Indian Journal of Cancer Education and Research

Third International Meeting of Clinical Practice Guidelines in Oncology–2014 and Indian Perspectives was conducted on December 20th 2014. The conference was organized by the unit of medical oncology, Sri Ramachandra University and Hospital, Porur, Chennai, India. Eminent people like oncologists, pathologists, radiologists, pediatric oncologists, medical practitioners, surgeons and about 500 delegates from all over the India participated and worked together to discuss treatment guidelines for most cancers such as colorectal, central nervous system, gastric, lung, renal cell, hepatocellular carcinoma, breast sarcomas, pancreas, pediatric, gynecological, hematological malignancies and supportive care. Of which, the case studies of Head and Neck cancer is given in this paper.

Keywords: Oncology; Hepatocellular Carcinoma; Breast Sarcomas; Pancreas. 

Introduction: HPV16 is the most common viral subtype associated with malignant transformation, ranging between 90% and 95% of all cases [8]. It is present in 86.7% of all HPVpositive oropharyngeal SCCs compared with 68.2% of HPVpositive oral SCCs and 69.2% of HPVpositive laryngeal SCCs [9]. Prevalence of HPV in oral cancers is similar in Europe (16%) and North America (16.1%), but greater in Asia (33%) [9]. Data from multiple studies have indicated that HPVassociated tumors account for 20% to 75% of OPSCC. Methodology: Patient who fulfill the inclusion criteria and his/her care takers were explained regarding the nature of the disease, radical treatment with concurrent chemo radiation, its effectiveness and possible side effects. Patient were counseled about the ill effects of tobacco and alcohol consumption and asked to discontinue the same. Patients were also counseled regarding maintenance of good oral hygiene throughout the treatment, good nutritional support, adherence to the planned treatment. Results: In arm A, 60%(9/15) of patients had oral cavity cancer, 13.3%(2/15) of patients had oropharyeal cancer and 26.6% (4/15) patients had hypopharyngealcancer. In arm B, 65. 7% (23/35) of patients had oral cavity cancer, 8.5%(3/35) of patients had oropharyneal cancer, 5.7% (2/35) patietns had laryngeal cancer, 2.8%(1/ 35) patients had were in nasopharyeal cancer and 17.1%(6/35) were in hypopharyneal cancer. Conclusion: No association found in nodal (N) stage at presentation between HPV positive and negative tumors.

Keywords: HPV; Nasopharyeal Cancer; Head and Neck Cancer. 

Introduction: The HPV prevalence in India ranges from 33.6% in the Eastern region to 67% in South India and 15% in Western India. The prevalence of HPV6, HPV11, HPV16, and HPV18 were 13%, 20%, 42%, and 47%, respectively. HPV16 was most common, followed by HPV18 and then cross infection (16 and 18); 41% of patients had multiple HPV infections. Methodology: A total of 50 patients with histo pathologically proven head and neck cancer were enrolled into the study. All the patients were given concurrent chemo irradiation after fulfilling the inclusion / exclusion criteria. Patients were enrolled into the study after basic investigations such as CBP, RFT, histopathology and metastatic workup with chest radiograph and ultrasound of abdomen was performed and found to be within normal limits. Results: Out of 50 patients 15 were positive for HPV (P16) and 35 were negative. Prevalence of HPV in HNSCC was 30%. All HPV positive patients were allotted to Arm A and rest of patients were Arm B. Conclusion: No significant association was found between habits like smoking, alcohol and betel nut chewing and HPV infection.

Keywords: HPV Infection; Head and Neck Cancer; Smoking. 

