Low Cost, Low Dose, Oral, Neoadjuvant Chemotherapy Protocol in Locally Advanced Borderline Oral Cancers-Feasibility Study.

A vast majority of oral cancer patients in developing countries present in an advanced stage with borderline resectable/inoperable stage to busy resource-constrained tertiary cancer centers. Conventional chemotherapy protocols are associated with issues like toxicity, tolerance, cost, and compliance. The present study was conducted to assess the feasibility of low-cost home-based chemotherapy options. Single-arm feasibility study was done in borderline resectable/inoperable oral cancer patients. Home-based oral neoadjuvant chemotherapy consisting of oral methotrexate 15 mg/m2 once a week and oral celecoxib 200 mg twice daily for 8 weeks was used. RECIST Criteria 1.1 was used to assess response to therapy. The study included 60 patients. The mean age was 51.98 years with male predominance (80%). Fifty-five patients adhered to the treatment; the compliance rate is 91.60%. Affordability (Rs 700 per month) and tolerance to therapy was 100%, and no grade III or IV toxicity was seen. Overall, 18 patients had stable disease (32.73%), partial response was seen in 15 patients (27.27%), and the disease progressed in 22 patients (40%). At the end of 8 weeks, 26 (43.3%) patients were deemed resectable. Neoadjuvant low cost, home-based metronomic chemotherapy using oral methotrexate and celecoxib seems to be a viable option in managing advanced oral cancer in resource-constrained setups.

A multimodality approach to sinonasal undifferentiated carcinoma: a single institute experience.

BACKGROUND: Sinonasal undifferentiated carcinoma is a rare aggressive tumour arising from the Schneiderian epithelium lining the sinonasal tract. Although considered the cornerstone of therapy, surgical resection can only be performed in a limited number of patients. This report describes the experience of treating sinonasal undifferentiated carcinoma with a multimodality approach. METHOD: The treatment charts of sinonasal undifferentiated carcinoma patients treated at a tertiary care centre from 2004 to 2012 were retrospectively reviewed. RESULTS: A total of 16 sinonasal undifferentiated carcinoma patients with a median age at diagnosis of 47.5 years (range 8-65 years) were included: 19 per cent had neck nodal metastasis at presentation. Four patients (25 per cent) underwent surgery: of these, two had post-operative radiotherapy, one had pre-operative radiotherapy and one had adjuvant chemotherapy alone. Six patients (38 per cent) received definitive radiotherapy: five had received neoadjuvant chemotherapy to reduce tumour size and help in radiotherapy planning, while four (25 per cent) received palliative radiotherapy. The median follow up was 10.4 months (range 1-42.5 months). The estimated median progression-free survival time was 29.3 months. One- and three-year progression-free survival rates were 77 per cent and 41 per cent, respectively. CONCLUSION: Surgery is the best treatment option for sinonasal undifferentiated carcinoma, although most patients require post-operative radiotherapy for advanced disease and close tumour margins. Definitive radiotherapy with or without chemotherapy may be suitable for patients with inoperable locally advanced disease. Elective nodal irradiation to address the high nodal involvement rates should be considered to improve the survival rate.

Aspiration pneumonia related deaths in head and neck cancer patients: a retrospective analysis of risk factors from a tertiary care centre in North India.

BACKGROUND: Aspiration pneumonia is an important cause of death in head and neck cancer patients. This study therefore aimed to evaluate the risk factors associated with aspiration pneumonia in head and neck cancer patients. METHODS: Hospital death records from 12 years (2000-2012) were reviewed to obtain the number of deaths. Treatment details and cause of death were analysed. Statistical analysis was performed to identify the risk factors for aspiration pneumonia. RESULTS: The records revealed that aspiration pneumonia was the cause of death in 51 out of 85 patients. Primary tumour site (oropharynx and hypopharynx, odds ratio 3.3; 95 per cent confidence interval 1.17-9.4, p = 0.02) and advanced tumour stage (odds ratio 4.2, 95 per cent confidence interval 1.16-15.61, p = 0.02) had significant negative impacts on aspiration pneumonia related mortality. CONCLUSION: Advanced pharyngeal cancer patients are at an increased risk of aspiration pneumonia related death. Investigations for the early detection of this condition are recommended in these high-risk patients.

Long-term treatment outcomes of juvenile nasopharyngeal angiofibroma treated with radiotherapy.

