Issue No. 10 - July 2011


Pages Title /Authors / Abstract
7-10 Mutations In EGFR Signal Pathway In Correlation With Response To Treatment Of Head And Neck Cancers
  J. Neuwirthová1, S. Pavel1, J. Rottenberg1, R. Kostřica1, M. Zdeněk1, M. Hajdúch2, J. Drábek2, J. Srovnal2, J. Berkovcová2
1Clinic of Otorhinolaryngology and Head and Neck Surgery, Masaryk University and St. Anne’s Faculty Hospital in Brno, Czech Republic
2Laboratory of Experimental Medicine, Department of Paediatrics, Palacky University and Faculty Hospital in Olomouc, Czech Republic

The prognostic and predictive value of the epidermal growth factor receptor (EGFR) expression and some genetic alterations in an EGFR signal pathway, such as the EGFR amplification, the EGFR activating tyrosine kinase domain mutations or the k-ras gene mutation were investigated in our study. The aim of the research was to evaluate the occurrence of the above-mentioned biomarkers in correlation with a therapeutic response and survival in patients with locoregionally advanced spinocellular head and neck cancers. Keywords: Head and neck cancer, EGFR, predictive marker, k-ras, EGFR amplification, EGFR tyrosine kinase domain mutation

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11-17 Comparison Of IMRT And Rapidarc Treatment Plans Using AAPM Task Group Test Suites

S. Sathiyan1, M. Ravikumar1, A.L. Boyer2, J. Shoales2
1Department of Radiation Physics, Kidwai Memorial Institute of Oncology, Bangalore, India
2Medical Physics Division, Department of Radiation Oncology, Scott & White Memorial Hospital, Temple, Texas, USA


The purpose of this study is to examine the plan quality and monitor unit with sliding window IMRT and RapidArc (RA) treatment plans using American Association Physicists in Medicine TG119 test suite DICOM-RT images and structure sets. The structure set includes multi-target (superior, central, inferior), prostate, head and neck and C-shape. Plans were performed with Eclipse planning system using AAA algorithm with the plan goals specified in TG119. The plan results for multitarget shows that the D99 is greater than the plan goal for all the targets. The D10 is less than the plan goal for superior and inferior targets in both IMRT and RA plans. The D10 is 5% more with IMRT plan and 7% more with RA plan for central target in comparison with plan goal. The plan results for prostate shows that D95 is greater than the plan goal for both IMRT and RA plans. The D5 is less than the plan goal for IMRT plan and almost equal to plan goal for RA plan. The D30 is less than the plan goal for bladder and rectum in both the plans. The D10 is higher than the plan goal by 1.9% and 2.5% in IMRT and RA plan for rectum. The plan results for head and neck shows that the D99 and D90 were greater than the plan goal for PTV. The spinal cord and parotid doses were less than the plan goal in both the plans. The plan results for C-shape shows that the D95 was greater than the plan goal and D10 was less than the plan goal for PTV. The dose to central core was less than the plan goal in both IMRT and RA plans. Both the IMRT and RapidArc plans have met the plan goal for all the target and normal structures. RapidArc optimization and treatment planning requires more time than the IMRT plan. The monitor unit calculated by the RapidArc plan is less compared to IMRT plan, which reduces the treatment error caused by patient motion during treatment and integral dose. Keywords: IMRT, RapidArc, AAA, MLC, Treatment planning


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Clinical Significance Of hTERC And C-Myc Genes Amplification In A Group Of Egyptian Patients With Cancer Cervix


M.M. Eid1, H.M. Nossair2, M.T. Ismael2, G. Amira3, M.M. Hosney2, R. Abdul Rahman2
1Human Cytogenetics Department, National Research Center, Cairo Egypt
2Faculty of Medicine, Alazhar University, Egypt
3National Cancer Institute, Cairo University, Egypt


Background: Cervical cancer is the second most common cancer in women worldwide after breast cancer. Cervical cancer is a preventable disease. The implementation of cervical cancer screening programs has greatly decreased the morbidity and mortality, as precancerous lesions and early invasive cervical cancer could be detected and treated effectively. The detection of hTERC gene amplification was suggested as a possible diagnostic marker for use in routine cytological screening. Objectives: The present study was designed to detect genomic gains of the hTERC and C-MYC genes using FISH technique and to investigate the relationship between genes amplification and the clinical data of the patients. Patients and Methods: The current study was carried out on twelve cases with cervical cancer at different grades (three cases were grade I, six cases were grade II and three cases were grade III). Interphase FISH analysis using LSI probe, Cervical Cancer probe hTERC (3q26) & C-MYC (8q24), was successfully performed on 12 patients with cancer cervix. Results: Interphase FISH analysis revealed positive hTERC gene amplification in all cases of cancer cervix (100%). However C-MYC gene amplification was detected in four cases only (33.3%). Statistical analysis of the data revealed significant correlation between hTERC amplification and grading. Also, there was significant correlation between C-MYC amplification and grading and highly significant correlation between C-MYC amplification and hTERC amplification. On the other hand hTERC and C-MYC genes amplification showed an inverse correlation with the ages of the patients. Conclusion: The present study highlights the importance of using hTERC and C-MYC genes FISH probes for cases with cancer cervix or premalignant lesions as a sensitive technique. This method provides an easy and effective applicable approach which helps in the diagnosis and prognosis, as an increased copy number is associated with a more advanced grade that could be detected in the early stages of the disease. Keywords: Cancer cervix, Telomerase, hTERC amplification

