ISSUE NO. 17 - JAN. 2015
Pages Title / Authors / Abstract


Impact of BMI on Locoregional Control among Saudi Patients with Breast Cancer after Breast Conserving Surgery and Modified Radical Mastectomy


E. F. Al Saeed1, A. J. Al Ghabbban1, M. A. Tunio2
1King Saud University, Riyadh, Saudi Arabia
2King Fahad Medical City, Riyadh, Saudi Arabia


Obesity and increased body mass index (BMI) are increasing among Saudi women across all age groups with an overall prevalence of 44%. Increased BMI is associated with advanced stage breast cancer and dismal survival; however impact of BMI on locoregional control (LRC) is less studied. We aimed to evaluate the impact of BMI on LRC in Saudi patients with breast cancer after breast conserving surgery (BCS) and modified radical mastectomy (MRM).

Materials and methods:Between February 1988 and August 2008, 112 patients with breast cancer were treated with BCS and MRM followed by adjuvant chemotherapy and radiotherapy. Median age was 47.01 years (23-76). Mean BMI was 38.1 kg/m2 (15.7-52.8); BMI < 18.5 kg/m2 (underweight) in 1 (0.9%), BMI 18.5-25 kg/m2 (normal weight) in 19 (16.9%), BMI 26-30 kg/ m2 (overweight) in 32 (28.6%), BMI 31-40 kg/m2 (obese) in 48 (42.9%) and BMI > 40 kg/m2 (morbid obese) in 12 (10.7%). Median follow up period was 9 years (5-17). Cox proportional hazard analysis was done using SPSS 19.0.

Results: A total of ten locoregional recurrences (8.93%) were seen. The 5 and 10 years LRC were 86.4% and 86.4% respectively. Multivariate analysis showed poor LRC in BMI <18.5 kg/m2 (HR: 4.2; 95% CI.3.8-3.6, p 0.001) and 26-30 kg/m2 (HR: 3.4; 95% CI.3.0-3.8, p 0.01). Others factors associated with poor LRC were: age less than 40 years, premenopausal status, and no adjuvant radiotherapy, and T4, N2 and N3 stages.

Conclusion: Underweight patients with breast cancer are more prone for locoregional recurrences as compared to obese and morbid obese patients.

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A statistical quantification of radiobiological metrics in Intensity Modulated Radiation Therapy evaluation

A. Surega, J. Punitha, S. Sajitha, BS Ramesh, A. Pichandi, P. Sasikala
Department of Radiation Oncology, HCG Bangalore Institute of Oncology, Bangalore, India


The dosimetric parameters from the DVH cannot predict the amount of tumor kill and normal tissue complications directly but it can assess the conformity and homogeneity of the physical dose distributions. For example, the D-V parameter V20 (Percentage of lung volume receiving 20Gy) is used to gauge the incidence of grade =2 or grade =3 radiation pneumonitis with the plan. But the complication can be correlated to more than one point in the DVH (eg. V5, V40, D50) and it is treatment technique dependent. The aim of this study is to quantify the uncertainty of physical dose metrics to predict the clinical outcomes of the radiotherapy treatments.

Methods: The radiobiological estimates such as TCP and NTCP were made for a cohort of 50 patients (15-Brain; 20-H&N; 15-Pelvis) using the D-V parameters. A statistical analysis based on Spearman ranking coefficient correlation was performed to determine the correlation of the physical plan quality indicators with that of radiobiological estimates.

Results: The correlation between the Conformity Index and the Tumor Control probability was found to be good and the dosimetric parameters for optic nerves, optic chiasm, brain stem, normal brain and parotids correlated well with the Normal Tissue Complication Probability estimates compared to other normal structures. A follow up study (median duration: 28 Months) was also performed. There was no grade 3 or grade 4 normal tissue complications observed. Local tumor control was found to be higher in brain (90%) and pelvic cases (95%) whereas a decline of 75% was noted with Head and Neck cases.

