Preliminary Comparative Study of Oral7® Versus Salt-Soda Mouthwash on Oral Health Related Problems and Quality of Life among Head and Neck Cancer Patients Undergoing Radiotherapy

Background

This quasi-clinical trial compared the effects of Oral7^® and salt-soda mouthwash on the development of dental caries, salivary gland function, radiation mucositis, xerostomia and EORTC QLQ H&N C35 scores in head and neck cancer patients who underwent radiotherapy.

Methods

We included patients with histopathologically diagnosed head and neck cancers who had received radiation, with an Eastern Cooperative Oncology Group (ECOG) performance status 0–1 and age range of 15–60 years. Patients with prior radiotherapy and chemotherapy, edentulous status, total parotidectomy, sicca syndrome or on xerosis-induced medications were excluded. We assigned 15 patients each to the Oral7^® and salt-soda groups.

Results

There was no significant difference in the mean Decayed, Missing and Filling Teeth (DMFT) score between groups. Head and neck cancer patients who were on Oral7^® had a significantly better quality of life than those on salt-soda in relation to the swallowing problems, social eating, mouth opening, xerostomia and illness scales. Patients who were on Oral7^® had a significantly lower xerostomia score than patients on salt-soda mouthwash. Patients on Oral7^® had a significantly lower mucositis score in week 5–7 compared to patients in the salt-soda group.

Conclusion

Oral7^® showed advantages over salt-soda solution in relation to reducing xerostomia, easing radiation-induced mucositis, and improving quality of life, despite the non-significant difference in the dental caries assessment.

Gender-specific association of NFKBIA promoter polymorphisms with the risk of sporadic colorectal cancer

The inhibitory protein IκBα, encoded by the NFKBIA gene, plays an important role in regulating the activity of nuclear factor-kappa B, a transcription factor which has been implicated in the initiation and progression of cancers. This study aimed to evaluate the association of NFKBIA -826C>T (rs2233406) and -881A>G (rs3138053) polymorphisms with the risk of sporadic colorectal cancer (CRC) in Malaysian population. A case-control study comprising 474 subjects (237 CRC patients and 237 cancer-free controls) was carried out. The polymorphisms were genotyped from the genomic DNA of the study subjects employing PCR-RFLP, followed by DNA sequencing. The association between the polymorphic genotypes and CRC risk was evaluated by deriving odds ratios (ORs) and 95 % confidence intervals (CIs) using unconditional logistic regression analysis. The two polymorphisms were in complete and perfect linkage disequilibrium (D' = 1.0, r (2) = 1.0). Overall, no statistically significant CRC risk association was found for the polymorphisms (P > 0.05). A similar lack of association was observed when the data were stratified according to ethnicity (P > 0.05). However, stratification by gender revealed a significant inverse association between the heterozygous genotype of the polymorphisms and the risk of CRC among females (OR 0.53, 95 % CI 0.29-0.97, P = 0.04), but not among males (P > 0.05). In conclusion, the heterozygous genotype of the polymorphisms could contribute to a significantly decreased CRC risk among females, but not males, in the Malaysian population.

Effect of Withania somnifera (Ashwagandha) on the development of chemotherapy-induced fatigue and quality of life in breast cancer patients

Hypothesis. Withania somnifera is an herb with antioxidant, anti-inflammatory, anticancer, antistress, and adaptogenic properties. Previous studies have shown its antistress effects in animals. Traditional Indian medicine has used it for centuries to alleviate fatigue and improve general well-being.

METHODS

This is an open-label prospective nonrandomized comparative trial on 100 patients with breast cancer in all stages undergoing either a combination of chemotherapy with oral Withania somnifera or chemotherapy alone. The chemotherapy regimens were either taxotere, adriamycin, and cyclophosphamide or 5-fluorouracil, epirubicin, and cyclophosphamide. Withania somnifera root extract was administered to patients in the study group at a dose of 2 g every 8 hours, throughout the course of chemotherapy. The quality-of-life and fatigue scores were evaluated before, during, and on the last cycles of chemotherapy using the EORTC QLQ-C30 (Version 3), Piper Fatigue Scale (PFS), and Schwartz Cancer Fatigue Scale (SCFS-6).