Introduction: Cervical cancer is the second most common cancer in women worldwide and in India, the fifth most common cancer in humans. Two new techniques of radiation therapy in cervical cancer have been widely shown interest in treatment, i.e., IMRT and VMAT. VMAT has proven superiority over conventional radiotherapy with regard to dose conformity and organ sparing. Aim: In this present study, we propose to compare VMAT with IMRT in terms of target coverage (homogeneity and conformity indices) and dose to organs at risk (OARs) by means of dosimetric studies in patients of cervical cancer. Materials and Methods: The present study was conducted in Inlaks & Budhrani hospital, a state of art cancer institute from September 2013 to February 2015 to compare the technique of VMAT to IMRT. All the cervical cancer patients as per inclusion and exclusion criteria who opted for either VMAT or IMRT were included in our Study, Thus a total of 63 patients were recruited of which 33 opted for IMRT and 30 opted for VMAT. Results: 98% of the patients included in our study were in the age group of 4069yrs. Age didn’t show to affect the results of the acute or chronic toxicities during our study period. 76% of VMAT patients and 67% of IMRT patients were of Stage IIB. Stage IIB was the most common stage of presentation in our study. After it, 23% of VMAT patients and 27% of IMRT patients were of Stage IIIB. FIGO stage is an established prognostic factor for survival. Both the techniques have almost similar number of patients of same stage of disease. Squamous cell carcinoma was the most common histopathological diagnosis in 89% of the patients combined.. VMAT proved to be better than IMRT when it comes to mean dose to bladder and rectum, and it was statistically significant. VMAT failed to show superiority over IMRT in mean dose to bowel bag, right and left femoral head. VMAT and IMRT reported similar target coverage. Uniformity index, heterogeneity index and conformity index between the treatment techniques didn’t show any difference. VMAT didn’t prove to be superior over IMRT when it comes to acute and chronic toxicities of gastrointestinal, genitourinary or hematological systems. Conclusion: Within limitations of the present study we found no significant difference between IMRT and VMAT was observed except VMAT showed superiority to IMRT only in minimizing dose to bladder and rectum

Keywords: Cervical Cancer; VMAT; IMRT. 

Background: Colorectal cancer (CRC) is the fourth most common cancer in the world. Its incidence varies worldwide being high in western countries and in older age group and low in developing countries. Though relatively uncommon in developing counties a raising incidence is seen in Asian population. Aim: The aim of the study is to analyse the incidence of Colorectal cancer in a tertiary health care centre, Materials and Method: at our center by year, age, and gender from a retrospectively collected data of about 1275 patients from 2013 to 2016. Results: The number colorectal cancer cases yearly increased at a rate of 2.3%. Rectal cancer incidence is more in males, compared to females. Though colon cancers are more in males, in the study, the rate of increase in incidence is more in females. Rectal cancers increased at a rate of 2.4%.The observations show that the incidence is more in middle adulthood (4160) age group i.e., about 51%, followed by older age group i.e., about 23.8%, followed by younger age group of about 23.6%. Conclusions: Considerable efforts should be made to increase public awareraness on early diagnosis and screening and life style modification.

Keywords: Colorectal Cancer; Screening; Life Style Modification. 

We report a retrospective study of Solid Pseudo Papillary Tumor (SPPT) of the pancreas, a rare entity, which is a low grade malignant abdominal tumor at manyinstitute; this is relatively frequent in young women, with a discussion about its presentations and management. In our study we report 20 Solid pseudo papillary tumors of pancreas over a period of 10 year. 15 out of 20patients in our study were female with the median age at diagnosis was 27.25 years (range 1158 years). Abdominal pain and lump were the most common presenting complaints. Median size was 10 cm (range 317 cm) Distal Pancreatectomy(11 pts) and Pancreaticoduodenectomy (6pts) were the most common surgeries performed. 2 patients were inoperable and in one patient wide excision were done. Diagnosis of Solid pseudo papillary tumors of pancreas should be considered in young women presenting with a large solid cystic pancreatic mass and the treatment of choice consists of surgical resection. The outcome after surgical resection is excellent with long term survival of 90%.

Keywords: Solid Pseudo Papillary; Rare Tumor; Multi Centric; Pancreas.

