A Retrospective Dosimetric Study in Breast Cancer Patients Who Received Conformal Radiation Therapy for Achievability of Recommended Dose Constraints of RTOG, DBCG, EORTC for Lung and Heart

PURPOSE/OBJECTIVE(S)

In India, carcinoma of breast is the commonest malignancy among women. In multidisciplinary approach of its management, radiotherapy (RT) is an important component. Different cooperative groups have defined dose constraints to lungs and heart to minimize these late side effects such as radiation pneumonitis and coronary artery disease. To assess the achievability of dose constraints given for lung and heart by RTOG, EORTC and DBCG in our cohort of breast cancer patients who underwent conformal radiation therapy to chest wall / breast along with supraclavicular nodal region.

MATERIALS/METHODS

This retrospective dosimetric study included all breast cancer patients who underwent conformal radiation in our institute from Jan 2021 to Dec 2022 and was treated with a dose of 40 Gy in 15 fractions.

RESULTS

A total of 302 patients (162 - Left sided, 140 - Right sided) were in the study cohort. Majority of them received RT with 3DCRT with FiF (266 patients) and 36 patients received RT by VMAT technique. Respiratory gating was done in left sided breast cancer by DIBH for 46.2 % of patients due to COVID pandemic during this period. Our analysis showed that for the ipsilateral lung, EORTC (77.8%) dose constraints were easy to achieve followed by DBCG (65.2%) and RTOG (61.9 %). For the heart constraints in left sided breast cancer patients, easily achievable constraints were by DBCG (91.9 %) followed by RTOG (66.6 %) and EORTC (53.1%). The DBCG constraints of Dmean <5 Gy was more liberal than any other recommendations. All the dose constraint recommendations were easily achieved for heart in right sided breast cancer patients, by more than 90 % of the population. Usage of respiratory gating with DIBH technique improves the rates of achievability of lung constraints in 56 (74.6%) out of 75 patient and heart constraints in 54 (72 %) out of 75 patients. Our institutional policy is to treat chest wall / breast along with supraclavicular nodal chain in case of NACT or T3/T4 disease and this could have been the reason why we were unable to achieved the dose constraints recommended.

CONCLUSION

The DBCG dose constraint recommendations for heart was achieved in the left chest wall treatment in majority of women and EORTC was best achieved for ipsilateral lung. All heart dose constraint recommendations were achieved for right chest wall treatment. Respiratory gating improves achievability rates of the recommendations. It is difficult to achieve all the dose constraints as recommended by different cooperative groups as there is variation among them.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Retrospective Outcome Analysis of Buccal Mucosal and Lower Alveolar Squamous Cell Carcinoma from a High-Volume Tertiary Cancer Centre

To evaluate treatment outcome and factors affecting locoregional control and distant metastasis in buccal mucosal and lower alveolar squamous cell carcinoma. A retrospective analysis of all diagnosed cases of buccal mucosal and lower alveolar squamous cell carcinoma in patients who underwent surgical treatment in 2011 was included from the data base. The patients were analysed for their habits, trismus, skin and bone involvement, neck nodes, type of surgery for primary and nodes, differentiation of tumour, pathological nodal status, recurrence site, and duration after completion of treatment and follow-up. A total of 114 patients were included in the study. The mean duration of follow-up was 23.8 months. On follow-up, 30 patients had recurrence (26.32%) either locoregional or distant metastasis. Age less than 45 years, nodal positivity, presence of perineural invasion, extracapsular spread, and degree of differentiation were found to be statistically significant by univariate analysis (p < 0.05). On multivariate analysis, node positivity and presence of perineural invasion emerged as independent predictors of recurrence. Cox regression analysis showed trismus, node positivity, and perineural invasion are significantly associated with recurrence. Aggressive multimodality treatment achieves good local control rates even in locally advanced disease, and the intent of treatment should be curative. Node positivity, presence of perineural invasion, and presence of trismus are found as independent predictors of recurrence. Clinically, presence of trismus is associated with poorer outcomes in view of higher stage.