Conclusions: The EUD concept of radiobiological model used in the software determines the TCP and NTCP values which can predict precise outcomes with the use of dose volume data in the voxel level. The uncertainty of using physical dose metrics for plan evaluation is quantified with the statistical analysis. It is also helpful in ranking rival treatment plans.

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Assessment of radiation treatment chain for cervical cancer with combined external and brachy radiation therapy


A. Chaparian1, P. Shokrani2
1Shahid Sadoughi University of Medical Sciences, Department of Medical Physics, Yazd, Iran.
2Isfahan University of Medical sciences, Department of Medical Physics, Isfahan, Iran


Performing radiotherapy of cervical cancer by combined external radiotherapy and brachytherapy includes several stages. Inaccuracy of each stage may cause insufficient dose delivery and produce complications in neighboring radiosensitive organs. In this study a technique was developed in order to assure the quality of treatment delivery.

Method: A solid pelvic phantom was designed and fabricated for simulation of the entire radiotherapy procedure of the cervical cancer. Treatment planning for external radiotherapy was accomplished using computed tomography images and for intracavitary brachytherapy using orthogonal radiographs. Dose measurements were performed with an intracavitary ionization chamber. External radiotherapy was done using linear accelerator. The Nucletron Selectron low dose rate (LDR) machine was used for brachytherapy. For both modalities, the software calculated dose values were compared to the values measured in the pelvic phantom.

Results: The calculated data obtained from the treatment planning system was consistent with the measured data. The comparison between measurements and calculations showed a maximum variation of ±2 % for external radiation therapy and ±3.6 % for brachytherapy.

Conclusion: The phantom and the procedure developed in this study successfully provided a tool for comprehensive evaluation of each step in the chain of radiation therapy under the same conditions found in actual treatment. This method can be used to verify the accuracy and reproducibility of this treatment in any department and also during commissioning of the treatment planning systems.

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Role of Lymphadenectomy And Its Impact On Survival In Endometrial Carcinoma – An Institutional Experience


S. Suchetha, P. Rema, S. Vikram, P.S. George, I. Ahmed
Regional Cancer Centre, Kerala, India


Pelvic and para aortic lymph nodes are the common sites of metastasis in endometrial carcinoma. The role of lymphadenectomy is widely discussed in literature with varying results. In this study we did a retrospective analysis of endometrial cancer patients to correlate lymphadenectomy with overall and disease free survival.

Methods: A retrospective review of 110 patients with carcinoma endometrium who underwent staging laparotomy at our institute during the period 2006-2010. Patients who underwent node dissections were categorized as group I and the rest as group II. Median lymph node count was 10. Grade of the tumor, nodal status and lymphadenectomy were correlated with overall and disease free survival.

Conclusion: Lymph node metastasis and grade of tumor are significant predictors of survival. Lymphadenectomy did not show significant survival benefit. It has helped to upstage the disease so that appropriate adjuvant therapy could be planned. A prospective randomized control trial with complete pelvic and para aortic node dissection and uniform adjuvant therapy considering nodal status may help to answer the confusion regarding lymphadenectomy.

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Epidemiology, Risk Factors and Tumor Profiles of Breast Cancer in Bangladeshi underprivileged women


M. Rahman1, A. Ahsan2, F. Begum3, K. Rahman1
1Dept. of Surgical Oncology, National Institute of Cancer Research and Hospital, Mohakhali, Dhaka, Bangladesh.
2Dept. of Medical Oncology, ShahidSurawardy Medical College, Sherebanglanagar Dhaka, Bangladesh.
3BangabandhuSkMujib Medical University, Shahbagh, Dhaka, Bangladesh


Similar to cancer statistics in developed countries, breast cancer is also the leading cause of cancer-related death in the women
population of Bangladesh particularly the poor and underprivileged. The objective of this study was to study the socio-demography, tumor patterns and risk factors that affect these women from Dhaka and Bangladesh in general.