RESULTS

The median age distributions in the study and control arm were 51 years (range = 36-70) and 50.5 years (range = 32-71), respectively. The majority (77%) of patients had stage II and III disease. Patients in the control arm experienced statistically significant higher estimated marginal means of fatigue score compared with the study group (P < .001 PFS, P < .003 SCFS-6). Furthermore, various symptom scales of the EORTC QLQ-C30 were statistically significant in 7 out of 18 symptoms in the intervention group compared with the control group (P < .001). The 24-month overall survival for all stages in study and control group patients were 72% versus 56%, respectively; however, the result was not significant (P = .176), at a median follow-up duration of 26 months.

CONCLUSIONS

Withania somnifera has potential against cancer-related fatigue, in addition to improving the quality of life. However, further study with a larger sample size in a randomized trial is warranted to validate our findings.

Resection and reconstruction of malignant tumor involving sternum

We present a series of four cases of chest wall tumor, which underwent sternum resection. The methods of resection and reconstruction chest wall defect are discussed and the final outcome highlighted.

Polymodal therapy for high grade gliomas: a case report of favourable outcomes following intraoperative radiation therapy

High grade gliomas, frequently with their infiltrative nature, often make the outcome from neurosurgical intervention alone unsatisfactory. It is recognized that adjuvant radiochemotherapy approaches offer an improved prognosis. For these reasons, we opted for surgical debulking, intraoperative radiation therapy (IORT) in combination with whole brain irradiation therapy and chemotherapy (temozolamide cycles) in the management of a 42 year-old lady with Glioblastoma Multiforme (GBM). Her troublesome symptoms improved after 3 months of this polymodal therapy and remained independently functional for more than two years.

LINAC based radiosurgery and radiotherapy for neurosurgical diseases: what have we learnt so far

BACKGROUND

Stereotactic radiosurgery uses a single fraction high dose radiation while stereotactic radiotherapy uses multifractionated lower dose focused radiation.

MATERIALS AND METHODS

Radiosurgery used rigid CRW head frame while stereotactic radiotherapy utilized GTC or HNL relocatable frames. Stereotactic planning and radiation involved Radionics X-plan and LINAC system.

RESULTS

Since December 2001, we have treated 83 lesions from 77 patients using either radiosurgery or fractionated stereotactic radiotherapy. Eighty six percent (86%) of our treated lesions showed favourable outcomes with median follow-up of 32 months (0-7 years).

CONCLUSIONS

Our lessons from LINAC precision radiation therapy uphold its value as a promising and effective tool in treating a range of nervous system pathologies.

Intra-abdominal desmoplastic small round cell tumor: Presentation of four cases and review of the literature

Desmoplastic small round cell tumor (DSRCT) of the abdomen is a recently identified aggressive neoplasm. Very few cases have been reported in the literature. Thus, the treatment guidelines are yet to be defined. The role of chemotherapy, radiotherapy and surgery is evolving. We treated four cases of DSRCT involving the abdomen using combination chemotherapy and/or tumor cytoreductive surgery. There were two men and two women. The chemotherapy drugs consisted of cisplatin, adriamycin, etoposide, ifosphamide, vincristine and cyclophsophamide. All patients achieved meaningful partial response to chemotherapy, which maintained for 6–9 months. There were very minimal chemotherapy-related complications. At the time of reporting, the median survival time was 15 months. Thus, DSRCT is an aggressive intra-abdominal tumor with excellent chemoresponsiveness, but relapse is frequent.

Correlation of Nuclear Morphometry and AgNOR Score with Radiation Response in Squamous Cell Cancers of the Head and Neck: A Preliminary Study

BACKGROUND

Prediction of radiation response before the completion of the radiotherapy schedule is challenging. Information about radiation response could help oncologist to choose the appropriate combination and sequence of therapies in the multidisciplinary management of cancer.

METHODS

The study involved 26 patients with squamous cell cancers of the head and neck region who received radiotherapy to a dose of 30 Gy in 10 fractions over a 2-week period as part of a split-course technique. Fine-needle aspiration cytology was performed on day 1 and day 5 of the schedule. The silver staining of the nuclear organiser region (AgNOR) and nuclear morphometric study were done on both days.

