to assess clinico‑pathological parameters and outcome in MBC patients. MATERIALS AND METHODS: This analysis was carried out in 76 patients of MBC who were registered at Institute Rotary Cancer Hospital of All India Institute Of Medical Sciences between 1996 and 2012. Patients’ records were retrospective reviewed and data obtained from the computer database using International Classification of Diseases code (C‑50). RESULTS: The median age was 59 years (range: 28‑80). The median duration of symptoms was 11 months (range: 0.5‑40). Breast lump was the most common presenting symptom (left > right side). American Joint Committee on Cancer (7th edition) stage distribution was Stage I‑2.6%, Stage II‑13.1%, Stage III‑59.3% and Stage IV‑25%. Modified radical mastectomy was the commonest surgical procedure. Moreover, 30% of tumors were high‑grade and 70% had pathological node positive disease. Estrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 (HER2)/neu positivity was 80% and 28%, respectively. Triple negative breast cancer constituted 19% of cases. With a median follow‑up of 36 months, 3 years relapse free survival and overall survival was 60% and 80%. Advanced stage and visceral metastasis at baseline predicted poor outcome. CONCLUSION: MBC constituted 0.8% at our institute. Our study population had a longer time to presentation, advanced disease at presentation, more HER2/neu positivity and triple negativity higher than the available literature.

Young breast cancer: A single center experience.

BACKGROUND: Breast cancer in women aged less than 35 years is uncommon and accounts for 1‑2% of all breast cancer in the West. There is a paucity of data on young breast cancer from India. The aim of this study was to analyze the clinical, pathological, prognostic factors and outcome in young breast cancer patients. MATERIALS AND METHODS: This analysis was performed in 251 patients aged <35 years or less (defined as breast cancer in the young), who were registered at our institute over an 11 year period between 2001 and 2011. RESULTS: The median age was 31 years (range 18‑35). Positive family history (siblings and parents) was elicited in only 10 patients. The TNM stage distribution was: Stage I was 2.5%, stage II ‑ 20.5%, stage III ‑ 55% and stage IV - 22%. The median clinical tumor size was 5.1 cm. Modified radical mastectomy was the most common surgical procedure and this was done in 79% of cases. 40% of tumors were high grade and 60% had pathological node positive disease. Estrogen and Progesterone and human epidermal growth factor receptor 2/neu positivity were 33% and 29% respectively. Triple negative breast cancer constituted 31% of patients. With a median follow‑up of 30 months, 3 years relapse free survival and overall survival was 51% and 66%. CONCLUSION: Young women constituted 8% of breast cancer cases. Advanced disease at presentation and triple negativity (nearly one third of patients) results poor outcome.

Pregnancy associated breast cancer: An institutional experience.

BACKGROUND: Pregnancy‑associated breast cancer (PABC) has been defined as breast cancer diagnosed during pregnancy or within 1 year of delivery. There is a paucity of data on PABC from India. The aim of our study was to assess the clinical‑pathological parameters and outcome of PABC at Institute Rotary Cancer Hospital, All India Institute of Medical Sciences. MATERIALS AND METHODS: We screened approximately 3,750 cases registered from January 2001 to December 2012 and found 26 cases of PABC. Patients’ records were obtained from the computer database using International Classification of Diseases code (C‑50). RESULTS: The median age was 26 years (range 20‑35). The median duration of symptoms was 11.5 months. The American Joint Committee on Cancer stage distribution was Stage I ‑ 1, Stage II ‑ 3, Stage III ‑ 14 and in Stage IV ‑ 8 patients. Median clinical tumor size is 5.5 cm. Four patients were presented with the inflammatory breast cancer. Positive family history was elicited in three patients. Twenty‑one patients were diagnosed after delivery, two patients in the first trimester, two patients in the second trimester and three patients in the third trimester. Estrogen receptor (ER), progesterone receptor (PR) negativity and human epidermal growth factor receptor 2 (HER2/neu) positivity was 56% and 38%, respectively. Nearly, 40% of patients had a high‑grade tumor and 70% had pathological node positivity. With a median follow‑up of 33 months, 3 years relapse free survival and overall survival was 40% and 50% respectively. Bone was the most common site for systemic relapse. CONCLUSIONS: PABC constituted 0.7% of all breast cancer patients. It is associated with advanced stage at presentation. Half of them were ER/PR negative and one‑third was HER2/neu positive.