Developing a Model of Distributed, Decentralized Digitally Connected Cancer Control Program

Background and context: Traditional method of managing cancer through establishing large comprehensive cancer centers are ineffective in developing country setting that has poorly developed primary health care facilities. These larger cancer centers become victims of their success and attract increasing number of patients from distant places, overstretching the resources and increasing out-of-pocket expenses for the patients. Increasing the number of cancer centers also is not effective as each unit by itself will not have the critical mass of expertise to offer comprehensive cancer care. In addition, for sustainability and improved resource utilization, the cancer care needs to be integrated with the existing health care system. The state with a population ∼ 33.3 million has 19 cancer treatment facilities distributed throughout the coastal districts. The cancer incidence rate of the state is 128 per 100,000, which is the fourth highest in the country. Aim: To develop a model for distributed, decentralized digitally connected cancer control program for the state of Kerala, India. Strategy/Tactics: A model for distributed, decentralized digitally connected cancer care that offers resource stratified cancer care and integrate with the existing health care. Program/Policy process: The distributed cancer care network for the state that will be digitally connected using a recently introduced e-health program to interconnect the cancer care as well as to integrate with the existing healthcare network. The cancer centers will be stratified in 4 levels. Level 1 would be 3 apex cancer centers with most advanced infrastructure and serves as quaternary centers and coordinate cancer care in 3 zones. The Level 2 cancer centers established at medical colleges and cancer centers in major private medical hospitals offer comprehensive cancer care in a geographic area and serve as tertiary cancer referral centers. Level 3 centers are located in the district and Taluk hospitals that offers primary cancer care for common cancers including palliative daycare chemotherapy. Level 4 units are established as part of the national health mission in primary and family health centers which provide the important task of cancer surveillance and improving cancer literacy for the public with peoples participation. Outcomes: The expected outcomes are downstaging of cancer, developing a resource-stratified referral pathway that minimize treatment delay, provide cancer care within 90 minutes of travel and lowering out-of-pocket expenses. What was learned: Planning of the program involved participation of major stakeholders of cancer and health care of the state as well as NGO.

Respiratory signs, fever and lymphopenia in calves inoculated with Brazilian HoBi-like pestiviruses

Hobi-like viruses (HobiPeV) comprise a novel, recently classified species of bovine pestiviruses, originally identified in commercial fetal bovine serum of Brazilian origin and, subsequently, isolated from diseased animals in several countries. Although frequently isolated from clinical cases, most HobiPeV isolates failed to reproduce overt disease in cattle upon experimental inoculation. Herein, we describe the outcome of experimental infection of four to six months-old seronegative calves with two Brazilian HobiPeV isolates. Calves inoculated intranasally with isolate SV478/07 developed viremia between days 2 and 9 post-inoculation (pi) and shed virus in nasal secretions up to day 11pi. These animals presented hyperthermia (day 7 to 10-11 pi) and lymphopenia from days 4 to 8pi. Clinically, all four calves developed varied degrees of apathy, anorexia, mild to moderate respiratory signs (nasal secretion, hyperemia), ocular discharge and pasty diarrhea in the days following virus inoculation. In contrast, calves inoculated with isolate SV757/15 presented only hyperthermia (days 3 to 10-11 pi) and lymphopenia (days 4-8 pi), without other apparent clinical signs. In these animals, viremia was detected up to day 9 pi and virus shedding in nasal secretions lasted up to day 12-14 pi. Both groups seroconverted to the inoculated viruses, developing virus neutralizing (VN) titers from 320 to 5120 at day 28pi. These results extend previous findings that experimental infections of calves with HobiPeV are predominantly mild, yet they also indicate that field isolates may differ in their ability to cause disease in susceptible animals.

Evaluation of stapled closure following laryngectomy for carcinoma larynx in an Indian tertiary cancer centre

BACKGROUND AND AIM

Stapling devices are used for pharyngeal closure after laryngectomy for the past few decades although it has not gained wide acceptance. This study is aimed at evaluating the role of stapler in pharyngeal closure after laryngectomy.

METHODS

Thirty consecutive patients who underwent stapled laryngectomy at our institution from October 2004 to February 2008 were evaluated retrospectively. Linear stapler (Proximate TX 60; Ethicon Inc.) was used for closure of neopharynx.

