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, a case study of lung is discussed in this paper.

Keywords: Case Study; Lung Cancer; Clinical Practice.

Hypoxia is characterized as a decrease oxygen levels in tissue, represents a fundamental pathophysiological condition in the microenvironment of solid tumors. The key component of hypoxia sensing in the cell is the hypoxia­inducible factor (HIF), a transcriptional activator that mediates adaptive responses to hypoxia. HIF is a heterodimer comprising an oxygen­regulated a­subunit (HIF­1a) and a constitutively expressed b­subunit (HIF­1b). HIF­1 activity increases in the majority of human cancers and acts as a master transcription factor that has received the most intense attention in the field of cancer biology. The stability and activity of HIF­1 are regulated by its post­translational modifications such as hydroxylation, ubiquitination, acetylation, and phosphorylation. HIF­I induces a series of genes that participate in angiogenesis, iron metabolism, glucose metabolism, and cell proliferation/survival. Some novel agents have been shown to be targeted  HIF­1 through a variety of molecular mechanisms and could represent a novel approach to cancer therapy. 

Keywords: Hypoxia­InducibleFactor­1;CancerProgression;  TherapeuticTarget

 Aim: To analyse and correct inter­fractional set up error in cervical carcinoma patients with intact cervix, treated with VMAT technique through daily online kilo voltage cone beam CT. 

Materials and Methods: The present study was conducted in for 2 years to assess interfractional setup error by online CBCT in VMAT technique in patients of intact carcinoma cervix. A total of 30 patients, as per inclusion and exclusion criteria who opted for VMAT are included in our study. They were planned as per guidelines. 

Results: 63.33% of patients included in our study were in the age group of 41­60 years of age. 43.33% of patients were Stage IIB was the most common stage of presentation in our study. Squamous cell carcinoma was the most common type of histopathology in our study. Systematic error in X­Axis was 0.19cm, in YAxis was 0.17cm, and in Z­Axis was 0.15cm and the average systematic error in all three directions was 0.17cm. Random error in X­Axis was 0.40cm, in YAxis was 0.44cm and in Z­Axis was 0.36cm and average random error in all three directions was 0.40cm. P value was >0.05 in X and Z directions, setup error wasnot significant in these directions. On YAxis, P value was <0.05 and setup error was significant in Y direction. In X­Axis (Medial­Lateral direction) CTV­PTV margin was 0.75cm, in Yaxis(Superior­Inferior direction) CTV­PTV margin was 0.73cm and in Z­Axis (Anterior­Posterior direction) CTV­PTV margin was 0.63cm. Bladder average D35 dose was 49.41Gy with standard deviation of 2.37; average D50 dose was 47.33Gy with standard deviation of 2.96. In VMAT due to minimum CTV­PTV margin, dose to Organ at Risk (OAR) was less. 

Conclusion: use of daily online cone beam CT in cervical carcinoma patients treated with VMAT, we can achieve a lesser CTV­PTV margin, which can thus minimise the dose to organs at risk.

Keywords: Cone Beam Computed Tomography, (CBCT); Volumetric Modulated ARC Therapy
(VMAT); Cervical Carcinoma.

A Study To Evaluate Effectiveness of application of ice cubes on oral mucositis among clients receiving cancer chemotherapy in Yashoda Hospitals, twin cities, A.P. This study was undertaken by Miss. Sunitha Elizabeth Chacko in partial fulfillment of the requirement for the degree of master science in nursing under Dr. N.T.R. University of Health Sciences Gunadala, Vijayawada, and Andhra Pradesh. 