Triple‑negative breast cancer: An institutional analysis.

AIM: Triple‑negative breast cancer (TNBC) is defined by the lack of expression of the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER 2)/neu. It has been identified as an independent poor prognostic factor for survival. The aim of this study was to compare the clinico‑pathological characteristics and treatment outcomes of patients with TNBC and non‑TNBC. MATERIALS AND METHODS: We carried out an analysis of 706 patients with invasive breast cancer between January 2007 and December 2011 in whom information on the status of ER, PR, and HER2/neu were available. RESULTS: One hundred and fifty‑five patients (21.9%) patients had TNBC. Patients with TNBC had a significantly lower median age [46.2 vs. 49.8 years; P = 0.005, 95% confidence interval (CI): 0.98 to 2.38] and a higher proportion of high‑grade tumors as compared to the non‑TNBC group (43 vs. 24%; P < 0.0001). After a median follow‑up of 30 months, the three‑year relapse‑free survival (RFS) was significantly lower in the TNBC group (76 vs. 64%; log rank P = 0.002). Three‑year overall survival (OS) was lower in the TNBC group but not statistically significant. Age <49 years, higher nodal stage, and larger tumor size (>5 cm) were associated with poor outcome. CONCLUSION: TNBC is significantly associated with younger age and high‑grade tumors and constitutes 21.9% of all breast cancers in our institute. Triple negativity was a significantly poor prognostic factor for RFS but not OS.

Clinical and pathological response rates of docetaxel-based neoadjuvant chemotherapy in locally advanced breast cancer and comparison with anthracycline-based chemotherapies: Eight-year experience from single centre.

Introduction: The administration of neoadjuvant chemotherapy (NACT) prior to local therapy is advantageous for women with locally advanced breast cancer (LABC), since it can render inoperable tumors resectable and can increase rates of breast conservative surgeries. Materials and Methods: We retrospectively analyzed LABC patients who received NACT from January 2000 to December 2007. Out of 3000 case records screened, 570 (19%) were LABC and 110/570 (19%) treatment-naïve patients started on NACT were analyzed. Ninety-one (37 docetaxel [D], 54 anthracycline [A]) patients were eligible for response and survival analysis. Pathological complete remission (pCR) was defined as no evidence of malignancy in both breast and axilla. Results: Median age of the whole cohort was 45 years (range 25-68 years). Premenopausal were 42% and estrogen receptor + 49.5%. Most (90%) were T4 tumors and 70% were Stage IIIB. Median numbers of preoperative cycles were six and three in the D and A group respectively. Overall clinical response rates for breast primary were 74.3% and 53.7% (CR 28.6% vs. 16.7%, P=0.58) while for axilla ORR were 75.7% vs. 54.8% (51.4% vs. 40.4% CR, P=0.77) respectively for D and A. Corresponding pCR rates were 19% vs. 13% respectively. There was no significant difference in disease-free (three-year 56.84% vs. 61.16%, P=0.80) and overall survival (three-year 70% vs. 78.5%, P=0.86) between the two groups. Conclusions: Although pCR rates were higher with docetaxel-based NACT, it did not translate into superior disease-free survival / overall survival compared to anthracycline-based chemotherapies.

Outcome of combined modality treatment including neoadjuvant chemotherapy of 128 cases of locally advanced breast cancer: Data from a tertiary cancer center in northern India.