RESULTS

There were 28 males and 2 females with mean age of 54.5 years (54.5 ± 11.2). Nineteen of these patients (63.3%) had salvage laryngectomy and two patients (6.7%) had laryngectomy for a second primary tumor. Twenty-eight patients had total laryngectomy (TL), whereas two had extended TL. Eight patients had salivary leak (26.7%). Of these, 6 (75%) had prior radiation. All salivary leaks except one were managed conservatively. Follow-up ranged from 7 to 54 months (median: 21 months). Seven patients (23.3%) developed recurrence, six at the stoma, of which 5 (83.3%) had initial extension of disease to the subglottis. Four-year disease-free survival was 54.4%.

CONCLUSION

Pharyngeal closure by linear stapler is an efficient and safe method of fashioning the neopharynx after laryngectomy with no added risk of occurrence of pharyngocutaneous fistula in primary and salvage laryngectomies.

Schwannoma base tongue: Case report and review of literature

Schwannomas are benign peripheral nerve sheath tumors. These are rare in the oral cavity (1%). The most common site of involvement in oral cavity is the tongue. Posterior third of tongue is not frequently involved. The aim of this paper is to present a case report of base tongue schwannoma and review literature of this rare tumor. Data from literature were analyzed for age, gender, presenting symptom, size at presentation, and surgical approach. We report a case of 26 year-old male who presented with swelling posterior 1/3rd tongue and change in quality of voice. He was evaluated for the same with MR and incision biopsy and was planned for surgery. Surgery was abandoned at a district hospital due to difficulty in intubation. At our center he underwent fibro optic bronchoscopy guided intubation followed by general anesthesia. He underwent excision of mass using left paramedian lip spitting approach with mandibulotomy and mandibular swing. Tumor was excised in toto. His postoperative recovery was uneventful. Literature review between 2001 and 2012 was done. 15 cases of base tongue schwannoma were identified. The most common age group involved was between 30-40 years. There was a slightly higher incidence in females. All patients were symptomatic at presentation. Most common complaints were related to swallowing and throat pain. Most patients underwent transoral excision of the tumor.

Anterior skull base reconstruction after cranio-facial resections using galeal pericranial flap

The tumors of the anterior cranial cavity can either be malignant or benign. They usually arise in the nasal or Para nasal sinuses. Treatment of these tumors includes major craniofacial resection and reconstruction to prevent cerebrospinal fluid leak and meningitis. In this study we are presenting a technique which is simple and cost-effective. We are reporting a series of nine cases in which this technique was tried out and we found that it can be used for dural repair and anterior cranial fossa reconstruction with no major complications.

Objective and perceptual analysis of outcome of voice rehabilitation after laryngectomy in an Indian tertiary referral cancer centre

Post laryngectomy voice rehabilitation is very challenging in centres with limited resources because of cost concerns and morbidity. A study of laryngectomised voice rehabilitated patients on follow up was performed to look into overall quality of life (QOL), morbidity and voice quality. Those patients who had visited head and neck surgical outpatient department during the period of January 2008 to October 2009 were evaluated for their QOL, morbidity and voice quality, objectively and subjectively. Voice rating and QOL rating showed a distinct discrepancy which could be explained by the morbidity recorded for surgical voice restoration in the present study. Voice rehabilitation strategy after laryngectomy in a low resource setting has to take in account financial social educational background of the patient besides technical issues.

Multiple ancient schwannoma of the accessory nerve: a case report

We are reporting a case of multiple ancient schwannoma of the accessory nerve in a 57 year old male. Accessory schwannomas are rare with only 19 cases reported in literature so far. Ancient schwannoma is even rarer in the head and neck region with no other cases associated with the accessory nerve being reported in literature so far.

Cancer survival in Karunagappally, India, 1991-1997

The rural cancer registry of Karunagappally was established in 1990 to study cancer occurrence due to high natural background radiation in the coastal area of Kerala state. Cancer registration was done by active methods. The registry contributed data on survival for 22 cancer sites or types registered during 1991-1997. Follow-up has been carried out predominantly by active methods, with median follow-up time ranging between 3-57 months for various cancers. The proportion of histologically verified diagnosis for different cancers ranged between 39-100%; death certificates only (DCOs) comprised 0-25%; 75-100% of total registered cases were included for survival analysis. The 5-year age-standardized relative survival rates for common cancers were lung (6%), breast (45%), cervix (55%), mouth (42%), oesophagus (14%) and tongue (31%). Five-year relative survival by age group showed no distinct pattern or trend for most cancers. A majority of cases are diagnosed with a regional spread of disease among cancers of the tongue (48%), oral cavity (66%), hypopharynx (54%), larynx (46%), cervix (61%) and breast (53%); survival decreases with increasing extent of disease.