Objectives of the study: 1. To assess the severity of oral mucositis among experimental and control group by pre test. 2. To assess the effectiveness of ice cubes application on severity of oral mucositis among experimental group by post test. 3. To evaluate the severity of oral mucositis by application of ice cubes to the experimental group by post test. 4. To assess the severity of oral mucositis in control group by post test. 5. To find out the post test association between the severity of oral mucositis among experimental and control group with selected demographic variables. The research approach adopted for the study was evaluative approach and the research design adopted was quasi­experimental design. 40 oral mucositis clients, among which 20 oral mucositis clients who receiving cancer chemotherapy are in experimental group and 20 in control group, by using Purposive sampling. by using questioning method with structured questionnaire and assesses the severity of oral mucositis, by using WHO five point observation check list and assessed satisfactory level of clients who are receiving cancer chemotherapy, by using Smitten Satisfactory scale.The reliability of the tool was tested by using spearman brown split half method and it was found in experimental group to be r=0.9 and control group r=0. On the first day experimental group and control group severity of oral mucositis was assessed by using WHO grading scale. Application of ice cubes to the 20 experimental groups 5 minutes before the administration of chemotherapy for 30 minutes where as 20 control group didn’t receive any intervention. Severity of oral mucositis will assess from day 1 to 5. Among 5 days score, 5th day score is taken as final observational score of severity of oral mucositis in both experimental and control group. Data were analyzed by SPSS version ­ 15, paired and unpaired ‘t’ test was used for finding the effectiveness and Chi square test was used for finding out the association between severity of oral mucositis and selected demographic variables. The calculated value of ‘t’ (13.5427) is greater than the tabulated value of ‘t’ (2.0244) at 5% level of significance with 38df by means that researcher can conclude that there is significance difference between experimental group and control group among clients who are having oral mucositis and who are receiving chemotherapy. Hence it is concluded that after applied ice cubes on oral mucositis among clients receiving cancer chemotherapy of the clients have been decreased the severity level. This positive result is a clear indication that effectiveness of application of ice cubes on oral mucositis among clients receiving cancer chemotherapy. 

Keywords: Chemotherapy; mucositis.

Introduction: Since the introduction of pancreaticoduodenectomy the major morbidity and cause of mortalityhas been pancreatic leak from  the pancreatic anastomosis(pancreatojejunostomy or pancreatogastrostomy).

Materials and Methods: This is a prospective non­randomized study, aimed at short term analysis of outcome of pancreaticogastrostomy with external stenting in Whipple’s procedure conducted inthose patients found to be suffering from periampullary carcinoma. 

Results: A prospective series of 12 patients, with pancreatic and preambulary cancers outlined Whipple’s procedure as required. Pancreatic anastomosis was done by pancreaticogastrostomy with external stenting. Whipples procedure in our hands had a mortality of 8.3% and a morbidity of 40­ 50%. The procedure is technically feasible with an operating time of four hours and a blood loss of 1000ml. Preoperative biliary stenting did not influence the leak rate. The one mortality in our study was not related to the pancreatic leak. The one patient with pancreatic leak and had only a minimal leak (Grade A) which was easily managed conservatively. All the other complications were managed conservatively with success in all patients. 

Conclusion: Pancreaticogastrostomy with external stenting is a safe and reliable procedure which can be routinely performed in Whipples procedure.

Keywords: Pancreaticogastrostomy; Whipples Procedure; Anastomosis; Adenocarcinoma.

Background: IGRT is the latest development for increasing the precision and accuracy in radiation therapy. Usage of specialized multi professional teams for coordinating geometric verification and use of clearly defined protocols are essential for IGRT. Reducing dose to the OARs using IMRT & VMAT and reducing the size of PTV using IGRT enables radiation dose escalation, which in turn improve the treatment outcomes. 

Aims: To evaluate set up errors in patients treated with Intensity modulated radiotherapy / Volumetric modulated arc therapy using Cone beam CT (CBCT) in head and neck and pelvic cancer sites and to study adequacy of PTV margin by applying set up errors. 

Methods and Materials: A total of thirty two patients were enrolled into the study, which included 16 Head and neck site, 16 pelvic sites that were planned with either IMRT or VMAT. CBCT was acquired for each patient on day 1, 2, 3 and thereafter every week until the completion of treatment. The CBCT images were fused with planning CT images. The PTV margin was estimated by calculating the systematic and random errors in X, Y, Z directions. 