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Disease Profile And Treatment Results Of Anal Canal SCC: Experience From AIIMS, New Delhi

  R. Hadi1, BK Mohanti2, S. Pathy2, NK Shukla3, SVS Deo3, A. Sharma4, V. Raina4, GK Rath2
1Department of Radiation Oncology, Dr RMLIMS, Lucknow- 226010, UP, India
2Dept of Radiation Oncology, 3Dept of Surgical Oncology, 4Dept of Medical Oncology, Dr. BRA Institute Rotary Cancer Hospital, A.I.I.M.S., New Delhi-110029, India

Introduction: Anal Canal squamous cell carcinoma (SCC) accounts for nearly 2% of all cancers of the alimentary tract. Over the past few years, the management of anal canal cancer has changed from primary surgery to primary chemoradiotherapy (CRT). Methods: A total of 83 patients’ (pts) records (62 males, 21 females) were retrospectively reviewed. Length of disease was <5 cm in 44 pts and confined to primary in 46 pts. Ten pts have anti-cancer therapy outside. We delivered radiotherapy (RT) alone to 16 pts, chemotherapy (CT) alone to 4 pts, CRT in 51 pts and preoperative (pre-op) RT in 2 pts. RT dose was up to 30 Gray (Gy) =16; 30-50 Gy=12 and >50 Gy=41 pts. Results: RT compliance was optimal in 64/69, grade (Gr) ≤ 2 toxicity in 56/69 and Gr ≥ 2 in 13/69 pts. Thirteen pts (18.84%) were found in 4/83, <50% in 18/83, >50-<100% in 39/83 and complete response (CR) in 22/83 pts. Recurrence at primary site was seen in 7 and loco-regional in 2 pts. Salvage therapy was done in all 9 pts (surgery=8 and CT=1). Status at last follow up, alive without disease = 22/83 and with disease = 61/83 pts. Conclusion: This retrospective analysis revealed that the advanced disease was in 47%, the optimal anticancer therapy could be delivered to 63.9%. Despite heterogeneity of patient population and management, the overall disease-free survival (DFS) with sphincter-preservation was achieved in 26.5% pts. Keywords: Anal canal, squamous cell carcinoma, chemo-radiotherapy, sphincter preservation, disease free survival


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Prediction Of Anthracycline Induced Cardiotoxicity: Study Of Thirty-One Iraqi Adult Patients

  AMJ Al-Mudhafar1, AAS Ali2
1Baghdad Teaching Hospital, College of Medicine, Baghdad University, Iraq
2Baghdad Teaching Hospital, The Medical City, Baghdad, Iraq

Objective: To look for a nearly ideal tool for prediction of anthracycline-induced cardiotoxicity. Method: Thirty-one patients with various hematological malignancies were included in the study which was conducted from Sept. 2005 to Sept. 2006 in Baghdad Teaching Hospital - Hematology Unit. Initial cardiovascular assessment including cardiac troponin I, electrocardiography and echocardiography were done and repeated one month after the commencement of anthracycline-based regimen. Cardiotoxicity was considered present if the patient has clinical and electrocardiographic evidences, troponin positivity, echocardiographic evidence, or any combination of these. Results: The mean age for the study sample was 34.1±17.2 years comprising of 17 male and 14 female patients. Increasing age, body surface area, anthracycline dose as well as the concomitant use of cyclophosphomide/ All Trans Retinoic Acid were associated with increased risk of cardiotoxicity. The cut-off point of body surface area above which the risk of anthracycline-induced cardiotoxicity is increased was 1.88 m2 while the cut-off point for anthracyclines dose was 145.5 mg/m2. The constellation of clinical data, ECG, and cTnI was 92% predictive of early evidence of anthracycline-induced cardiotoxicity. More weight is added when echocardiography is used as a diagnostic tool. The incidence of cardiotoxicity attributed to treatment was 38.7%. The predictive power of cardiac troponin I alone was 58.3%, whereas it increases to 91% when combined with electrocardiography and to 95% when combined with echocardiographic study. Conclusion: The age, anthracyclines dose and the use of other chemotherapeutics increase the risk of anthracycline-induced cardiotoxicity. Cardiac troponin I is a simple non-invasive indicator for the presence of anthracyclineinduced cardiotoxicity especially when used in combination with other parameters. Keywords: Anthracycline, Cardiotoxicity, Troponin


