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   Table of Contents - Current issue
July-December 2021
Volume 1 | Issue 2
Page Nos. 49-101

Online since Wednesday, August 24, 2022

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Bengal’s journey in oncology: Back to the future p. 49
Tejpal Gupta, Abhishek Chatterjee, Jai Prakash Agarwal
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Toward personalized treatment for head and neck cancers: The role of SNPs p. 51
Sushmita Ghoshal, Arnab Pal
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Pattern of practices of oncologists of Bangladesh in the COVID-19 era p. 53
Arman Reza Chowdhury, Parvin Akhter Banu, Md. Arifur Rahman, Dario Trapani
Purpose: The aim of this study was to investigate the impact of coronavirus disease-2019 (COVID-19) on the practice of oncology care in Bangladesh during the first pandemic surge in 2020. Materials and Methods: This was a cross-sectional survey-type study, based on a questionnaire, which was shared via email to national oncologists and enhanced by snowballing in April–May 2020. Results: A total of 48 responders joined the survey, mostly clinical and radiation oncologists practicing in specialized cancer centers of the major cities. Patients’ triage for COVID-19 was implemented in 60% of the settings surveyed, and an impact on the clinical care was unanimously reported. Delays and interruptions in cancer treatments were common, as was a reduction of patient volume treated with radiation therapy (RT). Mechanisms for priority-setting to inform clinical decisions were set by 80% of the oncologists, including changes in the treatment protocols––more commonly for palliative care interventions and regarding the RT fractionation; also, alternative therapeutic options were more commonly discussed, particularly when patients were candidate to multimodal treatments. Value-driven and choose-wisely approaches were emphasized. Telemedicine was identified as a mechanism to reduce access to hospitals, but only for selected services (e.g., follow-up) by 78%. Protecting hospitals and health workers were identified as priority interventions to shape effective COVID-19 responses. Conclusion: This survey serves as a case study of adaptations of cancer care during COVID-19 in low- and middle-income countries. Elements of priority-settings and value-driven decision-making emerged, although the long-term impact cannot be stated, at this time.
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Pattern of failure among HNSCC: An institution-based study p. 58
Afsana Shah, Dinesh Kumar, Govind Preet Singh, Pragya Shukla
Aim: This retrospective study was conducted to evaluate the pattern of recurrence in head and neck squamous cell carcinoma (HNSCC) patients who received a definitive chemo-radiotherapy. Materials and Methods: In this retrospective study, the data of 308 head and neck patients from January 2015 to March 2015 were analyzed. Only patients who received definitive chemo-radiotherapy were included in the study. The pattern of recurrence was stratified based on age, gender, site involved, histopathological differentiation, stage, habitual risk factors, and treatments received. Results: The mean age of the patients was 51.6 years. No association in the pattern of recurrence based on age, gender, or histopathologic differentiation was found. Patients with habitual risk factors (smoking, tobacco chewing, and alcohol) showed the poorest response to chemo-radiotherapy and unresolved residual disease. Among the primary sites involved, oral cavity patients showed the poorest response with maximum cases of residual disease. In addition, patients with advanced stage remained with residual disease and have a maximum recurrence, and the difference was statistically significant. All the patients who received neoadjuvant chemo-radiation (NACT-RT) as compared to chemo-radiation (CT-RT) had residual disease. According to the pattern of recurrence, the local recurrence was the most common followed by regional and then local and regional, but the distance recurrence was the lowest. Conclusion: Of the patients who have received definitive chemo-radiotherapy, more than half of HNSCC had residual disease. Of the patients with no residual disease, about half of them had recurrence at follow-up. However, no association in the pattern of recurrence was found based on gender or histopathologic differentiation. Patients who have multiple habitual risk factors showed the worst outcome as compared to the patients who have a single habitual risk factor. Patients with multiple habitual risk factors have maximum cases of residual disease and maximum cases of recurrence. Among the habitual risk factors, tobacco chewing was the worst habitual risk factor for refractory residual disease and recurrence. Based on the sites, the patients with carcinoma of the oral cavity showed the worst outcome in terms of residual disease, which is followed by hypopharynx, oropharynx, and then larynx carcinoma, but the rate of recurrence does not depend on the site involved. Advanced-stage patients had a poor response and with maximum cases of recurrence. A combination of chemotherapy with radiation showed better results as compared to the radiation alone in terms of response and recurrence. As to the site of recurrence, the local recurrence was the most common, followed by regional and then distance recurrence. This study indicated that HNSCC is locally aggressive, and local failures are the most common.