Results: Data collected was analyzed with single sample t test. A total of 288 CBCT were taken for this study. The systematic and random errors were calculated in both head and neck and pelvis 16 patients each. The systematic error for H&N site in cranio caudal (CC), medio lateral(ML), anteroposterior (AP) were 0.2cm, 0.2 cm, 0.2 cm respectively. The random errors in H&N sites patients in CC, ML, and AP were 0.2 cm, 0.2cm, 0.2 cm respectively. The PTV margin for H&N site in CC, ML, AP were 0.7cm, 0.5cm, 0.5cm respectively. For pelvic site, the systematic error in CC, ML, AP were 0.3 cm, 0.2 cm, 0.2cm respectively, where as the random errors were 0.2 cm, 0.3cm, 0.2 cm respectively in the same direction. The estimated PTV margin for pelvic site in CC, ML, AP were 0.8cm, 1.0cm, 0.7cm respectively. 

Conclusion: For H & N and pelvic sites, treated with IMRT/VMAT the PTV margin of 5mm is not sufficient. Hence treatment verification with IGRT is very crucial to identify and correct the set up errors in order to deliver the planned treatment. 

Keywords: Image Guided Radiotherapy (IGRT); Intensity Modulated Radiotherapy (IMRT); Volumetric Modulated Arc Therapy (VMAT) 

Background: The incidence of mucositis is increased by adding concurrent chemotherapy as well as by altered fractionation radiation. The main aim of the study is to compare the efficiency of magic mouth wash and benzydamine mouth wash in prophylaxis and treatment of radiation induced oral mucositis in patients with head and neck cancers. 

Materials and Methods: The present randomized, comparative study conducted at Department of Radiotherapy at Guru GobindSingh Medical College and hospital a period between April 2016­June 2016. A total of 60 patients with head and neck cancer being treated with 6 or more weeks of radiotherapy to a total dose of 66Gy, 200cGy per day, 5 days a week,with shrinking field technique using 2D conventional method on cobalt teletherapy machine were randomly assigned to receive either the magic mouthwash (group A) or benzydamine (Group B) with equal number of patients i.e 30 patients in each group. All the results obtained were arranged in a tabulated form and analysed using SPSS software. 

Results: In the present study, the distribution of patients according to age was comparable in both groups. The mean age was 57.033 ± 12.397 in group A and 54.633 ± 11.418. There was no development of severe mucositis (grade 3­4) until week 3rd of treatment in both the groups. 4 patients (13.3%) in group B developed grade 3­4 mucositis in 4rth week. In the 5th week 1 patient  (3.33%) in group A and 6 patients (20%) in group B developed grade 3­4 mucositis. In the 6th and the 7th week 3 patients (10%) in arm A and 6 patients (20%)
in arm B developed severe reactions in each of these weeks respectively. 

Conclusion: From the above study, we can conclude that mouthwashes are an effective alternative for managing cases of mucositis, with magic mouth wash giving better results but there was no significant difference between both the groups.

Keywords: Magic Mouthwash; Benzydamine; Mucositis

Background: Microvascular free flap surgery for  reconstruction of head and neck region in surgical ablation of cancer cases has gained tremendous advancement and interest of oncology and plastic surgeons in recent few years as a sophisticated surgical procedure. This study was conducted at our center to evaluate the patient demographics, determine risk factors on outcome of surgery and complications related with the commonly used free flaps for head and neck reconstruction at our center. 

Methods: This prospective clinical study was conducted in JSS hospital for duration of 3 yrs between January 2013 and December 2016. Free flaps used at our center, i.e. free radial artery forearm flap (FRAFF), free fibular osseocutaneous flap (FFOCF) and free anterolateral thigh flap (FALT) were considered for the study. 