Method: This cross-sectional study involved 250 patients who presented to NICRH, Dhaka for treatment. These patients were interviewed, physically examined and vital information were gathered using approved questionnaires. Various personal, social, reproductive and tumor related factors were recorded and analyzed.

Result: The mean age of the study group was 44.7 years, standard deviation (SD) was 9.82 (range: 21-67), 87% have children, 57.2% were postmenopausal, 92% were housewives, 51.4% were illiterate, 62% attended 6 months after initiation of symptoms, 72% of the patients’ yearly family income were less than US$1000/year. Almost 100% of the patients gave history of cooking from wooden fire source in the rural areas. In our study group, 79.7 percent women were within the group of BMI 20 kg/m2or more. Locally advanced breast cancer patients (T3 and T4) were 52.6%, axillary lymph node involvement was present in 80% of cases, 61.6 % patient received neoadjuvant chemotherapy. In the elderly group (>40 years) Estrogen receptor was positive in 53.2% cases, 26.6% were Triple negative breast cancer patients.

Conclusion: Women with poor socio-economic status and have none or low educational level are often victims of late presentation and tend to have a higher stage at diagnosis. Poverty, literacy and assorted risk factors have influenced the outcome of breast cancer cases among Bangladeshi women.

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Early hematological effects of chemo-radiation therapy in cancer patients and their pattern of recovery - A prospective single institution study

H.N. Lee1, M.K. Mahajan1, S. Das2, P. Jeyaraj1, J. Sachdeva1, M.S. Tiwana1
1Dept. of Radiotherapy, 2Dept. of Pathology, Christian Medical College and Hospital, Ludhiana, Punjab 141 008, India


The purpose of this prospective study is to understand the early hematological effects of chemo-radiation therapy in cancer patients, their pattern of recovery and to ascertain their prognostic value.

Methods: 255 diagnosed cancer patients planned for definitive treatment with radiation therapy alone or with chemotherapy were included in this two year prospective study. A complete blood count was done at baseline, weekly during the course of therapy and thereafter, monthly for a period of 6 months. For the purpose of grading clinical toxicity, the Common Toxicity Criteria, CTCAE v2.0 was used while RECIST criteria was used to define the tumor response rates. This study was statistically analyzed using SPSS software.

Results: 255 patients were included in the study wherein head and neck cancers comprised the major patient population (28.6%) followed by cervix (18.8%) and breast (15.7%). Out of these, 37% in head-and-neck cancer subgroup, and 58.3% in cervix had anemia at start of treatment. 92.2% cases with chemoradiation developed anemia during treatment, while with radiation alone it was 95.5%. This was statistically significant in patients with cancer uterine cervix (p < 0.01). At the end of treatment 65% patients with normal hemoglobin had complete responses (CR), while 58.3% with mild anemia and 33.3% with moderate anemia had CR (p=0.1).

Conclusions: Severe anemia during treatment is a poor prognostic indicator and is usually a sign of advanced disease. Leucopenia and thrombocytopenia occur more commonly during chemoradiotherapy as against radiotherapy alone, but improves with supportive management.

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Platinum-based chemotherapy in metastatic triple negative breast cancer: Experience of a tertiary referral centre in India

Authors: V. V. Maka, H. Panchal, S. N. Shukla, S. S. Talati
Collaborators: P. M. Shah, K. M. Patel, A. S. Anand, S. A. Shah, A. A. Patel, S. Parikh
Department of Medical Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India.


Experimental data suggest that triple-negative breast cancer (TNBC) may have increased sensitivity to platinum-based chemotherapy but there is lack of relevant clinical data. Clinical outcomes in patients with metastatic TNBC treated with Platinum-based chemotherapy were evaluated in this prospective study.

Methods: 21 selected patients with metastatic TNBC presenting at GCRI during the study period from 1st August 2009 to 31st October 2011 formed the study group with median follow up period of 10 months. They were given palliative chemotherapy based upon prior adjuvant chemotherapy along with an additional platinum compound. Response rates, response duration and toxicities of platinum-based chemotherapy were recorded and analyzed.