Juvenile nasopharyngeal angiofibroma (JNA) is a disease of adolescent males characterised by high vascularity with local aggressiveness. This analysis was intended to see the effectiveness of radiation in locally advanced JNA. We included patients treated from 1990-2012. A total of 31 patients met study criteria. Median age was 16 years (range: 12-33 years). Radiation was used for refractory, residual or unresectable locally advanced disease. The median radiation dose was 30 Gy (range: 30-45 Gy). Median follow-up was 36 months (Range: 1-271 months). The median progression-free survival [PFS] was not reached. PFS at 3, 5 and 10 years was 91.7, 70.7 and 70.7% respectively. Three patients progressed at 38, 43 and 58 months after completion of treatment and opted for alternative therapy. One patient developed squamous cell carcinoma of the nasal ale 15 years after radiation.

Re-irradiation in head and neck cancers: an Indian tertiary cancer centre experience.

OBJECTIVE: To explore the treatment outcomes of patients treated with re-irradiation for recurrent or second primary head and neck cancer. METHOD: An analysis was performed of 79 head and neck cancer patients who underwent re-irradiation for second primaries or recurrent disease from January 1999 to December 2011. RESULTS: Median time from previous radiation to re-irradiation for second primary or recurrence was 53.6 months (range, 2.7-454.7 months). Median age at diagnosis of first primary was 54 years. Median re-irradiation dose was 45 Gy (range, 45-60 Gy). Acute grade 3 or worse toxicity was seen in 30 per cent of patients. Median progression-free survival for recurrent disease was 15.0 months (95 per cent confidence interval, 8.33-21.66). The following factors had a statistically significant, positive impact on progression-free survival: patient age of less than 50 years (median progression-free survival was 29.43, vs 13.9 months for those aged 50 years or older; p = 0.004) and disease-free interval of 2 years or more (median progression-free survival was 51.66, vs 13.9 months for those with less than 2 years disease-free interval). CONCLUSION: Re-irradiation of second primaries or recurrences of head and neck cancers with moderate radiation doses yields acceptable progression-free survival and morbidity rates.

Concomitant chemoradiation versus radical radiotherapy in advanced squamous cell carcinoma of oropharynx and nasopharynx using weekly cisplatin: a phase II randomized trial.

BACKGROUND: To know the effectiveness and tolerance of weekly cisplatin added to radiotherapy (RT) in advanced carcinoma of oropharynx and nasopharynx. PATIENTS AND METHODS: Stage II-IV cancer patients were randomly assigned to either radical RT, 70 Gy/35 fractions over 7 weeks (RT arm), or chemoradiotherapy (CRT), cisplatin 40 mg/m² weekly for seven doses plus RT. Primary end points were (i) the responses, (ii) toxicity profile, and (iii) overall survival (OS) in two groups. Study period was from June 2003 to July 2005. RESULTS: One hundred and fifty-three patients were randomly allocated to the study, 76 in RT arm and 77 in CRT arm. Seventy-one in each arm completed the planned treatment; complete response (CR): 67.1% versus 80.5% in RT and CRT arms (P = 0.04). Grade III and IV toxicity were 16% and 40% in RT and CRT arms, respectively (P = 0.01). There were frequent treatment interruptions (9.3% versus 28.9%; P = 0.003) and hospitalization (20% versus 40.8%) in the CRT group. OS was superior in the CRT arm (P = 0.02): 27 months [95% confidence interval (CI) 15.2-36.8] for RT versus not reached for CRT. Three-year OS was 42% for RT and 62% for CRT group. CRT and CR were independent prognostic factors. CONCLUSION: This trial on Indian head and neck squamous cell carcinoma patients confirms that the use of weekly cisplatin is safe and CRT is superior to RT alone resulting in higher OS.

Primary epithelioid angiosarcoma of the breast masquerading as carcinoma.

Here we report a case of primary epithelioid angiosarcoma (eas) of the breast occurring in a 30-year-old woman. Following fine-needle asspiration cytology (fnac) and tru-cut biopsy, the patient was initially diagnosed with mammary carcinoma and thereafter underwent modified radical mastectomy. Postoperative histopathologic examination and immunohistochemistry revealed a diagnosis of primary epithelioid angiosarcoma of the breast. The patient received postoperative radiotherapy to the chest wall and was started on adjuvant thalidomide. Preoperatively, eas can be mistaken for carcinoma because it is difficult to appreciate the typical morphology on fnac or tru-cut biopsy. Indeed, this is an area of potential diagnostic error because, nowadays, neoadjuvant therapy is often instituted after core biopsy of a breast mass. This case is being reported not only for its diagnostic difficulty, but also because of its rarity in English literature.

Palliative radiotherapy in paediatric malignancies.