Aim: To evaluate the changes in pulmonary function with concurrent chemoradiation. Materials and Methods: We analyzed 60 patients who had received 60 Gy radiotherapy, chemotherapy for primary NSCLC who had undergone pulmonary function tests (PFTs) before and within one year after treatment. Before every cycle of chemotherapy, pulmonary function tests were done. Postradiation PFT values (percentage of predicted) were evaluated amongst individual patients compared to the same patient’s preradiation value at the following time intervals: 0 to 4 months, 5 to 8 months, and 9 to 12 months. Results: Lung diffusing capacity for carbon monoxide (DLCO) is reduced in the majority of patients along the 3 time periods after radiation, whereas the forced expiratory volume in 1 second per unit of vital capacity (FEV1/VC) showed an increase and decrease after radiation in a similar percentage of patients. There were baseline differences (stage, RT dose, concurrent chemotherapy) among the radiation technology groups. On multivariate analysis, the following features were associated with larger post treatment declines in DLCO: pretreatment DLCO, gross tumor volume (GTV), Only pretreatment DLCO was associated with larger posttreatment declines in FEV1/VC. Conclusions: DLCO is reduced in the majority of the patients after chemoradiation.

Keywords: Radiotherapy; Chemotherapy; pulmonary function tests (PFTs). 

Background: Cervical cancer is the second most common cancer among women worldwide. Despite strong evidence that cancer screening saves lives through early detection and treatment, there is lack of empirical studies on it. Cervical cancer is a global health problem and the most common cancer in women living in subSaharan Africa. Worldwide, about 500,000 new cases are diagnosed every year with at least 288,000 deaths. About four out of every five new cases and most of the deaths from cervical cancer occur in the developing world. The highest mortality rates have been reported in Western and Southern Africa, Southern and Central America, Caribbean and South Central Asia. Cervical cancer unlike other gynaecological cancers is a preventable disease because it has a preinvasive phase that can be detected and treated if women are screened for it. Objectives: To assess the knowledge, awareness, perception and behavior of female healthcare workers in Oshimili South LGA of Delta State towards cervical cancer and its screening. Methods: A crosssectional descriptive study done from January to March 2014. Multistage sampling technique was used in the selection of the LGA and study participants. Data was collected using a semistructured questionnaire and were analyzed using SPSS version 17. Results: A total number of four hundred and twenty four (424) female healthcare workers were interviewed. The mean age was 36.5 years and the ages ranged from 21 to 58 years. A total of 389 respondents (92.8%) were aware of cervical cancer. A total of 238 respondents (56.1%) knew about pap smear screening test. The most common risk factors for cervical cancer were early onset of sexual intercourse (25.7%), followed closely by multiple sexual partners (18.0%). Eighty five point one percent (85.1%) of the respondents are aware that early detection of cervical cancer could help improve prognosis; while 73.3% would like to do pap smear; 24.8% have done pap smear and 64.9% would require their husbands consent to do pap smear. Conclusion: This study revealed a high level of awareness of cervical cancer and an average level of awareness of pap smear screening test among this group. A poor knowledge of cervical cancer risk factors was also observed. Marital status was found to significantly influence the level of awareness of cervical cancer and its screening. Educational level and Age did not have significantly influence on the knowledge of cervical cancer and its screening.

Keywords: Knowledge; Cervical Cancer; Screening; Health Workers. 