RESULTS

The median age of the patients was 44 years old. The primary tumours were distributed in the nasopharynx (n = 11), larynx and hypopharynx (n = 5), metastatic node (n = 4), and miscellaneous tumours were found in the head and neck sub sites (n = 6). The mean initial AgNOR score was 3.0, range 1.2-7.0. The median of nuclear and nucleolar diameters were 11.07 μm, range 7.70-16.6 μm, and 2.92 μm, range 1.09-11.66 μm, respectively. Patients with a pre-radiotherapy AgNOR score of greater than 2.5 were associated with disease progression and metastasis. However, the increased of nuclear diameter on day 5 compared with baseline predicted a good radiation response in patients (P = 0.016).

CONCLUSION

Intra-radiotherapy nuclear morphometry combined with baseline AgNOR score could be a simple and useful tool for the prediction of radiation response in head and neck cancers.

Current trends in the management of oral mucositis related to cancer treatment

Oral mucositis is one of the most common toxicities observed during radiotherapy and chemotherapy treatment for cancers. Mucositis results in sore mouth, altered taste sensation, pain and dysphagia leading to malnutrition. Left untreated, oral mucositis leads to ulceration, orodental infection, bleeding and discontinuation of effective radiotherapy or chemotherapy. Frequent hospitalization, enteral or parenteral nutrition, increased demand for analgesics ultimately account for increased cost of healthcare. Quantification of oral mucositis using standardized grading system is important for appropriate evaluation, reporting and management. In the recent past there is a paradigm shift in the pathobiology of cancer therapy related mucositis. Clear understanding of its pathogenesis is essential for the formulation of effective mucositis care. Numerous drug therapies, radiation techniques and oral care protocols have been tried in the past to reduce oral mucositis, None have proven to be consistently effective. Current trends for the prevention and treatment of oral mucositis is multi-targeted treatment supplemented by aggressive oral hygiene, reactive oxygen species (ROS) inhibitors, growth factors and use of specific topical agents to improve treatment of oral mucositis in future.

Is Kelantan joining the global cancer epidemic?--experience from hospital Universiti Sains Malaysia; 1987-2007

OBJECTIVE

To determine the trend of cancer cases in one major hospital in Kelantan over a 20 year period from 1987 to 2007 and to speculate the change in trend due to the socio-economic and other health status in the state.

METHODOLOGY

All data on clinically diagnosed cancer cases in Hospital Universiti Sains Malaysia [HUSM] were retrieved from the hospital medical records. The cancers were classified according to ICD10 and scrutinized to avoid duplicate or more entries. The increment in cancer incidence was calculated based on total numbers of cancer cases per each 5-6 year period.

RESULTS

A total of 12,228 solid cancers were diagnosed during the period. There is an increment of 20.1% for 1991-1996 from 1987-1990 period, 67.4% for 1997-2001 from 1991-1996 period and 305.9% for 2002-2007 from the 1997-2001 period. The rise was steep in the last 5-6 years. After excluding referred cases from states outside Kelantan, the increments were 20.1%, 67.4% and 143.6% for the consecutive 5-6 year periods. The predominant rising trends were seen for cancers of the female organs, digestive tract and endocrine organs.

CONCLUSION

Cancer cases in HUSM are showing a rising trend, associated with increasing prevalence of smoking, obesity and diabetes in the community served by the hospital. Since HUSM is the only hospital managing cancer in the state of Kelantan, to reduce cancer incidence in the state, life-style issues need to be addressed.

An extensive sinonasal osteosarcoma mimicking chondrosarcoma

Osteosarcoma is a rare tumour in the sinonasal region. Early diagnosis is essential for adequate management and better prognosis and this requires a meticulous histopathological examination. Reported is a case of osteosarcoma misdiagnosed as chondrosarcoma and treated by surgery followed by radiotherapy. However, appropriate diagnosis and pre-operative chemotherapy would have been significant in the prognosis. The pitfall of accurate diagnosis and the subsequent treatment is discussed in order to find the ways to maximize five years survival which is not more than 25% in this type of lesions.