Results: This study included 43 patients with oral cavity cancer, of which 36 were males and 7 females, with a mean age of 39.8 yrs. Tobacco consumption was seen in staggering more than 90% of cases with most common primary tumor site being buccal mucosa (27.9%), and squamous cell carcinoma being most common cancer type in 88% of the study cases. FRAFF was the most common flap used for reconstruction in 67% of cases with overall flap loss being in 20%. Recurrence was recorded in 20.9% of cases with a minimum follow up of 6 months but no mortality was noted during the study period. 

Conclusion: This study emphasizes that free flaps are ideal for good cosmetic and functional outcome in reconstruction of oral cavity. Among the flaps used in our study, FRAFF is safe, reliable, and versatile. In mandibulectomy cases, FFOCF is ideal but technically more demanding and needs more expertise to improve the outcome and success rate. We would like to conclude that we need to hone our surgical skills and technique to improve the outcome of free flaps with proper flap selection accordingly, adequate preparation and isolation of reliable recipient vessels and good surgical technique.

Keywords: Oral Cavity; Cancer; Reconstruction; Free flap; Free Radial Artery Forearm Flap; Free Fibular
Osteocutaneous Flap; Free Anterolateral Thigh Flap.

Modern civilization, urbanization, industrialization, changes in daily life style, population growth and aging all have contributed to epidemiological changes in many diseases, including cancer in India and other countries. Knowledge based on epidemiological patterns and trends would be of great help in identifying persons at high risk for the development of a particular cancer and also forms the scientific basis for the planning and organization of prevention, diagnosis and treatment of cancer in a community. An attempt was made to study the age, sex, site and histopathological type of malignancy occurring in the population reported in our hospital in the last four years. Of the total 18540 cases received for histopathological evaluation, 2560 cases (13.8%) were diagnosed as malignant. Among them 1364 cases (53%) were females and 1196 cases (47%) were males. 41­60 years (53%) of age range constituted maximum number of cases. Cervix was the most common site of malignancy in females and oesophagus and oral cavity in males. Squamous cell carcinoma was the most common type followed by adenocarcinoma in various sites. Lymphoma, sarcoma, germ cell tumors and metastatic deposits were among others reported.

Keywords: Adenocarcinoma; Cervix; Malignancy; Oesophagus; Oral Cavity; Squamous Cell Carcinoma.N

Introduction: Humerus is a common site for malignant tumors. Advances in adjuvant therapies  and reconstructive methods provide salvage of the upper limb with improved outcomes.

Materials and Methods: In our surgical oncology department five patients with tumors of the proximal humerus were operated over the course of two years from 2010 ­to 2012.

Results: All patients had different tumor pathology emphasising the wide heterogeneity of sarcomas of bone and soft tissue. Ages ranged from 12yrs to 52yrs, again a broad range. Five patients described above all presented with arm swelling and pain. One patient diagnosed outside as a Giant Cell Tumor by CT scan and FNAC had curettage performed. Both children had high grade sarcomas of the proximal humerus. The 12 year old had a STS of bone and had an intraarticular resection albeit with abductors resected. The 14 year old had an osteosarcoma for which 5 cycles of cisplatin based neoadjuvant chemotherapy had been given. In her
case a modified Tickhoff ­ Linberg resection had to be performed for adequate margin and the prosthesis was suspended statically and dynamically for a stable shoulder. As her abductors had been resected along with the glenoid she had severe restriction of shoulder motion. The 45 year old female underwent a modified Tickhoff ­ Linberg resection with deltoid sacrifice for a low grade STS due to extensive soft tissue involvement and therefore had severe restriction of shoulder function. We obtained our best results in the two male patients with benign tumors as we were able to spare both the abductors and glenoid and replace the resected humerus with a prosthesis. Both recovered rapidly and had excellent abduction at the shoulder. All had near complete relief of pain and complete function at elbow and wrist.