Aim: To assess the toxicity differences between neo adjuvant and adjuvant chemo radiation in carcinoma rectum. Materials and Methods: Patients who underwent neoadjuvant or adjuvant chemoradiation for carcinoma rectum were enrolled into study. The total number of patients 30 (neoadjuvant 15+ adjuvant 15). All patients with histopathological diagnosis of carcinoma rectum. Adenocarcinoma of rectum. Patients belonging to M0 (without metastasis. Results: Majority of the patients in this study were males in both neoadjuvant (80%) and adjuvant arms (73.3%) Majority of tumours in neoadjuvant arm were in lower rectum and majority of tumours in adjuvant arm were in upper & lower rectum. Both neoadjuvant and adjuvant arm were of moderately differentiated adenocarcinoma histology. Majority of patients (except four patients) had pathological node positive disease. The difference in yield of lymphnodes between the groups were statistically significant as assessed by two tailed t test P = 0.023. Similarly number of positive lymphnodes were more in patients who underwent surgery first (mean ± SEM = 6.33 ± 2.12) compared those who underwent neoadjuvant concurrent chemo radiotherapy and then underwent surgery (mean ± SEM = 0.28± 0.28), the difference is statistically significant P <0.0001. In neoadjuvant arm one patient had perineural invasion & one patient had lymphovascular invasion, where as in adjuvant arm none of the patients had perineural invasion but one patient had lymphovascular invasion. in neoadjuvant arm majority of patients had pathological T1 status, where as in adjuvant arm majority of patients had pathological T3 status. In neoadjuvant arm most of the patients had pathologically node negative status, where as in adjuvant arm 5 patients had pN2b, 4 patients had pN0, 2 patients had pN1a and 2 patients had pN2a. In the neoadjuvant arm only one patient had pathological positive lymphnodes. In neoadjuvant arm majority of patients had pathological T2 status, where as in adjuvant arm majority of patients had pathological T3 status. In neoadjuvant arm most of the patients had pathological node negative status, where as in adjuvant arm 5patients had pN2b, 4patients had pN0, 2 patients had pN1 and 2 patients had pN2a. In neoadjuvant arm most of the patients were pathological stage 0, I & IIA, where as in adjuvant arm most of the patients were pathological stage IIIB & IIIC. In neoadjuvant arm most of the patients were pathological stage IIA, I and 0, where as in adjuvant arm most of the patients were pathological stage IIIC & IIIB. 3 patients had complete response and 12 patients had partial response. Conclusion: Pathologic response (p CR& p PR) in patients who underwent Neoadjuvant chemo radiotherapy arm was good. Chemo radiotherapy down staged the tumour in all patients in the neoadjuvant arm. Haematological toxicities were more pronounced in Neoadjuvant arm, while Gastrointestinal and Genitourinary toxicities were more in Adjuvant arm.

Keywords: Colorectal Cancer; Neoadjuvant Chemo Radiotherapy; Haematological Toxicities. 

Aim: The aim of the present study is to compare the acute toxicities between the accelerated course of hypo fractionated whole breast irradiation and conventional standard fractionation of Radiotherapy. Objectives: To determine the acute toxicities of skin. To determine the influence of breast volumes on acute skin toxicities. Materials and Methods: This is a single institutional prospective trial done in females who are known cases of early breast cancer treated by breast conservation therapy and referred to the department of radiotherapy for radiation. These patients meet the inclusion and exclusion criteria. This was conducted in Department of Radiation Oncology, MNJ institute of oncology and regional cancer centre, red hills, Hyderabad. A total of 40 cases were included in the study. 20 cases in the study arm and 20 cases in the control arm. The study is conducted during the period of august 2014 to November 2016. Inclusion Criteria was that age was 2080 years, ECOG performance score of 12, pathologically proven breast cancer, treated with breast conservation surgery, margins negative, AJCC stage 1 and 2 i.e. T1T 2, N0N 1. Exclusion Criteria was age <20 years and >80 years, bilateral breast cancer, prior H/O radiation to chest, metastatic disease at presentation, patients who do not give an informed consent. Results: Out of 40 patients, 20 patients were in the conventional arm and 20 patients were in the hypo fractionated arm. Compared to patients in the CF arm, patients in the hypofractionated arm had lesser number of grade 2 or more acute skin reactions. There was no statistical significance between the volume of breast and severity of reactions in the study. As there was homogenous dose distribution in the PTV (100 ± 7), there was no correlation between\ Dmax and the skin toxicities. As the follow up period was less, no comments could be made regarding local control rates and distant metastases. Hypofractionated radiotherapy had logistical advantages like less hospital stay, lesser financial expenditure and lesser burden on the radiotherapy equipment and personnel. Hence, hypofractionated radiotherapy can be safely practiced as an alternative to conventional fractionation. Conclusion: A comparative analysis of acute toxicities in hypofractionated radiotherapy vs standard fractionation in early breast cancer post breast conservation therapy was performed. No conclusion can be drawn from our study about locoregional recurrence because of the very short follow up period.