Early Malaysian experience on the use of head and neck localizers in the precision radiotherapy of intra and extra cranial sites for first 28 cases

Precision Radiotherapy at high doses require a fixed, referable target point. The frame system fulfills the required criteria by making the target point relocatable and fixed within a stereotactic space. Since December 2001, we have treated 28 central and peripheral nervous system lesions using either radiosurgery as a single high dose fraction or fractionated 3-dimensional conformal radiotherapy using a lower dose and a multi-leaf collimator. Various pathological lesions either benign or malignant were treated. Eighty six percent of our treated lesions showed growth restraint, preventing them from causing new symptoms with a median follow-up duration of 20.5 months. However, the true benefit from this technique would require a long-term follow-up to document the progress.

Aggressive giant cell tumour of bone

INTRODUCTION

The surgical treatment of Stage III or aggressive giant cell tumour of the bone, whether to perform intralesional or en-bloc resection, remains controversial. The aim of this study is to identify the effectiveness of en-bloc resection for local control and final oncological outcome of the disease.

METHODS

The data of 20 consecutive patients with Stage III giant cell tumour were retrospectively reviewed to determine the local control and oncological outcome after treatment with wide resection.

RESULTS

The majority of the patients presented late with mean duration of symptoms of 24 months, and four patients presented with recurrences. All patients were treated with wide resection except for two patients who underwent ablative surgery due to major neurovascular involvement. Ten patients required free vascularised tissue transfer to cover massive soft tissue defect. Local recurrence occurred in one patient who was again treated with wide resection and vascularised flap. Six patients had pulmonary metastases. Two patients with resectable disease were treated with thoracoscopic surgery and they remained disease-free 36 months after surgery. Two patients with multiple lung metastases were treated with chemotherapy and the disease remained non-progressive. The remaining two patients who refused chemotherapy showed radiological progression, and one succumbed to the disease with massive haemoptysis.

CONCLUSION

Aggressive giant cell tumour of bone should be treated with wide resection for better local control, and treatment of pulmonary metastases is mandatory for overall prognosis.

Prognostic factors of differentiated thyroid cancer patients in Hospital Universiti Sains Malaysia

INTRODUCTION

The aim of this study was to identify the prognostic factors that influence the survival of differentiated thyroid cancer patients treated at Hospital Universiti Sains Malaysia (HUSM).

METHODS

A total of 178 patients diagnosed with and treated for differentiated thyroid cancer in HUSM between January 1974 and July 2003 were included in this retrospective cohort study. The additional follow-up period was one year after the end of the recruitment phase. The data was collected from the medical records of the patients.

RESULTS

The overall five- and ten-year relative survivals of differentiated thyroid cancer patients in HUSM were 90.6 percent (95 percent confidence interval [CI] 84.4-94.4) and 85.3 percent (95 percent CI 76.0-91.2), respectively. The significant prognostic factors for differentiated thyroid cancer were age (hazard ratio [HR] 6.9; 95 percent CI 1.7-28.6), loss of appetite (HR 10.9; 95 percent CI 2.7-43.7), tumour size (HR 3.7; 95 percent CI 1.1-13.8), regional recurrences (HR 3.2; 95 percent CI 1.1-9.8), high-risk stage (HR 19.9; 95 percent CI 4.4-90.4), and treatment (HR 0.2; 95 percent CI: 0.1-0.5).

CONCLUSION

The survival rates obtained in this study were slightly lower than other studies but the pattern of survival rates between groups were similar. Prognostic factors identified in this study were similar to those of other studies, suggesting that the experience of HUSM was almost similar with that of other institutions.

Rational management of differentiated thyroid cancer

Differentiated thyroid cancer ( DTC ) is usually not very common ( incidence is about 1 % of all cancers and women are more often affected than men ). However, higher incidences has been reported in many parts of South East Asia particularly in iodine deficient areas. Unlike other solid tumors, DTC is potentially curable with documented survival rate of > 90 %. Even if the disease is not totally cured, through repeated high dose radio iodine therapy the progress of the disease can be controlled with significant improvement in quality of life for many years. This is possible if a proper and state of the art therapeutic approach is made. Since the incidence is relatively low, individual experience of treating physicians or centers is mostly inadequate leading to improper management with subsequent increase in morbidity and mortality. The purpose of this review is to evolve a rational management protocol for the treatment of thyroid cancer. Centers which do not have all facilities like high dose radio iodine therapy etc. may still follow the protocol by referring the patient for a particular step to another centre. What is needed is the awareness of the treating physician about the appropriate management of DTC. In recent years, there have been some important developments in the management of differentiated thyroid cancer like use of recombinant human thyrotropin (rhTSH), use of retinoic acid for redifferentiation etc. Some of these developments having practical relevance have been briefly mentioned.