Influence of methylenetetrahydrofolate reductase polymorphisms in oral cancer patients

BACKGROUND

Methylenetetrahydrofolate reductase (MTHFR) is a key enzyme in folate metabolism. Two common polymorphisms associated with MTHFR gene - C677T and A1298C - influence the thermolabile nature and activity of the enzyme. This study aimed to investigate the role of MTHFR polymorphisms on oral cancer susceptibility and its potential impact on the prognostic outcome.

METHODS

Oral cancer cases and controls were genotyped using PCR-RFLP technique for MTHFR C677T and A1298C polymorphisms. Disease susceptibility analysed using regression analysis. The association between clinical outcomes and the polymorphisms were analysed using univariate and multivariate model.

RESULTS

The 677CT+TT genotype showed a significant three-fold reduction in oral cancer risk (RR-0.35, p-0.009). 1298CC genotype showed decreased cancer risk when compared to AA+AC genotype (RR-0.55, p-0.062). When prognostic significance of MTHFR polymorphism was evaluated, 677CT+TT patients showed improved survival than the CC individuals (RR = 0.56, P = 0.378). The 1298 CC and AC+CC showed an increased risk for treatment failure and poor survival when compared with the wild AA genotype (HR = 4.27, P = 0.001).

CONCLUSION

Here we observed MTHFR C677T to influence oral cancer susceptibility, while A1298C polymorphism associated with patient prognosis. Our data support MTHFR polymorphism to be an independent prognostic marker in oral carcinoma.

Treatment outcome in patients undergoing surgery for carcinoma larynx and hypopharynx: A follow-up study

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Background: In the Regional Cancer Centre (RCC) Trivandrum, India, carcinoma of the larynx account for approximately 5% of all new registries and carcinoma of the hypopharynx for another 3%. It is estimated that the division of surgical oncology RCC has performed about 200 laryngectomies since it’s beginning (1989). Currently i.e. after the year 2000,about 30–40 laryngectomies are estimated to be performed a year thus forming about 3–4% of overall major head and neck surgeries performed which is around 1000 cases per year. 80% of these surgeries are salvage procedures for failed radical radiation/chemoradiation. Aim: (1) To evaluate the role of surgery in disease free and overall survival. (2) To evaluate the prognostic significance of factors that generally affect the surgical outcome in laryngectomies. (3) To evaluate the morbidity associated with salvage surgeries and laryngectomies involving complex reconstructions. (4) To follow up all the patients and evaluate quality of life. (5) To evolve a protocol for selecting cases for primary and salvage laryngectomy. (6) To evolve a protocol for reconstructing the pharynx after laryngectomies. Methods: All patients who have undergone laryngectomy at the Division of Surgical Oncology RCC from June 1995 to Dec 2005 are included in the study which retrospectively records the age and sex distribution initial TNM staging and staging of recurrence/ residual disease at the time of surgical salvage, the indications and types of laryngectomy, and reconstructive options used and analyze the therapeutic outcome, disease free survival (DFS), overall survival (OS), voice preservation, post operative voice rehabilitation and quality of life. Major outcome measures Complications and factors contributing to it, DFS, OS, Voice Preservation, Postoperative rehabilitation and Quality of life. Results and Conclusions: An update of the results as on 31/12/05 the final conclusions and recommendations will be presented.( The study is currently on going with the Institutional Review Board (IRB) and the local Ethical committee (EC) clearance already obtained.and final document is expected to to be prepared by March 2006).

No significant financial relationships to disclose.