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Early Gastrointestinal Complications of Stem Cell Transplant - Results of Prospective Study at IRCH, AIIMS, India

  G.M. Bhat
Department of Medical Oncology, SKIMS, Soura, Srinagar, Kashmir, India, 190011

Background: The study was conducted with the purpose of finding clinical profile of early gastrointestinal complications of stem cell transplant at this center. Methods: 70 consecutive subjects, who were subject to bone marrow transplant from October 2002 to September 2004, were prospectively studied. The gastrointestinal complications were followed in first 100 days of transplant and recorded in a pre-determined format. Results: Study population comprised of 23 allo-transplant (with 3-non-myelablative procedures) and 47 auto-transplant subjects. Gastrointestinal complications included: nausea and vomiting occured in 19 (82.60%), mucositis- 20 (86.95%), diarrhea- 15 (65.21%), veno-occlusive disease (VOD) - 3 (13.04%) and acute pancreatitis- 1 (4.34%) in allo-transplant group. Nausea and vomiting occurred 36 (76.59%), mucositis- 46 (97.88%) diarrhea- 39 (82.98%), VOD- 5 (10.64%) in auto- transplant subjects. Acute graft versus host disease (AGVHD) involved gut in 3 and liver in 1 case of allo-BMT-group. Keywords: Stem cell transplant, Mucositis, Veno-occlusive disease, Graft versus host disease


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Medullary Carcinoma Of The Breast: Ten Year Clinical Experience Of The Kuwait Cancer Control Centre

  S.M. Samir1, M.S. Fayaz1, A. Elbasmy2, M.M. Motawy1, S.Abuzallouf1, T. George1, M. Abdelhady1, A. Bedair1
1Radiation Oncology Department, 2Epidemiology and Biostatistics Department,
Kuwait Cancer Control Center, State of Kuwait

Background: Medullary carcinomas of the breast account for fewer than 7% of all invasive breast cancers. Some investigators include medullary carcinomas in the favourable histologic subtype, despite its aggressive histologic appearance. However, others fail to confirm its favourable prognosis. Methods: This was a retrospective analysis of sixtyone (61) cases of breast cancer cases diagnosed with Medullary Carcinoma, presenting to the Kuwait Cancer Control Center between 1995 and 2005. Results: Median survival time was 122 months and the seven-year disease free survival was 82%. Overall survival rate was not assessed as no cases died during the study period. No cases were metastatic from the start and only eight cases developed metastases, local recurrence or contralateral breast primary. 68.8% of the cases were Stage I or IIA (i.e. no lymph node affection). Conclusion: There is no overt favourable prognosis of medullary carcinoma when compared to invasive ductal carcinoma. Prognosis is more related to stage than histologic subtyping. The majority of cases were negative estrogen and progesterone receptor status and node negative. Keywords: Breast, Medullary carcinoma, favourable histology


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Respiratory Gated Simultaneous Integrated Boost- Intensity Modulated Radiotherapy (SIB-IMRT) After Breast Conservative Surgery For Carcinoma Of The Breast: The Salmaniya Medical Complex Experience

  D. Majumdar, S.S. Mohammed, M.A. Naseer, J. Jacob, R. Mohan, S.B. Ebenezer, B. Al-Najar, S. Al-Janahi, V. Ramanathan, S.A. Sabt, R.S. Patnaik, A. Hassan