Keywords: Hypofractionated Radiotherapy; Breast Conservation Therapy. 

Context: Malnutrition among cancer patients is a frequent problem and has been observed in 40 and 80% patients. It is a more common problem in patients with head and neck cancer owing to the nutrition impact symptoms. It incidence has been found between 3050% in various studies. Aims: The purpose of this study was to assess the nutritional status using PGSGA and its correlation with performance status in patients with Head & Neck cancer. Material & Methods: Fifty one patients of proven Head and Neck Cancer were assessed using scored Patient Generated Subjective Global Assessment (PGSGA), SGA classes and functional status was scored using Karnofsky

Performance Scale (KPS). Results: Mean age was 50.78 years. Site wise distribution was as: Oropharynx25% (13/51), Hypopharynx8.0% (4/51), Nasopharynx2% (1/51), Larynx12% (6/51) and Oral cavity53% (27/51). Mean PGSGA Score was 7.72. The prevalence of malnutrition was eighty one percent (41/51) patients as assessed by scored PGSGA and SGA classes. Median KPS was 70. Eight one percent patients had compromised performance status as assessed by KPS. Scored PGSGA, SGA and KPS were significantly correlated (r=. 934, p<0.00001 and r=0.868, p<0.00001) respectively. Conclusion: Patients with Head & Neck Cancer have a high prevalence of malnutrition. Scored PGSGA and SGA classes can be used to assess malnutrition and are significantly correlated with performance status assessed using KPS.

Keywords: Head and Neck Cancer; Malnutrition; PGSGA; KPS. 

Aim: To compare toxicities and outcome in head and neck cancers patients treated with IMRT and 2D conformal radiotherapy along with concurrent chemotherapy. Materials and Methods: Patients presenting to the Department of Radiation oncology with head and neck squamous cell cancers TNM staging T14 N03 M0. Twenty patients of head and neck cancer and 20 undergoing conventional 2DConformal Radiotherapy alone served as controls were included in this study. Results: Most of these patients were found to be in highly advanced stage of disease with poor nutritional status and poor performance status (stage III and IVA) at the time of diagnosis. All the 40 patients received concurrent cisplatin chemotherapy. All the patients were examined and graded for mucositis, dysphagia, xerostomia, skin reactions and tumor response. This study was conducted to compare whether Simultaneous Integrated BoostIntensity Modulated Radiotherapy (SIBIMRT) could reduce radiotherapy induced acute mucositis, dysphagia, xerostomia and increase tumor response and tolerance to it in head and neck cancer patients compared to standard conventional Radiotherapy. IMRT may have had a role in reducing the incidence, delaying the onset & diminishing the severity of mucositis in some patients. However it did not completely prevent the occurrence of mucositis. Our study demonstrated that the IMRT may not reduce the incidence of dysphagia. It may be because of high dose per fraction in IMRT delivered to swallowing apparatus. IMRT reduced the incidence of xerostomia. Also the duration of xerostomia was decreased by IMRT. IMRT was also able to reduce the dose to parotids along with adequate coverage of planning target volume. Submandibular glands received less doses, particularly in hypopharyngeal and nasopharyngeal cancers. The contralateral parotid in all IMRT patients were within the tolerance dose of 26 Gy of mean dose. In few selected IMRT patients depending on the primary site, ipsilateral parotid were confined to their tolerance doses of 26 Gy of mean doses. Our study did not show any benefit for tumor response due to IMRT. However the incidence of recurrence is reduced due to IMRT. Conclusion: IMRT offers a safe, effective, reduction of normal tissue dose in head and neck cancer patients undergoing radiotherapy & was generally well tolerated. Hence we recommend using IMRT in head and neck cancer patients undergoing radiotherapy in order to reduce RT induced acute mucositis and xerostomia. 