Results: In evaluable TNBC patients, overall response rate and complete clinical response were 72% and 38% with median response duration of four months. Response could not be assessed in three patients due to patient refusal for evaluation, lost to follow up and toxicities. In three TNBC patients after completion of platinum based chemotherapy have early isolated CNS relapse with systemic disease in remission. Haematological adverse effects were febrile neutropenia in 19% of patients, and grade 3–4 neutropenia (9%) thrombocytopenia and anaemia (7%). The main non-hematological adverse effects reported in the present study were peripheral neuropathy (14%) and severe emesis (9%). The most common Platinum-based chemotherapy combination was carboplatin and paclitaxel in 11 patients (52%) of evaluable patients. Patients who received this regime have complete response rate, overall response rate and toxicity was 45%, 65% and 10%.

Conclusions: TNBC patients with platinum-based chemotherapy have better overall response rates, higher complete clinical response rates, prolonged response duration and acceptable safety profile. The results of the present study need to be confirmed with a larger randomized study with a longer follow up.

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A Single Institution 18-Years Retrospective Analysis of Malignant Melanoma


A. Mukherji1, A.K. Rathi2, P.K. Mohanta2, K. Singh2
Dept of Radiotherapy, Regional Cancer Centre, JIPMER, Puducherry, India.
2Dept of Radiotherapy, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India


Melanoma accounts for about 2% of all cancer-related mortality in western populations. Surgical excision of localized disease is curative in many patients with 80% overall 5-year survival rate. There are many indicators of prognosis of which tumor burden is predicted by primary site with nodal status being the next most important variable. Patients with advanced stage have very high risk of developing distant metastases and should receive systemic therapy. Despite treatment, majority of locally advanced patients develop metastatic disease.

Materials and Methods: A retrospective analysis of cases of malignant melanoma registered over a period of eighteen years, from October 1990 to September 2007 was done. Patient profile, presentation, disease load, treatment protocols and response on or after treatment were analyzed.

Results: The median age at diagnosis in men was 48 years and 50 years in women. At presentation, more than half of studied cases (56.5%) presented with nodal metastases at diagnosis while about three fourths (74%) had distant metastases (stage IV disease). More than half (56%) of the patients had superficial spreading type. The most common presenting complaints were swelling (70% of patients), ulcer (50% of patients) or pain (50%). Primary sites included extremities, central nervous system, abdomen, trunk, and bones. Liver, brain, abdomen and lungs were common metastatic sites. Surgical excision of primary lesion was done in about half of the cases. Four patients subsequently received palliative radiotherapy and two more received adjuvant radiotherapy. Another six patients received adjuvant chemotherapy and radiotherapy. Among treated patients, 26% showed partial response and another 8% have stable disease while 65% patients progressed on or after initial treatment.

Conclusion: Malignant melanoma carries an overall poor prognosis especially in advanced stages. Multimodality therapy with surgery, radiotherapy and chemotherapy may provide local or nodal remission but cannot improve long term survival in advanced cases.

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MRI and Ultrasonography for assessing multifocal disease and tumor size in breast cancer: Comparison with histopathological results


V. Rudat1, A. Nour1, N. Almuraikhi5, I. Ghoniemy3, I. Brune-Erber2, N. Almasri4, T. El-Maghraby3
1Dept. of Radiation Oncology, 2Dept. of Surgery, 3Dept. of Radiology, 4Dept. of Pathology and Laboratory Medicine, Saad Specialist Hospital, Al Khobar, Saudi Arabia.
5SAAD Research and Development Center, Al Khobar, Saudi Arabia


The purpose of the study was to compare the accuracy of breast MRI and ultrasonography in assessing the tumor focality and tumor size of newly diagnosed non-high risk breast cancer patients.