Conclusions: Routine endoprosthetic reconstruction for proximal humeral reconstruction is recommended in view of its simplicity of fixation, durability and excellent long term outcome and we reserve autologous fibula only in situations where a prosthesis cannot be used.

Keywords: Humerus; Tickhoff ­ Linberg Resection; Osteosarcoma.

Aim: Study was to evaluate feasibility and benefits of Bone Marrow Sparing IMRT over Standard IMRT. 

Materials and Methods: Cervical cancer patients undergoing Concurrent Chemo Radiation and brachytherapy and evaluated for haematological, gastrointestinal and genitourinary toxicity at weekly intervals were included in study. Results: Dose constraints to bone marrow of V10<90% and V20<75% were achieved in all patients. Significant reduction in bone marrow V10 and V20 is possible using bone marrow sparing as compared to standard IMRT (V10 87.15% vs. 93.7% and V20 73.55% vs. 83.15%). Bone marrow sparing can be achieved without compromise to target coverage and without increased dose to OAR’s which include bowel, rectum and bladder. Bone marrow sparing appears to show significant reduction in haematological toxicity in terms of fall in haemoglobin, haemoglobin nadir and grade 2 and worse anaemia. Bone marrow sparing appears to show a trend towards reduced haematological toxicity in terms of fall in WBC count, leukocyte nadir and grade 2 and worse leukopenia. 

Conclusions: SPECT­BM imaging may be added to the ever growing list of functional imaging techniques that may play a role in IMRT planning. Bone marrow sparing approach may also benefit patient s with anal and rectal cancers. 

Keywords: Intensity Modulated Radiation,Therapy (IMRT); Single­Photon Emission Computed, Tomography (SPECT) bone Marrow (BM) Imaging; Cervical Cancer

Background: The Axillary Lymph node status is of paramount importance in staging, treatment planning, prognosis and survival in Breast Cancer. Hence appropriate investigating criteria for AXLN assessment, which is easy, noninvasive, repeatable and accurate method is need of the hour. 

Materials and Methods: All the upfront operable breast cancer were considered for the Study. A detail history, thorough clinical examination was done and all the patients were subjected for Axillary Ultrasound and Mammogram. All the patients underwent Axillary dissection of level 1 and 2 clearence along with Mastectomy or Lumpectomy. The Histopathological finding of axillary lymphnode status is compared with clinical, Sonological and mammographic findings. 

Results: In our study of 120 cases,112 cases underwent Modified Radical Mastectomy and 8 cases Lumpectomy with Axillary Dissection. The sensitivity and specificity of AXLN metastases detected by Clinical examination method is 40.16% and 49.83%. The Ultrasound has high sensitivity of 97.59%, indicating that it identifies all the enlarged lymph nodes harboring the metastases, although the specificity is low 81.08% Mammogram showed sensitivity of 60.32% and specificity of 87.72%. Combination of clinical and ultrasound examination showed improved sensitivity as 0.5 cms size lymphnodes could be detected by sonology.  

Conclusion: The clinical staging of axilla in cancer breast is best done using both clinical and Ultrasound examination, as they complement each other and enhance the accuracy.

Keywords: Axillary Lymph Node; Breast Cancer; Axillary Dissection

Cancer is a multi­factorial and multi­step disorder driven by acquired mutations/defects in components that contribute to coordinating replication, behaviour and fate in the individual cells of multi­cellular body organizations. Ten ‘hallmark’ cellular defects have been broadly­documented in the chronologies of neoplastic progression from cancer cases, two of which have previously been compared to the malfunction of automobile pedals. Weinberg’s carcentric analogy is hereby extended to the other hallmark cellular defects and the inherent survival strategies that they employ, towards understanding transformation from the perspective of parallel mechanical defects that may plague the control network in an automobile during its ‘lifetime’, and how making timely repairs may prevent a catastrophic chain of dysfunctions in both systems, as they age.

Keywords: Cancer; Ageing; Car; Analogy.