Background: Breast cancer is now the most common cancer in many parts of India and the incidence varies from 12 to 31/100000, and is rising. Locally advanced breast cancer (LABC) accounts for 30 - 35% of all cases of breast cancers in India. LABC continues to present a challenge and imposes a major health impact in our country. Materials and Methods: We carried out a analysis of our LABC patients who received neoadjuvant chemotherapy (NACT) at our hospital over a 10-year period, from January 1995 to December 2004. We analyzed the response to NACT, disease-free survival (DFS), and overall survival (OS). Results: Patients with stages IIIA, IIIB, and IIIC were included. LABC comprised of 26.24% (609 patients) of new patients. One hundred and twenty-eight (31.1%) patients received NACT. Median age was 48 years and estrogen receptor was positive in 64%. Chemotherapy protocol was an FEC (5-Fluorouracil, Epirubicin, Cyclophosphamide) regimen in the following doses: Cyclophosphamide 600 mg/m2, 5-FU 600 mg/m2, and Epirubicin 75 mg/m2 given every three weeks, six doses, followed by modified radical mastectomy (MRM) and locoregional radiotherapy. The overall response rate (complete response (CR) + partial response (PR)) was 84.4%, clinical CR (cCR) was 13.3% and pathological CR (pCR) was 7.8%. Median DFS and OS were 33 and 101 months, respectively. The disease-free survival (DFS) and overall survival (OS) at five years were 41 and 58%, respectively. Conclusions: This study analyzes the outcome in patients who received NACT, in the largest number of LABC patients from a single center in India, and our results are comparable to the results reported from other centers.

HIV-associated non-Hodgkin's lymphoma: Experience from a regional cancer center.

Aims : To analyze clinical features and survival in HIV-associated non-Hodgkin lymphoma (NHL) cases registered at Dr BRA Institute Rotary Cancer Hospital of AIIMS, New Delhi. Materials and Methods : We have retrospectively reviewed records of NHL patients registered, from January 2003 to July 2007 to analyze HIV-associated NHL. Results : Seven cases of HIV-associated NHL cases were identified. Age range was 14-56 years. Five were males. Baseline performance status (ECOG-PS) was >I in 6. Mean LDH was 409 U/L. Mean hemoglobin was 10.5 g% and mean CD4 count was 243/mm3 (range 18- 454). Three cases had nodal lymphoma and four had extra nodal lymphoma. No primary CNS (PCNSL) lymphoma was seen. All patients were of advanced stages and of intermediate to high-risk group based on international prognostic index (IPI). Six cases had high-grade NHL. None had CNS involvement. Five had B symptoms. HIV infection was diagnosed as part of NHL work-up in five patients. All patients received HAART. All were planned for chemotherapy with CNS prophylaxis. Protocols used were CVP, CHOP, R-CHOP or MCP-842. One patient received IFRT. Response : One patient achieved complete response (CR) and continues to be disease free, with 4.5 years of follow-up. Three cases achieved partial response (PR) and 2 had progressive disease (PD). Currently, three patients are on follow-up. Conclusions : These NHL are of higher grade and advanced stage. Response and tolerance to chemotherapy is poor. Appropriate supportive care and CNS prophylaxis might improve outcome. We need to improve epidemiological data collection system in this part of world. With HAART, the goal of therapy is durable CR rather than palliation.

Economic cost analysis in cancer management and its relevance today.

The global cancer burden has shown a distinct shift in the last two decades and its financial impact can be large, even among patients living in high resource countries, with comprehensive health insurance policies. It is hard to imagine its impact on patients of developing countries where insurance policies exist infrequently and often cost becomes the greatest barrier in availing cancer treatment. It is recognized that these costs include the direct cost of disease treatment and care, indirect costs accrued by the patient and the family, and economic losses to the society as a whole. Economic cost analysis or cost-effectiveness analysis has emerged as a basic tool in the evaluation of health-care practices. To date, these cost data have been collected only sporadically, even in the most developed countries, and there is a great need for incorporating economic cost assessment practices in developing countries, so that patients and their families can access the care adequately. The current review has been done using pubmed and medline search with keywords like cancer, cost-analysis, cost-effectiveness, economic burden, medical cost, etc.