Methods: The tumor focality status and the maximal tumor diameter by MRI and ultrasonography were retrospectively compared with the corresponding histopathological findings as reference. Test characteristics concerning the tumor focality status were calculated. Bland-Altman plots were generated to evaluate the agreement of the tumor size measurements by imaging and histopathology. The t-test for dependent samples and the Fisher exact test were used to test differences between groups for statistical significance. The Pearson correlation coefficient r was calculated to measure the degree of association between the tumor diameter by imaging and histopathology.

Results: Sixty-four patient diagnosed between 2011 and 2013 were analyzed. MRI showed a good sensitivity of 83% for detecting multifocal disease (ultrasonography, 75%). The positive predictive value was 67% and the ratio of true-positive to false-positive findings 2.0. MRI showed better limits of agreement (-21 to 26 mm versus -29 to 26 mm) and a better correlation (r=0.77 versus r=0.66) with the histopathological tumor diameter compared to ultrasonography. The mean differences between the tumor diameter by MRI and histopathology and ultrasonography and histopathology were not significantly different (p=0.09). The T classification (T1a, T1b, T1c, T2, T3) was correctly estimated by MRI in 43 patients (67.2%) and by ultrasonography in 39 patients (60.9%) (p=0.58).

Conclusion: In our patient cohort only a modest diagnostic advantage of MRI compared to ultrasonography could be detected.

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Patient’s Compliance on the Use of Extended Low Molecular Weight Heparin Post Major Pelvic Surgeries in Cancer Patients at King Hussein Cancer Center


M. Baba, M. Al-Masri, M. Salhab, M. El-Ghanem
Department of Surgery, King Hussein Cancer Center, Amman, Jordan


Effective Venous Thrombo-Embolism (VTE) prophylaxis is used in less than 50% of oncology patients despite its wide availability. Low molecular weight heparin (LMWH) as a daily injection is an essential tool for effective prophylaxis against deep vein thrombosis (DVT). Daily outpatient self-injection by the patients or their family members is common practice. The effectiveness of this measure depends on patient compliance.

Objective: The purpose of this study is to determine the degree of compliance and the factors that affect compliance to the extended out-patient use of prophylactic LMWH for 1 month after major abdominal/pelvic surgeries in cancer patients at King Hussein Cancer Center (KHCC).

Patients and Methodology: Following major abdominal/pelvic surgeries, data on 160 cancer patients at KHCC from January 2007 until July 2012 were collected concerning knowledge of DVT and compliance with prophylactic self-injections by answering a questionnaire.

Results: We have achieved a high compliance rate, this was explained by the medical team’s role in educating the patients about the risk of VTE and the importance of thromboprophylaxis. The compliance with self-injections was directly associated with younger age, employment and higher degree of education.

Conclusion: The high compliance rate outside clinical trials can be achieved through comprehensive patient education by a well-qualified medical team, clarification of the importance of DVT prophylaxis and patients’ support.

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Can we use Sorafenib for advanced Hepatocellular Carcinoma (HCC) Child Pugh B?

K. Rasul, A. Issameldin, S. Elazzazi, R. Ghasoub, A.Gulied
NCCCR, Hamad Medical Corporation, Doha, Qatar


HCC is the third cause of cancer-related death worldwide and the fifth most common cancer in the world with an increasing incidence in some areas like Europe, USA and the Gulf region. In this study patients with advanced HCC in both group child pugh A and B were treated with sorafenib.

Methods: This is a retrospective observational study to assess the safety and effectiveness of sorafenib in patients with advanced HCC child pugh A and B who failed local palliative ablation therapy or were not eligible for such therapy. Forty six patients included.

Results: In both child pugh A and B group the sorafenib was well tolerated and survival was improved but it was more pronounced in the child pugh A group.

Conclusion: This is the first study that includes high percentage (47%) of child B group to be treated with sorafenib. Compared with international data there was improved overall survival in both groups.