Oral cancer detection using diffuse reflectance spectral ratio R540/R575 of oxygenated hemoglobin bands

A low-cost, fast, and noninvasive method for early diagnosis of malignant lesions of oral mucosa based on diffuse reflectance spectral signatures is presented. In this technique, output of a tungsten halogen lamp is guided to the tissue through the central fiber of a reflection probe whose surrounding six fibers collects tissue reflectance. Ex vivo diffuse reflectance spectra in the 400 to 600-nm region is measured from surgically removed oral cavity lesions using a miniature fiber optic spectrometer connected to a computer. Reflectance spectral intensity is higher in malignant tissues and shows dips at 542 and 577 nm owing to absorption from oxygenated hemoglobin (HbO2). Measurements carried out, within an hour of surgical excision, on malignant lesion and adjoining uninvolved mucosa show that these absorption features are more prominent in neoplastic tissues owing to increased microvasculature and blood content. It is observed that reflectance intensity ratio of hemoglobin bands, R540/R575, from malignant sites are always lower than that from normal sites and vary according to the histological grade of malignancy. The diffuse reflectance intensity ratio R540/R575 of the hemoglobin bands appears to be a useful tool to discriminate between malignant lesions and normal mucosa of the oral cavity in a clinical setting.

FACT-G: reliability and validity of the Malayalam translation

BACKGROUND

Emphasis is currently being placed on the need for quality of life in cancer survivors. There is a great need to identify an appropriate tool for quality of life estimation in these linguistically and culturally different settings.

PATIENTS AND METHOD

The Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire was translated into the Malayalam language complying with the standard cross-cultural translation methodology. The tool was validated and used for estimating quality of life (QOL) of 214 cancer patients undergoing treatment with curative intent.

RESULTS

Cronbach's alpha for the Malayalam version of the FACT-G was 0.8, and for the subscales it ranged from 0.64 to 0.83, compared to source tool alpha of 0.89, with the subscale's ranging from 0.63 to 0.89. The mean overall FACT-G score was 79.8 (standard deviation [SD] = 18.7). Socio-economic factors such as education, education of the spouse, occupation of the spouse, and family income were found to influence FACT-G scores.

CONCLUSION

Despite cultural variations, the local Malayalam language version of the FACT-G scale was found to be reliable like the source scale and sensitive cross-culturally. The instrument makes it possible to identify domains influencing QOL and thereby may help direct interventions to them.

Salvage chemotherapy and surgery for radio recurrent carcinoma glottis

Chemoradiotherapy is increasingly used in advanced laryngeal cancers. Failures are generally managed by surgery. They include histologically confirmed recurrent or residual disease or a symptomatic life threatening treatment sequelae. Tumour recurrence or residivism can be managed by chemotherapy when radical surgery is either refused by the patient or if the general condition of the patient do not permit it. However surgery becomes inevitable when life threatening treatment sequelae like absolute pharyngo-oesophageal stricture and aspiration sets in.

Survival in patients under 45 years with squamous cell carcinoma of the oral tongue

Squamous cell cancer among young adults is rare and thought to have aggressive biological behaviour and poor prognosis. Clinical case records of 76 patients under the age of 45 years treated for squamous cell carcinoma (SCC) of the oral tongue were retrospectively analysed to calculate the survival rates and the predictors of survival. The overall survival (OS) and disease free survival (DFS) at 5 year were 78.0% and 57.4% respectively. Tumour status, pathological node status, surgical clearance, the selection of appropriate treatment, type of primary and neck surgery, were found to significantly influence the survival rates. Young patients with SCC of the oral tongue were seen to have a comparable outcome and prognosis compared to that in older patients.

Soft tissue sarcoma of the head and neck region in adults

Soft tissue sarcomas (STS) are rare solid tumours accounting for less than 1% of all malignancies and are very unusual in the head and neck region. Histopathologically diagnosed cases of STS treated at Regional Cancer Centre (RCC). Trivandrum, India, between January 1989 and November 2000 were analyzed retrospectively. Survival analysis was carried out by Kaplan-Meier method and curves were compared using log rank test. A total of 22 cases were seen during the study period. The mean age of the patients was 36.4 years with male-to-female ratio of 2:1. The neck, lower jaw, tongue, cheek, scalp and maxilla were the commonest sites affected. None of the patients had palpable neck nodes or distant metastasis at presentation. All the patients were treated with primary surgical resection and this was followed by adjuvant treatment in 14 cases (63.6%). After a median follow-up of 14.5 months, two patients died, six developed local recurrence, four developed metastatic disease and another patient developed second primary sarcoma. The overall 5-year survival was 80% while the 5-year disease-free survival rate was 24.1%. The majority of the patients failed within first and second year. None of the parameters except grade of tumour (P=0.008) were found to have a significant effect on survival. The overall survival rate for patients with soft tissue sarcoma of the head and neck is good, however, disease-free survival is poor as the majority of these fail within 2 years of completing treatment.