Primary testicular non-Hodgkin lymphoma: a single institution experience from India.

BACKGROUND: Primary testicular non-Hodgkin lymphoma (NHL) is an uncommon extra nodal presentation, constituting 1% of all NHL. Median age at time of presentation is 60 years. Anthracycline based chemotherapies are most frequently used. There is not enough data on use of monoclonal antibody (Rituximab) in testicular NHL. METHODS: We screened approximately eight hundred and fifty NHL cases registered from January 2002 to May 2008 and found six primary testicular NHL patients. These six cases were analyzed for baseline clinical features, investigations, staging, treatment and outcome variables. RESULTS: Median age was 55 years (range 7-72 years) and median duration of symptoms was 3.5 months (range 1-8 months). All patients had testicular swelling and abdominal lymphadenopathy. Five patients (83%) had stage IV and one had stage IE disease. Majority had diffuse large B-cell histology (83%). All patients were treated with anthracycline based combination chemotherapy and CNS prophylaxis after local therapy except one pediatric patient who did not receive any local therapy. Four patients completed therapy and are on follow up while two patients having extensive disease with poor performance status died of neutropenic sepsis after 1-2 cycles of chemotherapy. The surviving four patients achieved complete remission and are without any recurrence with a median follow up of 26 months (1-78 months). CONCLUSION: Primary testicular NHL is an uncommon entity and with current combined modality treatment and CNS prophylaxis, the outcome may be as good as nodal NHL.

Prophylactic beclomethasone spray to the skin during postoperative radiotherapy of carcinoma breast: a prospective randomized study.

BACKGROUND AND AIMS: Radiation induced wet desquamation of skin in carcinoma breast patients is a painful condition. In this study topical beclomethasone dipropionate spray was used as prophylaxis with the purpose of reducing risk of the wet desquamation of skin in irradiated field. MATERIALS AND METHODS: Sixty patients of carcinoma breast were planned for postoperative loco regional radiotherapy (50 Gy in 25 fraction over five weeks) were prospectively randomized into two groups (1) steroid group-patients were advised to use beclomethasone dipropionate spray in irradiated axilla from day one of radiotherapy, (2) control group-patients were not allowed to use any topical agent in irradiated area. Radiation induced skin reaction was noted in terms of erythema, dry desquamation and wet desquamation weekly till end of prescribed 50 Gy dose of the radiation therapy. STATISTICAL METHOD: Chi-square test was used to see the statistical significance of the difference in wet desquamation between two arms of the study. Chi-square value and P-value was calculated for the difference of wet desquamation in two study arms. RESULT: In steroid group 4/30 (13.33%) patients developed wet desquamation of the axillary skin at the end of the radiotherapy. For the control group, this figure was 11/30 (36.66%). The difference in wet desquamation of the axillary skin in the two groups was statistically significant (P-value = 0.0369). CONCLUSION: Topical steroid (beclomethasone dipropionate spray) for skin during radiotherapy significantly reduces the risk of wet desquamation of the skin.

Phase II study of cisplatin, etoposide and paclitaxel in locally advanced or metastatic adenocarcinoma of gastric/gastroesophageal junction.