INTRODUCTION: Providing effective palliative treatment in childhood malignancies is a challenging task. This study evaluated the role of palliative radiotherapy in the management of incurable paediatric malignancies. METHODS: Records of 40 paediatric patients treated between January 2003 and November 2005 were reviewed and analysed retrospectively. All had received palliative external beam radiotherapy for symptom control either as a single modality or in addition to surgery, chemotherapy and drugs for symptomatic relief. RESULTS: Predominant symptoms noticed were swelling with or without pain, bleeding, and weakness of limbs. Median duration of symptoms was 90 days. Malignant round cell tumours were most common followed by retinoblastoma, neuroblastoma, Ewing's sarcoma and acute myeloid leukaemia with chloromas. 45 percent of children had disseminated disease at presentation. Nine underwent surgery, while 32 patients received chemotherapy, and all but two received drugs for symptomatic relief in addition to palliative radiotherapy. Dose schedules were either 5 Gy or 8 Gy in single fraction, while for fractionated radiotherapy, the range was 20 Gy in five fractions to 30 Gy in ten fractions. With regard to symptomatic relief, four patients had complete relief, 20 showed good relief, 15 had little and one did not have any relief. On completion of multimodality treatment, tumour response was complete in two patients, 18 had partial response, eight had stable disease, eight had progressive disease, and the disease status of four was unknown. CONCLUSION: The role of radiotherapy as a palliative modality in children with locally-advanced lesions provides better symptomatic relief in combination with other treatment modalities.

Vascular surgery is an unattractive career option for current basic surgical trainees: a regional perspective.

INTRODUCTION: The workload of vascular services will substantially increase in the foreseeable future with the recent changes in surgical training presenting a challenge to training and recruitment in vascular surgery. This study aimed to determine the current feelings towards vascular surgery as a career choice from basic surgical trainees (BSTs) within a single region. MATERIALS AND METHODS: BSTs from a single region were questioned. Probable career specialty choice was ascertained, as were suggestions for changes to the career pathway of a vascular surgeon to make it a more attractive career choice. RESULTS: Seventy-seven of 110 BSTs returned the questionnaire. Of the 77, 52 had previous experience of a vascular firm. Ten BSTs had been on a pure vascular firm as an SHO and 52 had been on a general surgical firm. No BST specified vascular surgery as their ultimate career choice. Career choices included general surgery (n = 30), orthopaedics (n = 17), plastic surgery (n = 9) and urology (n = 5). Thirty-three BSTs would not be tempted at all to a career in vascular surgery. Changes in the career structure that would result in BSTs contemplating a career in vascular surgery included the inclusion of endovascular surgery (n = 13), no compulsion to undertake a period of research (n = 5), pure vascular training (n = 2), more general surgical training (n = 2) and less onerous on-calls when older (n = 2). CONCLUSIONS: The lack of trainees wishing to become vascular surgeons is of grave concern. Increasing the endovascular capabilities of vascular surgeons as well as altering the stance on research may have an increasingly positive role in recruitment.

Periorbital tuberculosis.

An observational case series of seven cases of periorbital tuberculosis, a rare tubercular presentation occurring in patients with and without systemic disease, is presented. Non-healing sinus and osteomyelitis of periorbital flat bones was observed. All cases had a positive Monteaux test and PCR. AFB cultures of the sinus discharge were negative. The response to triple-drug therapy was dramatic. Follow-up at the end of one year showed clinical recovery. The authors stress the need for a high index of suspicion in cases of non-healing lesions and atypical inflammatory presentation in the periorbital region.

Association of lignifying enzymes in shell synthesis of oil palm fruit (Elaeis guineensis--dura variety).

Scanning electron microscopic (SEM) observation demonstrates the differentiation of mesocarp and endocarp tissues and their lignified nature in dura fruits at 8 weeks after pollination (WAP). During shell formation, the endocarp cells become lignified to a hard shell while the mesocarp tissue remains cellular and fibrous. A transition zone made up of fibrous units was also visible beneath the shell. The soluble phenols of mesocarp and endocarp tissues at their developmental stage was analyzed using Reverse phase high performance liquid chromatography (RP-HPLC). The appearance of ferulic acid at 4 WAP and its absence at 8 WAP indicates the role of ferulic acid in lignin synthesis. The HPLC data was supported by the lignin concentration. To ascertain the biochemical relationship of lignin pathway enzymes, phenylalanine ammonia lyase (PAL), cinnamyl alcohol-NADPH-dehydrogenase (CAD) and peroxidase (POD) with shell synthesis, the activities of these enzymes and lignin content were assessed during development of the shell between 4 and 8 WAP. The three enzymes, PAL, CAD and POD expressed high level of activity in the mesocarp and endocarp at 4 WAP. At 8 WAP a sharp decline in activity was observed in the endocarp whereas the mesocarp showed a moderate reduction. This variation is an indication of the role of these enzymes in shell formation.