Infrequent loss of heterozygosity of the major tumour suppressor genes in Indian oral cancers

The loss of heterozygosity (LOH) in tumour suppressor gene loci such as p53, retinoblastoma (rb) and adenomatous polyposis coli (apc) were analyzed in oral cancer tissues with matched controls by employing polymerase chain reaction based/restriction fragment length polymorphism (PCR-RFLP), variable number of tandem repeats (PCR-VNTR) analysis and microsatellite assay. The PCR-RFLP analysis showed an infrequent LOH in rb (17%), p53 (11%) and apc (10%) loci in these cases. The microsatellite assay also revealed only a low frequency of LOH in the microsatellite markers such as TP53 (25%), D5S505 (10%) and D3S1067 (0%) in the same samples. In contrast to the present study, similar studies from Western countries have reported a high frequency of LOH in p53, rb and apc genes in oral cancer tissues. The present preliminary study indicates that the gene aberration by LOH may be an insignificant mechanism in Indian oral cancers with respect to the tumour suppressor genes examined.

An unusual bilateral cervical paraganglioma: a case report

Paragangliomas are neoplasms originating from paraganglion tissue derived from mesoderm, the most common location being adjacent to carotid bifurcation. Rarely these tumours can be bilateral. We present here a case of bilateral paraganglioma occurring in a young woman. On one side the tumour was arising from the vagus nerve and on the other, from the carotid body. Clinical, radiological and histopathological features and treatment dilemmas are discussed.

Intramuscular lipomatosis of tongue

A rare case of intramuscular lipomatosis of the tongue with intramuscular invasion in a 42 year old man is presented. The literature is reviewed and the clinical features, pathology, and treatment are discussed briefly.

Primary malignant mucosal melanoma of the head and neck region: pooled analysis of 60 published cases from India and review of literature

Malignant melanoma arising in the head and neck mucosa is a rare entity with incidence ranging from 2% to 10%. Because of the lack of data, the biological behaviour of these lesions still remains unpredictable and outcome dismal. We carried out a literature review for cases of mucosal melanoma of the head and neck reported from India and performed a pooled analysis on the available data. A total of 60 cases of head and neck melanomas were reported, of which 46 were in men. Palate and alveolus were the commonest sites. A total of 29 (48.3%) patients had regional node metastasis at presentation while five (12%) had distant metastasis. Three-year overall survival of 27.7% was observed. However, the disease-free survival rates at 3, 5 and 6 years were 39.4%, 39.4% and 13.1%, respectively. Metastasis at presentation and use of adjuvant radiotherapy were found to be the only significant predictors of survival. Malignant mucosal melanoma has aggressive biological behaviour and poor outcome. Radical surgery and adjuvant radiotherapy may provide a better local control and may help in improving survival.

Primary tuberculosis of the tongue: report of three cases

Tuberculosis of the oral cavity is uncommon and poses a diagnostic challenge. We report three patients with primary tuberculosis of the tongue, all of whom responded well to treatment and were cured.

Nasolabial flaps in oral reconstruction: an analysis of 224 cases

The nasolabial flap is a simple option for the reconstruction of selected oral defects. Though its use in floor-of-mouth reconstruction has been described, other uses in the oral cavity have not been studied extensively. We present a series of 224 oral malignancies where the nasolabial flap was used for reconstruction after surgical excision.

Primary intraosseous carcinoma of the jaw: pooled analysis of world literature and report of two new cases

Primary intraosseous carcinoma (PIOC) is a rare malignant neoplasm of the jaw. These tumours are believed to arise from the odontogenic epithelium and hence are also referred to as odontogenic carcinoma. A detailed search was made for squamous cell PIOC of the jaw in English literature using Medline Cancer CD. The data obtained were transferred onto dBase software. Two detailed case reports of patients treated at Regional Cancer Centre, Trivandrum during 1996 and 1997 were also included. A pooled analysis was carried out. Survival analysis was carried out using Kaplan-Meier method and log-rank statistics were used for comparing survival. A total of 35 cases were analysed, of which 33 were from published literature. The mean age of the patients at the time of diagnosis was 52.3 years with male to female ratio being 2.5:1. Posterior mandible was the predominant site. The median follow-up time was 28 months. Overall survival at 5 years was 37.8% (95% CI; 14.8-61.0) while the corresponding disease free survival was 29.8% (95% CI; 9.2-54.1). Primary intraosseous carcinoma is a rare tumour of jawbones, characterized by progressive swelling of the jaw, pain and loosening of tooth. The tumour is locally aggressive and metastasizes to regional nodes. The overall and disease free survival is poor with almost 50% patients failing loco-regionally within the first 2 years of follow-up.

