A Pilot Study on the Addition of Tramadol or Eutectic Mixture of Local Anesthetics (Prilocaine Plus Lignocaine) to Local Lignocaine Infiltration for Prevention of Bone Marrow Aspiration/Biopsy Associated Pain.

Objectives Bone marrow aspiration although being a common procedure is associated with significant pain and its reduction remains an unmet need. We evaluated the use of tramadol and eutectic mixture of local anesthetics (prilocaine plus lignocaine) (EMLA) for reducing the severity of pain. Materials and Methods In this pilot study, we compared the addition of either tramadol 50 mg per oral (T) or EMLA local application (E) or no intervention (L) in addition to the usual procedure of local infiltration with lignocaine 2% before bone marrow aspiration and biopsy (BMAB) in adults suspected/confirmed with malignancy. Both, tramadol and EMLA were administered 1 hour prior to the procedure. Primary end point was reduction in pain intensity with these interventions compared with local infiltration alone. Pain was assessed using numerical FACES pain scale, a visual analogue scale. Secondary end points were to see the effect on pre procedure apprehension and to find out the other factors associated with increased pain related to the procedure. Statistical Analysis and Results A total of 300 patients were included in the study, 100 each in tramadol (T), EMLA (E), and only lignocaine local infiltration (L) arms, respectively. The mean pain intensity on the visual scale was significantly lower in the tramadol arm (T, E, L-3.4, 4.4, 4.7, respectively) ( p < 0.0005). There was a significant reduction in percentage of patients who experienced moderate/severe pain (four or more) in the tramadol arm (T, E, L-45, 77, 82%, respectively) ( p < 0.0005). Duration of procedure >10 minutes, body mass index >30, ECOG (Eastern Oncology Group) performance status ≥3, and age >50 years were positively correlated with more pain. Leukemia patients experienced significantly more pain compared with patients with lymphoma and other solid malignancies. Tramadol was well tolerated. No significant effect on pre-procedure apprehension was noted in any of the arms. Conclusion Tramadol appears to have a preventive effect on bone marrow aspiration/biopsy-associated pain and appears to be well tolerated, whereas EMLA was not associated with such an effect. Larger studies may be done to ascertain the same.

Primary non-Hodgkin's lymphoma of bone: poly-ostotic versus mono-ostotic subtypes.

Primary non-Hodgkin's lymphoma of bone (PNHLB) accounts for less than 5% of all primary bone tumours and less than 1% of all non-Hodgkin's lymphoma. Due to its rarity, only a few retrospective studies have been published describing the prognosis and its treatment. We report our experience of 20 cases of PNHLB with their clinicopathologic correlation that were treated at our centre over a period of ten years. There were 16 cases of the mono-ostotic subtype and four cases of poly-ostotic subtype. All of these had a histological diagnosis of diffuse large B-cell lymphoma. The age of presentation was fifth to sixth decade. The mono-ostotic subtype commonly presented with the involvement of femur or humerus, while the poly-ostotic subtype commonly had paraparesis due to vertebral involvement. Cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP)-based chemotherapy was given to all patients, but definitive radiotherapy was used only in the mono-ostotic subtype. At median follow-up of 38 months (range 5-96 months), event-free survival was 81% and 25% with mono-ostotic and poly-ostotic subtypes, respectively. Thus poly-ostotic PNHLB is a distinctive entity with a poor prognosis, and larger studies are needed for better management of this subtype.

Wilms' tumor: single centre retrospective study from South India.

Wilms' tumor is the most common malignant renal tumor in paediatric age group, and is classically managed by multimodal treatment which involves surgery, radiotherapy and chemotherapy. The last few decades have seen a dramatic change in the prognosis of this disease, which once was a uniformly lethal malignancy. While there is plenty of data in world literature on the outcome of Wilms' tumor, there is paucity of data from India. Hence, we conducted the present study to analyze the outcome of Wilms' tumor at our institute. To study the clinicopathologic profile and outcome of Wilms' tumor with NWTS (National Wilms' Tumor Study Group) IV protocol. Sixty-one patients with histopathological proven diagnosis of Wilms' tumor and had received treatment at our institute from Jan 2003 through Dec 2010 were included for analysis. Patients received treatment based on NWTS IV protocol. Patients were analysed for overall survival and event free survival and these outcomes were correlated with age, sex, stage at presentation and histology. Favourable histology which included focal anaplasia was found in 80.3 % while unfavourable histology was elicited in 19.7 % of the cases. The estimated 5 year event-free survival was 83.3 % and overall survival was 85.2 %. Tumour histology was the single most important factor predicting the survival. Patients with childhood Wilms' still present very late in our setting, this poses management challenges as large tumor are technically difficult to deliver at surgery. Histology has a crucial role in outcome of this disease. With multidisciplinary approach, similar survival rates to National Wilms' Tumor Study Group seems to be achievable even in Indian scenario.

Primary central nervous system lymphoma a report of nine cases.

Primary Central Nervous System Lymphoma (PCNSL) is a rare neoplasm of B cell origin and constitute less than 1% of Non-Hodgkin's lymphoma (NHL). Histology is mainly of high grade and intermediate type. Although NHL is known to be highly sensitive to both irradiation and cytotoxic drugs, being a curable malignancy, the therapeutic results remain disappointing. Clinical observations on nine cases of PCNSL seen in one of the major cancer centres in India is presented in this paper. Radiotherapy combined with Chemotherapy although yielded encouraging initial response in these patients, the long term response was unsatisfactory with median survival for these patients being only 19 months. This warrants an alternative therapeutic approach to improve the dismal prognosis of PCNSL.

Spinal cord compression by primary non-Hodgkin's lymphoma.

Epidural Cord Compression (ECC) by primary lymphomas is rare entity and constitutes less than 3% of total malignant lymphoma with Non-Hodgkin's Lymphoma (NHL), diffuse large cell type being the most common histological subtype. In this paper 16 cases of primary NHL with cord compression seen at the Department of Medical Oncology, during the period 1988-1990 are reviewed. At presentation all patients had undergone Laminectomy with decompression of epidural mass. The histological diagnosis of NHL was subclassified according to the International working formulation and was evaluated for disease process elsewhere in the body. All patients with ECC by lymphoma received high dose steroids with concurrent Radiotherapy (local) and combination Chemotherapy. These patients had longer duration of neurological deficit prior to treatment had poor response. After 6 courses of chemotherapy 50% of the patients had complete neurological recovery (CR), 31% had partial neurological recovery (PR) and in 19% there was no neurological recovery (NR).