Department of Radiation Oncology, Salmaniya Medical Complex, Kingdom of Bahrain


Purpose: To present our clinical experience using SIBIMRT Technique for Intact Breast cancer. Materials and Methods: A retrospective review of 45 cases of Stage I-IV breast cancer patients treated with SIBIMRT with respiratory gating after conservative treatments from 25th November 2008 to 16th February 2010. The most common fractionation was 1.8 Gy to Ipsilateral Breast tissue and 2.2 Gy to the lumpectomy cavity giving whole breast dose as 50.4 Gy and Lumpectomy cavity dose as 61.6 Gy over 28 fractions concomitantly. Respiratory gating was done and CT-images were taken in inspiratory breath hold position. Results: A total of 45 patients with breast cancer - stage I (17.7%), II (71%), III (8.9%), IV (2.2%) were treated with SIB- IMRT with respiratory gated radiotherapy. Out of 45 patients, 24 are of left sided breast cancer and 21 are of right sided breast cancer patients. The median, Dose maximum (D-max) in SIB-IMRT is 106.2% of prescribed lumpectomy site dose. The median isodose line prescribed to PTV-2 is 100%. The Conformity index (CI) is 0.9688 (median value) and Homogeneity index (HI) 1.06 (median). The median ipsilateral lung, mean dose is 21.66 Gy and V-20 is 37.4%. For left sided cases the median value of mean heart dose, V-30 and V-40 are 22.98 Gy, 23.45% and 9.45 % respectively. Acute skin toxicity was of Grade-I in 2.2 %, Grade-II in 64.4 %, Grade-III in 31.1 %, and Grade-IV in 2.2 %. The global Breast cosmoses were seen excellent in majority (93%) of case at median follow up of 8 months duration. Conclusions: Breast SIB–IMRT Technique is feasible and comparable with other treatment techniques with reduced treatment duration by six fractions. At median follow up of 8 months the skin toxicity and cosmoses are excellent in high percentage of cases. Keywords: Breast Cancer, Intensity Modulated Radiotherapy, Simultaneous Boost


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Case Report And Review Of Literature: Temporary Asymptomatic Sinus Bradycardia With Carboplatin, Paclitaxel And Bevacizumab: Under-Reported In Clinical Trials And Under-Disclosed In Practice

  J. Zekri
King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia

Introduction: Paclitaxel, Carboplatin, and Bevacizumab (PCB) is one of the standard chemotherapy regimens for the treatment of non-small cell lung cancer. Temporary asymptomatic bradycardia is recognized toxicity of paclitaxel. However, it is under-disclosed to patients during consent for treatment and is under-reported in clinical phase III trials. Case report: Here, we report a case of severe but temporary asymptomatic sinus bradycardia (heart rate 39 bpm) in a patient immediately after receiving PCB. The patient was not informed of this risk during consent to therapy leading to noncompliance with future plan of management. Literature search showed that bradycardia is documented. However, it is not reported adequately in land mark phase III trials’ reports. Conclusion: The cause of bradycardia in this patient is probably paclitaxel. Oncologists should disclose this potential risk to patients during consent to chemotherapy. Investigators should monitor and report it when conducting land mark trials. Keywords: Asymptomatic Sinus Bradycardia, PCB, CBED, ACCA


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Verruciform Xanthoma Of The Penis In A Young Male Masquerading As Squamous Cell Carcinoma: Case Report

  M. Kukreja1, M. Kamal2, R. Ray3, AASR Mannan4
1Department of Pathology, PDM Hospital, Bahadurgarh, India. 2Government College Rohtak, India. 3Department of Pathology, AIIMS, New Delhi, India. 4Department of Pathology, Al Jahra Hospital, Kuwait

Verruciform xanthoma (VX) is a relatively rare benign lesion of unknown etiology with a predilection for oral mucosa. Penis is an uncommon location and to date only 17 cases of VX of penis have been reported. The lesion assumes importance as it can be easily mistaken for verrucous carcinoma or squamous cell carcinoma. We present herein a case of penile VX in a 25-year-old man who was referred to our institute with a histopathologic diagnosis of squamous cell carcinoma reported elsewhere. On microscopy the lesion demonstrated florid verruciform hyperplasia of the epidermis with hyperkeratosis, parakeratosis and acanthosis. There was a dense infiltrate of foam cells in the papillary dermis (a hallmark of VX), which were positive for CD68 and negative for S-100 protein. We present this case to highlight the significance of recognizing VX in extra oral location. An awareness of this entity is crucial to prevent misdiagnosis and halt inappropriate therapeutic intervention. Keywords: Penis, squamous cell carcinoma, verruciform xanthoma, verrucous carcinoma


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Acute Respiratory Distress Syndrome In Poor Prognostic Germ Cell Tumor With Multiple Lung Metastases: A Case Report

  M.A. Naseer1, S.S. Mohammed1, S.K. Das Majumdar1, R. Patnaik1, H.M.N. Al Tublani2, J.S. Justin1, J.A. Meddikar1
1Department of Oncology and Hematology, Salmaniya Medical Complex, Bahrain
2ICU, Salmaniya Medical Complex, Bahrain

We report a case which is unique as this patient was diagnosed pathologically as adenocarcinoma of the endometrium but clinically progressed as germ cell tumor. This was evident by progressive and rapid raised tumor markers (BHCG & LDH) with the development of multiple bilateral lung metastases. She was treated by administrating low doses of systemic combination chemotherapy as per the literature. Unfortunately, she developed acute respiratory distress syndrome as the complication of treatment and died due to it. Keywords: Poor prognostic germ cell tumor, bilateral lung metastases, acute respiratory distress syndrome


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Abstracts of the 5th GFFCC Conference on Colorectal Cancer. Sharjah, UAE, 5-7 May 2011

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