Role of scintimammography in the diagnosis of breast cancer

X-ray mammography has been the backbone of early detection of breast cancer. Several large scale systematic studies have shown that judicious use of X-ray mammography can indeed save life. However, though reasonably sensitive, X-ray mammography lacks in specificity leading to many unnecessary biopsies. Scintimammography is a relatively new imaging method to demonstrate cancer tissue in the breast. A radiopharmaceutical agent (Tc-99m Sestamibi) is administered intravenously and images of the breast are taken under a Gamma Camera. There is no need for any manipulation like compression of the breast as required to be done during mammography. The radiopharmaceutical accumulates in the breast in the presence of cancer tissue which can easily be seen in the images. The affinity of the cancer tissue to this radiopharmaceutical is up to 9 times in comparison to normal breast tissue. Several multi centric studies with blinded image interpretation have established the sensitivity and specificity of scintimammography to be above 85 and 90 % respectively as compared to 89 and 14 % respectively for X-ray mammography. The positive and negative predictive values of scintimamography are 70 and 83 % as against 49 and 57 % respectively for X-ray mammography. With the increasing availability of Nuclear Medicine facilities it is expected that more and more patients will benefi with the use of this new imaging modality .

Abdominal aorta and inferior vena cava thromboses in advanced stage of malignant fibrous histiocytoma

Asymptomatic simultaneous thrombosis of abdominal aorta and inferior vena cava is a rare complication in advanced malignancy. We described an incidental finding of this clinical entity in our patient who presented with advance stage of malignant fibrous hystiocytoma of soft tissue and pathological fracture. The radiological evaluation with spiral computed tomography scan of abdominal aorta and inferior vena cava are presented and the subsequent management highlighted.

Pulmonary metastases of giant cell tumour of the bone

The clinical presentation and behaviour of giant cell tumour of bone vary. The progression of the disease and metastasis are unpredictable, but the overall prognosis is good. Six patients with pulmonary metastases of giant cell tumour have been treated at our institution since 1998. This represents 15% of all patients treated for giant cell tumour of the bone. Early detection and treatment of this tumour is important as complete resection of this tumour have favourable prognosis. Multiple lung nodules which preclude resection may remain dormant and asymptomatic with systemic chemotherapy.

Osteosarcoma: the outcome of limb salvage surgery

We reviewed the surgical and oncological management 23 consecutive patients with osteosarcoma of the long bones to determine the outcome of limb salvage technique performed in our centre. All patients received neoadjuvant chemotherapy. There were 15 males and 8 females with a mean age at diagnosis of 19 years (9 to 36). The median follow-up was 30 months (10 to 60). Fifteen had lesion around the knee joint followed by three in the proximal humerus, two in distal humerus, two in the pelvis, and one in the distal tibia. Six patients presented with lung metastases at diagnosis. We performed limb salvage surgery to control local disease in 16 patients and amputation in 7. The resection margins of the primary lesion were adequate and free of tumour cells in all patients. Local recurrence developed in 1 patient of limb salvage group. The overall median survival was 22 months and actuarial survival was 52% at 3 years. Eleven patients died of pulmonary metastases within 2 years of follow-up. Median survival of the limb salvage surgery group was 30 months compared to 6 months in the amputation group. As per our experience, limb salvage technique is a feasible option in extremity osteosarcoma without compromising survival.