BACKGROUND: Unresectable and metastatic gastric cancers carry a poor and dismal prognosis. Several phase II studies have identified effective anticancer drugs. AIMS: To evaluate safety and efficacy of low-dose cisplatin, etoposide and paclitaxel (CEP) based combination chemotherapy in locally advanced or metastatic adenocarcinoma of gastric/gastroesophageal junction. SETTING AND DESIGN: Prospective single-arm phase II study. MATERIALS AND METHODS: Thirty-three patients were enrolled onto this study, out of which, all but one received cisplatin 15 mg/m 2, etoposide 40 mg/m 2 and paclitaxel 50 mg/m 2, given on day 1 and 4 every week for three weeks in a 28-day cycle. Survival analysis was done using SPSS program. RESULTS: Median age of group was 56 years. Twenty-five were males. Twenty-nine had metastatic/inoperable disease and four patients had recurrent disease. Liver was the commonest metastatic site seen in 15 patients. With a median of 2 cycles per patient, a total of 76 cycles was administered. Grade III or IV toxicity were seen in 11 (35%) patients; diarrhea, 5 patients; vomiting, 3 patients; and neutropenia, 7 patients, 5 of whom also had fever). One patient died of neutropenic fever. Best responses, seen in 32 evaluable patients, were 2 CR (6.1%), 21 PR (63%) and 3 SD (9.2%). Four patients were considered operable after chemotherapy. With median follow-up of 11 months in surviving patients, median OS was 10 months and PFS was 8 months. Median OS was 13 months in responders versus 8 months in nonresponders (P =0.04). Seven patients survived> 12 months. CONCLUSION: Combination of low-dose CEP shows good clinical response and an acceptable toxicity profile in advanced or metastatic adenocarcinoma of gastric/gastroesophageal cancers. Whether addition of 5 FU or capecitabine adds to the benefit should be explored. This may be tested with other standard/conventional protocols in a randomized fashion.

Organ-preserving multimodality management of squamous cell carcinoma of anal canal.

AIM: To study the efficacy of an organ-preserving, sequential chemoradiation therapy for squamous cell carcinoma of the anal canal, and of salvage surgery in those in whom this treatment fails. METHODS: Forty biopsy-proven untreated patients (28 men) with squamous cell carcinoma of the anal canal received two cycles of chemotherapy using cisplatin and methotrexate, followed by 45 to 60 (median 50) Gy external beam radiotherapy. Salvage surgery was offered to those in whom this treatment failed. Overall survival, disease-free survival and colostomy-free survival were analyzed. RESULTS: Most patients (n=35; 87%) had T3 or T4 lesions and 5 (12.5%) had involvement of inguinal nodes. Thirty-one patients (77.5%) had complete response after chemoradiation. Only three patients (7.5%) developed chemotherapy-related grade 3 mucositis and myelosuppression. Radiotherapy-related toxicity included grade III cystitis in one patient and grade III proctitis in three patients. Three patients had post-treatment anal stenosis requiring repeated dilatation and two had chronic non-healing ulcers at the anal verge. Nine patients had failure of chemoradiation or disease recurrence; of these, only 5 could undergo salvage surgery. After a median follow up of 60 months, overall survival, disease-free survival and colostomy-free survival were 80%, 77.5% and 72.5%, respectively. CONCLUSION: Chemoradiation is effective in the treatment of squamous cell anal cancer and has acceptable toxicity. Surgical salvage may be useful in those with failure of this treatment.

Breast conservation therapy for breast cancer: patient profile and treatment outcome at a tertiary care cancer centre.

BACKGROUND: Breast conservation therapy is a well-established treatment modality for early breast cancer. It is not widely practised in developing countries because of a lack of awareness and treatment facilities, and physician and patient bias. We analysed our experience of breast conservation therapy. METHODS: We retrospectively reviewed 102 patients who had undergone breast conservation surgery and axillary dissection for breast cancer. Surgery was followed by 45 Gy of radiation to the whole breast and 15-20 Gy of tumour bed boost. All high risk patients received adjuvant systemic therapy. The disease profile, morbidity and treatment outcome were analysed. RESULTS: Out of 902 patients, 102 underwent breast conservation therapy (90 had early breast cancer and 12 had locally advanced breast cancer). Only 19.6% of patients with early breast cancer received breast conservation therapy. One-third of the patients had had a prior surgical intervention. The mean tumour size was 2.8 cm, 44% had nodal involvement and 29% were oestrogen- and progesterone-receptor negative. At a mean follow up of 32 months, only 1 patient had local recurrence, and the 5-year projected disease-free and overall survival were 82% and 88%, respectively. CONCLUSION: Breast conservation therapy should be offered to suitable breast cancer patients. Strict adherence to protocol-based therapy and active multidisciplinary coordination are crucial for a successful breast conservation therapy programme. Education of the patient as well as the physician population is necessary for increasing the breast conservation therapy rates in India.