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Unscheduled treatment breaks during radical radiotherapy for head and neck cancers: An audit from a tertiary care center p. 66
Treshita Dey, Ankita Gupta, Nagarjun Roa Ballari, Sushmita Ghoshal, Avradeep Datta
Aims: The aim of this article was to audit radical radiotherapy practice in head and neck cancer to assess unscheduled treatment breaks and their reasons thereof. Materials and Methods: Records of all patients of head and neck squamous cell carcinomas registered in the year preceding the pandemic were analyzed. A total of 287 patients treated with radical intent with doses equivalent to 66 Gy in 33 fractions were eligible for final analysis. Results: More than half (148/287) of our patients suffered from treatment breaks during their radiotherapy treatment with primary cause being treatment-related toxicities. Radiotherapy dose of 66 Gy and above (P < 0.001), primary in the oral cavity (P = 0.009), and preceding surgery and concurrent chemotherapy (P = 0.032) were found to be significantly associated with treatment breaks as well as breaks lasting for 15 days or more. Patients having a break in their treatment were also found to have a significantly low progression-free survival (25.8 vs. 12.7 months; P = 0.012). Conclusion: It is in the interest of the patients that stringent patients’ selection criteria identify the ideal candidates for treatment intensification.
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Impact of covid-19 on cancer care – A single institution experience – Government Arignar Anna Memorial Cancer Hospital & Research Institute (RCC), Kanchipuram p. 72
IM Jarfin, V Srinivasan, S Ashok Kumar
Background: COVID-19 has impacted health care all over the world. In this article, we will discuss how the pandemic has influenced daily practice and treatment protocols in cancer care in our institution, during the course of its two waves, i.e., from March to September 2020 and March to June 2021. Materials and Methods: Several measures were taken to ensure safety and treatment of cancer patients. Setting up of isolation wards, admission of all patients for treatment, increasing radiotherapy machine ‘on time’, periodic sanitation, treatment area hygiene, personal protection equipments for medical personnel were some of them. Changes were made in radiotherapy, medical oncology, surgical oncology and anaesthesia practices. Patients who became COVID positive were managed in a Covid Care Centre, outside the premises of our institution. Results: The number of patients treated and procedures done in our institution during the first wave of the pandemic in 2020 was much lower compared to the same time period in 2019. But that was not the case with the second wave in 2021. Among the health care workers who tested positive for the virus during the two waves, none required hospitalization and no deaths occurred. Conclusion: Covid-19 has definitely influenced our cancer care for a transient period during the first wave. Modifications in treatment procedures were done only for a short period before we switched back to standard department protocols. With the onset of the second wave, taking previous wave’s experiences into consideration, measures were taken to ensure safe and continuous cancer treatment delivery.
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Predictive factors of recurrence free survival of patients with luminal breast cancer in southern Sri Lanka p. 78
Lakmini K B Mudduwa, Harshini H Peiris, Thushari Liyanage
Purpose: To assess the predictive factors of recurrence free survival (RFS) of luminal breast cancers in Southern Sri Lanka to bridge the existing gap in published literature on luminal breast cancers in our country. Materials and Methods: This was a bidirectional; retro prospective, cohort study. All breast cancer patients who sought the services of our immunohistochemistry (IHC) laboratory from 2006 to 2015 were included. Tissue micro arrays were constructed using the archives for the IHC analysis of Ki67, CK5/6 and EGFR. Details of ER, PR and Her2 expression were extracted from the laboratory records. Clinico-pathological data were retrieved from the records available in the laboratory, Oncology clinic and from patients. Pearson chi-square test, Kaplan-Meier model, log-rank test and Cox-regression model were used with SPSS for data analysis. Results: A total of 595 luminal breast cancers were included. Majority, were between 36–60 years of age (65.5%), Nottingham grade 2 (57.4%), TNM Stage II/III (82.0%) and had T2 tumours (53.6%). Recurrences were noted in 15.9% (n = 395, local-16.9%; distant metastasis-76.9%; second cancer-6.2%). Median follow up time was 35 months. Only 443 luminal breast cancers could be subtyped (luminal A-58.7%); luminal B Her2-negative- 22.3%; luminal B Her2-positive-19.0%). Five-year RFS of the cohort was 74.1% (luminal A-83.6%; luminal B(Her2-negative)-73.9%; luminal B(Her2-positive)-55.3%; P = 0.001). Over-expression of Her2 (P = 0.018) and CK5/6 expression (P = 0.003) had an independent effect on the RFS of the cohort. Conclusion: The three subtypes of luminal breast cancers are distinct in their recurrence free survival and tumor characteristics. Over-expression of Her2 and CK5/6 expression had an independent negative effect on the RFS of the luminal breast cancer cohort.