Oral cancer among patients under the age of 35 years

BACKGROUND

Cancer of the oral cavity is one of the commonest cancers among males.

AIMS

To assess the aetiological factors, patient characteristics, treatment and the outcome in young patients with oral cancer.

SETTINGS AND DESIGN

A retrospective descriptive study of patients under the age of 35 years with cancer of the oral cavity treated between 1982-1996, with the last follow-up till 2001, using the tumour registry data of Regional Cancer Centre (RCC), Trivandrum, Kerala, India.

SUBJECT AND METHOD

The detailed clinical, treatment and follow-up data were obtained from the computerised records of RCC and recorded on a preset proforma. This was analysed with emphasis on age, sex, risk factors, site, histology, clinical extent and treatment methods and survival in the study group.

STATISTICAL ANALYSIS

The survival analysis was carried by Kaplan-Meier method and the difference in survival was analysed using log-rank test.

RESULTS

Out of 264 patients analysed, tongue was the commonest site identified in 136 (52%) patients followed by buccal mucosa in 69 (26%) patients. A male female ratio of 2.3:1 was observed with a significantly higher male preponderance in buccal mucosa (4.3:1). Prior exposure to tobacco or alcohol was noted in 59.4% patients, with more habitués in buccal mucosa cancer. Histological confirmation was present only in 83.7% patients and among them most were squamous cell carcinoma (85.9%). Radiotherapy, surgery or combined modalities of treatment were employed for majority of patients. The 5-year survival was 57.3%. T stage of the tumour was found to be significant in predicting disease free survival (P=0.03).

CONCLUSIONS

The importance of early detection for clinical down staging is stressed. There is a need to investigate the aetiology of intra oral cancers in younger patients since a significant proportion (almost 40%) of these patients do not have associated risk factors for cancer.

Acute abdomen in patients receiving chemotherapy

OBJECTIVE

To assess the incidence of acute abdomen in patients receiving chemotherapy and to evaluate the factors affecting the clinical decision-making.

MATERIAL AND METHODS

Retrospective analysis of surgical oncology references for the patients developing acute abdomen while receiving chemotherapy was carried out. A surgical oncologist reviewed each referral and a full work-up was carried out. Surgical interventions were carried out as and when deemed necessary. Response to treatment, whether surgical or conservative, was used as main outcome variable.

RESULTS

Mean age of the patients was 37 years (7-58 years). Half of the patients were receiving chemotherapy for lymphoproliferative disorders, 13 for haematological malignancies and 3 for ovarian cancer. Clinical diagnosis was of acute appendicitis in 13, paralytic ileus in 9, typhilitis in 3 and intestinal perforation in 2, acute intestinal obstruction in 3, and obstructed hernia and intussception in one each. Six patients underwent surgery. Two patients expired postoperatively of progressive septicaemia and multi-system organ failure.

CONCLUSION

Evaluation of cancer patients on chemotherapy is difficult. Tenderness, presence of peritoneal signs and absence of exaggerated bowel sounds are most important clinical signs, however they may be blunted by progressive neutropenia or corticosteroid administration. Decision to operate, should be made with extreme caution as mortality and morbidity after surgery is high.

Giant cell tumour of hyoid bone: case report

Giant cell tumours of bones are uncommon and are usually found in the epiphyses of long bones. They are rare in flat bones (<10%). The tumour has to our knowledge never been described in the hyoid bone, although 18 cases have been reported in the cartilagenous laryngeal skeleton. We report a giant cell tumour of the hyoid bone in a 45-year-old man, which we excised along with the left half of the hyoid bone. It recurred locally one year later and was cured by excision and split course radiotherapy. The patient is disease-free after 30 months of follow-up.