Publications by radiation oncologists from India: a brief survey.

BACKGROUND: In India, the past three decades have seen a rapid growth of radiotherapy as a specialty. Has this led to an improvement in the quality and quantity of publications related to radiotherapy? To study this we evaluated publications by radiation oncologists of India from 1992 to 1998. METHODS: Twelve journals (5 Indian and 7 international) indexed in PubMed which publish radiation oncology-related papers were surveyed between January 1992 and June 1998 in terms of the content of the papers and institutional affiliation of the radiation oncologists from India. Of a total of 14 436 papers published during this period, 2562 were in Indian and 11 874 in international journals. We also evaluated the contents of the publications. RESULTS: The contribution of radiation oncologists from India accounted for 109 papers (0.75%)-64 (2.5%) and 45 (0.4%) in Indian and international journals, respectively. Three institutions from India contributed 52 of the 109 published papers (47.7%). Articles on radiation oncology from India constituted less than 1% of the surveyed publications. Also, publications with a 'good' scientific content formed a small part of the Indian radiotherapy publications. CONCLUSIONS: Collaborative studies, inter-institutional trials and randomized clinical trials relating to key oncological problems in India need to be carried out to establish consensus and guidelines at a national level.

Adenocarcinoma esophagus with choroid metastasis.

Metastases to the eye are rare and those from carcinoma esophagus are very rare, with only one report in the English literature. We report a 46-year-old man with adenocarcinoma of esophagus who developed isolated choroid metastasis after definitive treatment of the primary tumor.

Cutaneous metastasis from carcinoma of tonsil.

Hematogenous spread from carcinoma of tonsil is an uncommon event and skin is an extremely rare site of metastasis. We encountered a 40-year-old male patient who initially presented with carcinoma of the tonsil with T3N2cMO disease and treated by curative radiotherapy. After about 2 years, he developed a skin lesion in the periorbital region which on cytological examination turned out to be metastasis from tonsillar carcinoma. The present paper describes this rare case report along with a brief review of the literature.

Colorectal cancers--experience at a regional cancer centre in India.

BACKGROUND: The incidence of colorectal cancer (CRC) shows a wide geographic variation and India along with other Asian and African countries has a low incidence. Most patients present with advanced disease and no uniform treatment guidelines are followed at present. PATIENTS AND METHODS: An audit of 91 patients treated as per IRCH protocol between June 1994 and Jun 2000 in a single surgical unit was performed. RESULTS: The mean age of patients was 45.3 years (18-90 years) and there was a predominance of rectal cancer patients (Rectal vs Colon = 76% vs 24%). Majority of the rectal cancers were low rectal cancers (67%) and abdominoperineal resection was the commonest surgical procedure performed(40). The inoperability rate was 24% and sphincter salvage rate was 13%. Seventy nine percent of patients had adenocarcinoma and 90% of CRC patients belonged to Astler-Collers stage B2 and C. A total of 37 patients also received adjuvant radiotherapy and only 39 out of 60 patients planned for adjuvant chemotherapy could complete the treatment. The operative mortality was 2.2% and morbidity was 18%. A total of 13 (14%) patients had relapse of disease (local 5, regional 3, distant 5). CONCLUSIONS: A significant number of CRC patients in India present with advanced stage of disease and probably due to referral bias majority had low rectal cancers. By advocating multimodality protocols a good locoregional and systemic control can be achieved despite the advanced stage of presentation.