Prevalence of fatigue among cancer patients undergoing external radiotherapy

Between July 1999 to November 2000, 115 patients undergoing radiotherapy were evaluated for the development of treatment-related fatigue, using a modified Piper's fatigue scale. The above scale determines 4 dimensions of fatigue ie behavioral severity (6 items), affective meaning (5 items), sensory (5 items), and cognitive mood (6 items). Radiotherapy was delivered to the head and neck, breast, pelvis, and miscellaneous sub-sites. The area of the radiation field ranged from 25 to 480 cm2 (median 156 cm2). Forty-three percent of patients experienced significant fatigue, which altered their work environment. The individual components of fatigue were behavioral severity 25%, affective meaning 21%, sensory 18%, and cognitive mood 16%. Significant radiotherapy-related fatigue was higher in patients treated with advanced-stage disease, large radiotherapy field area, and low pre-radiotherapy hemoglobin level.

Assessment of the usefulness of hemibody irradiation in painful bone metastasis

Bone pain due to skeletal metastasis causes significant morbidity among cancer patients. A single large hemibody radiation field is shown to be effective in alleviation of pain for patients with wide-spread bone metastasis. Fifty documented cases of disseminated bone metastasis due to malignancy were evaluated to assess the efficacy of hemibody irradiation for pain control. Intensity of the pain was scored according to the 10th visual analogue score. The upper and/or lower segment of the body was exposed to a radiation dose of 6 Gy and 8 Gy respectively in single fraction applying extended SSD-technique, using a telecobalt unit. The sample consisted of 23 male and 27 female patients with a median age of 48 years. The primary malignancy was distributed as breast, myeloma, prostate, lymphoma and miscellaneous tumours. Thirteen patients were offered upper hemibody irradiation, 21 cases lower hemibody, and 16 patients were offered sequential double hemibody irradiation. The mean radiation field size was 2000 cm2. Thirty per cent of the patients achieved complete and 70% achieved good partial pain relief within 24 to 36 hours post-treatment and the relief was maintained for 2 to 3 months. The benefit of hemibody irradiation in disseminated bone metastasis with pain is described.

Assessment of knowledge, attitude and exposure to oncology and palliative care in undergraduate medical students

We conducted a questionnaire survey among 261 year-4 and year-5 medical students containing 27 questions related to cancer, radiotherapy, general oncology and palliative care to assess their knowledge, understanding, and exposure to oncology and palliative care in our medical school. Out of 261 students, 139 students returned their questionnaire for analysis. Twenty nine percent (29%) of the students had rarely visited the Radiotherapy and Oncology unit. There were profound deficiencies in the basic knowledge of cancer (46%), principles of radiotherapy treatment (59%), palliative care (64%), and cancer prevention (48%). They reported no specific teaching about early detection of common malignancies and cancer prevention. The main input of instruction about cancer came from surgery (46%) and pathology (28%) teachings. This study revealed that there is deficiency in cancer education in the undergraduate teaching program in our institution.

Topical application of honey in the management of radiation mucositis: a preliminary study

BACKGROUND

The aim of this study was to evaluate the effect of pure natural honey on radiation-induced mucositis.

PATIENTS AND METHODS

Forty patients diagnosed with head and neck cancer requiring radiation to the oropharyngeal mucosal area were divided in to two groups to receive either radiation alone or radiation plus topical application of pure natural honey. Patients were treated using a 6-MV linear accelerator at a dose rate of 2 Gy per day five times a week up to a dose of 60-70 Gy. In the study arm, patients were advised to take 20 ml of pure honey 15 min before, 15 min after and 6 h post-radiation therapy. Patients were evaluated every week for the development of radiation mucositis using the Radiation Therapy Oncology Group (RTOG) grading system.

MAIN RESULTS

There was significant reduction in the symptomatic grade 3/4 mucositis among honey-treated patients compared to controls; i.e. 20% versus 75% ( p 0.00058). The compliance of honey-treated group of patients was better than controls. Fifty-five percent of patients treated with topical honey showed no change or a positive gain in body weight compared to 25% in the control arm ( p 0.053), the majority of whom lost weight.

CONCLUSIONS

Topical application of natural honey is a simple and cost-effective treatment in radiation mucositis, which warrants further multi-centre randomised trials to validate our finding.