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Changing pattern of cancer incidence in India: 25-year report of the cancer registry of a large urban cancer center p. 86
Jyotirup Goswami, Samir Bhattacharya, Arnab Gupta, Rahul Roy Chowdhury, Gautam Bhattacharjee, Saradindu Ghosh
Introduction: Cancer registries are vital for understanding incidence and prevalence of cancer, as well as appropriate funding and control measures. Materials and Methods: The data of patients registered between 1996 and 2020 at a large urban cancer centre in Eastern India was used for analysis of cancer trends over time. Results: There were a total of 1,89,315 patients. The top 5 cancer sites over the most recent 5-year block (2016–2020) were lung, oral cavity, throat, stomach, and colorectum in males and breast, cervix, liver-gallbladder, oral cavity and ovary in females. There was a consistent rise in oral cavity cancers and lung cancer in males and a consistent rise in breast cancer and ovarian cancers in females. There was a consistent fall cervical cancers, which was overtaken by breast cancer in the mid-2000s as the leading cancer in women. Digestive cancers have doubled over the last 25 years, the commonest being stomach cancer and colorectal cancers. Conclusion: The data reflects India’s changing profile of cancer, with the increase of breast and ovarian cancers, as seen worldwide. Despite lack of a robust screening/vaccination programme, cervical cancer has declined. The rise in tobacco-associated cancers (lung and mouth) is a matter of concern.
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Volumetric changes in lumpectomy cavity during whole breast irradiation after breast conserving surgery p. 89
Abhay P Singh, Rahat Hadi, Ashish Singhal, Madhup Rastogi, Rohini Khurana, Shantanu Sapru, Ajeet Kumar Gandhi, Satyajeet Rath, Surendra P Mishra, Anoop Srivastava
Introduction: Irradiation to the conserved breast consists of whole breast radiotherapy (WBRT) followed by tumour bed boost. Seroma in the tumor bed is a commonly observed side effects after breast-preservation, which can alter the shape of breast during WBRT and also lead to tumour bed shrinkage during boost irradiation, causing larger volumes of normal tissue irradiated. The aim was to evaluate the change in the lumpectomy cavity volumes before and after WBRT. Materials and Methods: Thirty-three patients with demonstrable lumpectomy cavity after breast conservation surgery (BCS) were included in the study. CT simulation of the breast was performed twice, initially before the start of WBRT and then 2 days prior to completion of WBRT. WBRT was delivered after contouring breast and lumpectomy volumes guided by the presence of surgical clips, seroma, and other surgical changes. Change in volume of lumpectomy cavity was analysed by Students’ paired T-test. Results: The volume reduction in the lumpectomy cavity was noted in 97% of patients (32/33). The change in lumpectomy cavity volume decreased by a mean value of 34.59% (range 0 - 72%) (p < 0.0001). The mean change in breast volume was 8.44% (range, -2.44 to 10.12%) (p - 0.394). Age, weight, location of tumour, T stage, breast volume, lumpectomy cavity volume, presence of clips and pre-radiation chemotherapy were not significantly associated with volume reduction of the lumpectomy cavity. Conclusion: The results of this study have shown that a significant volume reduction of the lumpectomy cavity after WBRT.
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Dermatofibrosarcoma protuberans of the lower extremity: A rare tumor p. 95
Deepika Raina, Nitin Gupta, Muninder Negi
Dermatofibrosarcoma protuberans (DFSP) is a rare, uncommon, low-grade sarcoma of fibroblast origin. Clinical suspicion is confirmed by biopsy, and appropriate and confirmatory immunostaining with CD34, factor XIIIa, nestin, apolipoprotein D, and cathepsin K is to be performed in all cases of suspected DFSP. Initial treatment is surgical, and every effort should be made to completely remove the tumor at the time of initial therapy. If surgery yields positive margin, then re-resection is recommended whenever possible. For patients with DFSP in whom tumors cannot attain negative margins after surgery, adjuvant radiotherapy (RT) may be considered to improve local control. Herein, we describe a rare case of DFSP in the left leg of a 50-year-old woman treated with excision and adjuvant RT.
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Role of palliative chemoradiation in locally advanced head and neck cancer: A case series done in a tertiary care center in Uttar Pradesh p. 98
Gulafshan Jabi, Mohsin Khan, Pavan Deepak MandigalaVenkataRamana
Background: Shorter palliative hypofractionated schedules when given concomitantly with chemotherapy, preferably cisplatin (radiosensitizer), enhance the response rate with acceptable toxicity, resulting in better compliance of the patients. Objectives: This case series retrospectively evaluated the role of concurrent chemotherapy, preferably cisplatin, with palliative radiation 30 Gy in 10 fractions in locally advanced head and neck cancers in terms of response rates, symptoms palliation, and acute toxicities. Materials and Methods: Twenty-six patients of histologically confirmed locally advanced head and neck cancers were selected and treated during the period January 2018 and December 2020. All patients (100%) completed the treatment with an average of two follow-ups. Results: The overall response rate of 73% was observed in patients treated, and interestingly, one patient had complete response. Moreover, 100% of the patients reported improvement in at least one symptom with severity reduction in pain. As defined by the Radiation Therapy Oncology Group (RTOG) criteria for toxicity assessment, Grade 2 mucositis in 61%, Grade 1 mucositis in 11%, Grade 1 skin reaction in 15% of the patients were observed. No grade III toxicity was reported. Conclusion: Concurrent chemotherapy acts as a radiosensitizer and provides a synergistic action when coupled with radiation resulting in more efficacious control of locoregional disease of locally advanced head and neck cancers with acceptable toxicities facilitating the compliance of patients.
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