Palliative care education and training during residency: a survey among residents at a tertiary care hospital.

BACKGROUND: Palliative care is the active total care of patients in advanced and incurable stages of cancer. More than 70% of all cancer patients in India require palliative care for relief of pain, other symptoms and psychosocial distress. The need for education and training in palliative care has been emphasized by the World Health Organization (WHO) during the past 15 years. This survey aimed to assess the awareness, clinical knowledge, and education and training aspects of palliative care among the clinical residents of a tertiary care hospital. METHODS: During January and February 1999, a total of 100 residents were asked to respond to a questionnaire on palliative care education and training during residency. The questionnaire consisted of 10 questions (each question with 3 different responses). Awareness regarding palliative care was assessed by 3 questions; clinical knowledge by 4 questions; and education and training obtained during residency by 3 questions. Comparisons were made using the Chi-square test between the oncology and non-oncology resident groups. RESULTS: Forty-nine residents (23 oncology and 26 non-oncology) responded to the survey. Awareness that palliative care involves active total care was lacking in 8 (16%) residents. The cost of palliative care in India was considered high by 17 (65%) non-oncology residents and 21 (43%) of the whole group. Hospice, as the right place for palliative care, was chosen by 14 (61%) oncology and 3 (11.5%) non-oncology residents (p = 0.0003). In the whole group, 21 (43%) believed that palliative care could be provided on an outpatient basis. Pain, depression and cachexia were identified as the most distressing symptoms of patients with incurable cancer. Seventeen (83%) oncology and 4 (15%) non-oncology residents (p = 0.000) knew how to use the WHO step-ladder for cancer pain relief. All oncology residents and 10 (38%) non-oncology residents preferred the oral route for providing medications for pain relief (p = 0.0001). The didactic education and training imparted during residency was considered as 'not enough' by 39% of oncology and 62% of non-oncology residents (51% overall). The confidence to deliver quality palliative care was lacking in 43% and 58% of oncology and non-oncology residents, respectively. CONCLUSION: Clinicians in India need to be provided focused skills and training for them to be able deliver quality palliative care to the large number of patients with incurable cancer. The cost of palliative care and the optimum place to deliver it, the symptoms of advanced cancer, pain relief and symptom control methods and quality of life in end-stage cancer patients are some aspects that should be an integral part of clinical residency programmes.

Management of retinoblastoma with radiation.

OBJECTIVE: To evaluate the role of radiation therapy in the management of retinoblastoma. DESIGN: Retrospective analysis. METHOD: From January 1993 to March 1994, one hundred and eleven children (150 eyes) of retinoblastoma were referred for radiotherapy. The diagnosis was based on clinical examination and ocular ultrasonogram for both the eyes. The radiation treatment policy involved 40 Gy in 20 fractions over 4 weeks delivered with sedation for children under 1 year of age, 36 Gy in 9 fractions over 3 weeks under ketamine anesthesia for 1-4 years of age and for >4 years of age, a dose of 50 Gy in 25 fractions over 5 weeks. The initial tumor regression was evaluated by A and B mode ultrasonography and/or CT scan. RESULTS: The age distribution ranged from two months to six years (median - 20 months). Bilaterality was observed in 39 out of 111 cases (35%). The male to female ratio was 1.8:1. Eighty two of the 111 children were treated by definitive external beam radiation to one or both eyes. Fifteen cases received adjuvant radiotherapy after enucleation, and 14 had extensive disease for which palliative radiotherapy was offered. We observed a complete response in 54% of cases, partial response in 32%, and none in 14% of cases. Forty per cent (40%) eye survival was documented at the end of 28 months. The complication rate encountered was about 15%. CONCLUSION: Radiotherapy is an effective modality of treatment in significant number of patients with retinoblastoma. However, it requires appropriate fractionation, precise colimation and careful immobilization with general anesthesia.