Molecular genetic analysis of anaplastic pleomorphic xanthoastrocytoma

A case of pleomorphic xanthoastrocytoma in a 10-year-old Malay boy is reported. The patient presented with headache and epilepsy. On computed tomography, a ring-enhancing low-density lesion was observed in the left fronto-temporal area. During surgery, a cystic tumour containing serous fluid was found and almost totally removed. Histologically, the tumour exhibited marked pleomorphism of oval and spindle-shaped cells intermixed with uni- and multinucleated giant cells, and xanthomatous cells with foamy cytoplasm. The tumour displayed pericellular reticulin and periodic acid-Schiff positive granules. Focally, six mitotic characters per 10 high-power fields were seen, and necrosis was confined only to the inner lining of the cyst. Mutational analysis showed that a frameshift mutation (a 4-bp deletion) in the p53 gene had occurred in codons 273 and 274 of exon 8. No mutation was detected in the p16 gene. No allelic loss and/or loss of heterozygosity were observed on chromosome 10 using microsatellite marker D105532. The patient was treated with postoperative radiotherapy because of histological anaplasia and the presence of residual tumour. The patient showed marked neurological recovery after a follow-up period of 2 years.

Metastatic disease of the proximal femur

Since January 1999, ten patients had undergone surgical treatment for metastatic bony lesions of proximal femur at this centre. Seven of these patients were treated for complete pathological fractures, one for impending fracture and one for revision of internal fixation and loosening of hemiarthroplasty. Primary malignancies were located in breast in four cases, prostate in three and one in lung, thyroid and neurofibrosarcoma. Two patients had died within six months after surgery, four after 1 year while the remaining four were still alive. The mean duration of survival was eleven months. Nine patients had been ambulating pain free and there were no failure of reconstruction.

Adjuvant treatment in colorectal cancer. Experience from a referral center in eastern peninsular Malaysia

BACKGROUND

Colorectal cancer is one of the most common malignancies in the West, but in Asia the incidence is low. However in Malaysia, colorectal cancer is increasing with a reported figure of 15% of all cancer cases. Adjuvant chemo and radiotherapy are now more frequently used in such patients. The present retrospective analysis was performed to document the effect of such therapy among patients with colorectal cancer in Malaysia.

MATERIALS AND METHODS

This is a retrospective study on the use of adjuvant treatment in colorectal cancers. Patients with histopathological evidence of risk factors were subjected to adjuvant radiotherapy and/or chemotherapy. Cancers confined to rectum and rectosigmoid were subjected to pelvic radiotherapy to a tumor dose of 45 Gy in 20 fractions over 4-week period. 5-flurouracil based chemotherapy was predominantly offered for colonic cancers.

RESULTS

One hundred thirty patients with colorectal cancers received adjuvant treatment with a median age of 58 years (range 22-76 years). The male to female ratio was 1.4:1. There were 76% Malays, 19% Chinese, 2% Indians and 3% Siamese subjects in this study. Modified Dukes' stage B2 (28%) and C (38%) constituted the majority, which were distributed in rectum (40%), rectosigmoid (19%), and in the remaining colon (41%). Thirty-one patients received 5-fluorouracil with folinic acid based regime and 35 patients received 5-fluorouracil with levamisole based regimen. Locoregional radiotherapy was offered to 56 (43%) patients. Following treatment, the 2-year actuarial survival was 28% and 54% in colon and rectum cancer respectively.

CONCLUSIONS

This study showed that colorectal cancer is not infrequent among Malays in this region and rectal cancers had better survival than the colonic cancers.

Intramedullary spindle cell hemangioendothelioma of the thoracic spinal cord--case report

A 28-year-old Malay man presented with progressive paraparesis over a period of 6 months. Magnetic resonance imaging of the spine revealed a thoracic intramedullary spinal cord tumor at the T-7 level with homogeneous enhancement following intravenous gadolinium administration. Laminectomy and partial decompression of the tumor was performed. Histological examination of the tumor revealed features of spindle cell hemangioendothelioma. The patient was managed with limited field radiotherapy followed by systemic interferon therapy. Good neurological improvement was seen subsequently. The patient has survived 48 months with growth restraint at the primary site, although residual neurological deficit persists. Immunotherapy should be considered as a treatment modality for intramedullary hemangioendothelioma of the spinal cord after surgery and radiotherapy.