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External auditory canal as an unusual site for metastasis of breast cancer: A case report


B.A. Baraka1, B.J. Al Bahrani1, S.S. Al Kharusi1, I. Mehdi1, A.M. Nada1, N.H. Al Rahabi2
Medical Oncology Department, National Oncology Center, Royal Hospital, Muscat, Oman
2Histopathology Department, Royal Hospital, Muscat, Oman


Metastatic breast cancer is one of most common cause of death in women worldwide. The estimated incidence of breast cancer to be metastatic at diagnosis is 6%, with a five year survival rate of about 21%. There are three types of breast cancer recurrence: local, regional and distant metastasis mainly to the lung, liver, bone or brain. Review of literature indicate a relatively few reported cases about metastatic breast cancer to soft tissue. We present a case of metastatic breast cancer to left external auditory canal.

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Primary Mixed Cellularity Classical Hodgkin lymphoma of the Lumbar spine – An unusual presentation


K.R. Anila1, R. A. Nair1, S. Prem2, K. Ramachandran3
1Dept. of Pathology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
2Dept.of Medical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
3Dept. of Radiology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India


Primary spinal epidural lymphoma (PSEL) is a subset of lymphoma. For the diagnosis of PSEL there should be no other recognizable sites of lymphoma other than the spine at the time of diagnosis. The incidence of this subset of lymphomas is very low. Hodgkin lymphoma (HL) usually presents with painless enlargement of peripheral lymph nodes and only a small percentage arises from extra nodal regions.Very few patients with HL develops spinal cord compression due to an epidural tumor at some time during the course of their disease. But patients with HL presenting with isolated primary involvement of the epidural spinal region is very rare with very few reports available in the literature.

Case: A 19-year-old male presented to the local hospital with history of low back pain for almost one year. An initial biopsy was non-contributory and was reported as showing inflammatory change. The patient was empirically started on antituberculosis medication but his condition worsened and within weeks he developed paraplegia. MRI of the spine showed a large paraspinal mass with compression of L1 vertebral body. Urgent surgical decompression was done and final histopathology showed a mixed cellularity classical Hodgkin lymphoma (MCCHL). Systemic work-up did not show evidence of nodal disease. Following surgery, he received chemotherapy.

Conclusion: We report this case because of the unusual presentation of HL as a primary spinal mass. We would also like to highlight that apart from common causes, a differential diagnosis of HL should also be entertained while dealing with spinal masses. Otherwise diagnosis can be missed leading to delay in treatment and complications.

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Subdural hematoma during therapy of gastro-intestinal stromal tumor (GIST) with Imatinib mesylate


J. Feki1, G. Marrekchi1, T. Boudawara2, N. Rekik3, S. Maatoug4, Z. Boudawara5, M. Frikha1
1Dept. of Medical Oncology, 2Dept. of Anatomopathology, 3Dept. of Emergency Medicine, 4Dept. of Legal Medicine,
5Dept. of Neurosurgery, Habib Bourguiba Hospital, Tunisia


Imatinib mesylate is a widely used tyrosine-kinase inhibitor (TKI) in chronic myeloid leukemia (CML) treatment. Imatinib has contributed to complete and prolong cytogenetic responses so that it is now the standard treatment of CML. Recently, Imatinib mesylate has shown a significantly prolonged progression-free survival and overall survival in metastatic and locally advanced c-Kit positive gastro-intestinal stromal tumors (GISTs) and more recently a prolonged disease-free survival in operated high risk GIST. Imatinib is a welltolerated treatment with few side effects mainly gastro-intestinal symptoms (nausea, vomiting and diarrhea), headaches, rash and periorbital edema. Hemorrhage incidents are rare in patients treated with Imatinib. They are more frequently seen in CML patients. Hemorrhage incidents in CML include in many cases upper gastro-intestinal (GI) tract bleeding and central nervous system bleeding in rare ones. In GIST patients treated with Imatinib, hemorrhage incidents are exclusively made of upper GI tract bleeding consecutive to tumor perforation or necrosis. In our observation, we present the case of a subdural hematoma occurring in a patient treated with adjuvant Imatinib for a high risk localized gastric GIST. No other case of subdural hematoma in GIST treated with Imatinib has been reported in literature.

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