Aim: To clinically determine the treatment response and locoregional control in locally advanced oral cavity cancers with concurrent chemoradiation and radiation alone. Materials and Methods: This study was carried out in department of Radiotherapy, MNJ Institute of Oncology & Regional Cancer Center, Hyderabad from October 2010 to April 2012. A total of 50 patients with histologically proven squamous cell carcinoma of oral cavity was enrolled in this study. In this prospective study, patients were randomized to receive either chemoradiation alone (arm –A) or radiotherapy alone (armB). Response rate & locoregional control are primary end points, toxicity profile and feasibility are secondary end points. Inclusion Criteria: Patients with age < 60 years, both sexes. Patients with histologically proven advanced squamous cell cancer of the oral cavity (stage III & IV). Karnofsky’s performance scale  70. Haematopoietic : Hemogram >10 gm /dl, Total WBC count > 6000/mm3 and Platelet count > 1,00,000/ mm. Renal: Serum creatinine ï‚£1.5 mg/dl (or) creatinine clearance 60 ml/min, Hepatic : Bilirubin ï‚£ 1.5 times upper limit of Normal (ULN), AST (or) ALT < 2 times of ULN. Alkaline phosphate ï‚£ 1.5 times ULN , Normal chest Xray. Exclusion Criteria: Patients with age above 60 years. History of previous treatment with any of the following modalities–Surgery, radiotherapy, chemotherapy. Patient with distant metastasis. Hemoglobin <10 gm%. Associated comorbid conditions: Untreated tuberculosis, Uncontrolled diabetes mellitus and Uncontrolled Hypertension. Results: In this prospective study conducted from October 2010 to April 2012, a total of 50 patients proven cases of squamous cell carcinoma of oral cavity were enrolled, 25 patients in chemoradiation (armA) and 25 in radiotherapy alone (armB). Out of which 2 patient dropped out in armA. 23 patients in chemoradiation arm received cisplatin 40 mg/m2/ week for 6 cycles with Radiotherapy (66 Gy in 33 Fr 2 Gy/Fr, 5 days in a week) and 25 patients in radiation alone arm received 66 Gy in 33 Fr 2 Gy/Fr, 5 days in a week. There was good balance in prognostic factors, including performance status, tumor and nodal stages and histology between the two arms. buccal mucosa is predominant site of distribution in both arms. TNM Stage in armA, among 23 patients, 8 were in stage III and 11, 4 in stage IVA and IV B and in armB, out of 25patients, 8 in stage III and 13, 4 in stage IV A and IV B, respectively with a probability value (P=0.94) for stage. All the 100% patients in both arms completed the radiation procol that is 66 Gy in 33 Fr 2 Gy/Fr, 5 days in a week for 6.5 weeks. In armB (n=23), when compliance to chemotherapy considered, majority completed 6 cycles of chemotherapy. 87% (20/23) patients completed the full course of 6 cycles of chemotherapy. Only 13%(3/23) patients received cycles of chemotherapy. The complete response of primary tumor with T3 stage in chemoradiation arm was seen in 65%(5/8)and partial response in 35% (3/8) of the patients. The corresponding figures in the radiation alone arm were 50%(4/8) and 50% (4/ 8) respectively. The complete response seen in patients with T4a and T4b tumors in chemoradiation arm was 45%(5/11), 30%(1/4) and partial response was 55%(6/11) , 70%(3/4) while in the radiation alone arm, it is 35%(5/13), 20% complete response and 65% (8/13). 80% partial response. The median time to response from the end of the radiation was 3 months. Conclusion: Despite statistical insignificance locoregional control (tumor response) is superior (numerical benefit) with concurrent chemoradiation as compared to radiotherapy alone in locally