Hypertrophic osteoarthropathy: an unusual manifestation in nasopharyngeal cancer

A patient with nasopharyngeal carcinoma developed clubbing and hypertrophic osteoarthropathy 6 months before radiological detection of secondary deposits in the lung. Another patient with nasopharyngeal carcinoma developed digital clubbing and hypertrophic osteoarthropathy 6 months after the discovery of lung metastases. Development of a paraneoplastic syndrome in the form of hypertrophic osteoarthropathy and digital clubbing is very rare. This manifestation of nasopharyngeal cancers is presented, with a short review of its biology and pathogenesis.

Management of retinoblastoma with radiation

OBJECTIVE

To evaluate the role of radiation therapy in the management of retinoblastoma.

DESIGN

Retrospective analysis.

METHOD

From January 1993 to March 1994, one hundred and eleven children (150 eyes) of retinoblastoma were referred for radiotherapy. The diagnosis was based on clinical examination and ocular ultrasonogram for both the eyes. The radiation treatment policy involved 40 Gy in 20 fractions over 4 weeks delivered with sedation for children under 1 year of age, 36 Gy in 9 fractions over 3 weeks under ketamine anesthesia for 1-4 years of age and for >4 years of age, a dose of 50 Gy in 25 fractions over 5 weeks. The initial tumor regression was evaluated by A and B mode ultrasonography and/or CT scan.

RESULTS

The age distribution ranged from two months to six years (median - 20 months). Bilaterality was observed in 39 out of 111 cases (35%). The male to female ratio was 1.8:1. Eighty two of the 111 children were treated by definitive external beam radiation to one or both eyes. Fifteen cases received adjuvant radiotherapy after enucleation, and 14 had extensive disease for which palliative radiotherapy was offered. We observed a complete response in 54% of cases, partial response in 32%, and none in 14% of cases. Forty per cent (40%) eye survival was documented at the end of 28 months. The complication rate encountered was about 15%.

CONCLUSION

Radiotherapy is an effective modality of treatment in significant number of patients with retinoblastoma. However, it requires appropriate fractionation, precise colimation and careful immobilization with general anesthesia.

Biventricular central neurocytoma

A case of biventricular neurocytoma is reported. A 36 year old Malay lady presented with headache of 8 months duration. Physical examination revealed signs of increase intracranial pressure. CT-scan and MRI showed tumour in both lateral ventricles. Patient underwent tumour debulking followed by adjuvant radiotherapy. The radiological appearances of central neurocytoma are discussed.

Radiation therapy in pseudotumour haemarthrosis

Total or partial deficiency of factor VIII and IX in the coagulation cascade leads to haemophilia. Haemophilia affecting weight-bearing joints gives a 'pseudotumour' or haemarthrosis-like condition. Surgery and cryoprecipitate infusions have been the treatment for this condition. Radiocolloids and radiation therapy have been used with some benefit. One case of ankle pseudotumour which was treated by low-dose external beam radiation is presented here.

Human leucocytic antigens (HLA) in breast cancer

HLA frequencies of fifty (50) female breast cancer patients were compared with 200 age matched female controls. A total of 20 HLA-A locus, 35 HLA-B locus and 8 HLA-C locus antigens were studied. The HLA-A2, A11, Aw19 and A30; HLA-B8, B14 and HLA Cw6 were found significantly higher than the controls. The HLA-A11, HLA-Aw19 and HLA-B8 were found protective whereas, HLA-A2, HLA-B14 and HLA-Cw6 were a risk for breast cancer. The prective antigens' probable involvement through immunogenic mechanism in breast cancer is emphasized in this article.

Radiotherapy in locally advanced cancer of the cervix

Radical radiotherapy is considered as the treatment of choice in locally advanced cancer cervix. In late stages radiotherapy produce optimum palliation and to some extent cure. Three hundred cases of cancer cervix (stage I-IV) comprising stage-I (7), stage-II (144), stage-III (145) and stage IV (4) were evaluated and treated with radiotherapy between April 1990 to July 1994. FIGO stage IB, IIA and IIB (early), were treated with predominant intracavitary radiotherapy (34 Gy X 2 fractions; within one week) followed by external pelvic radiotherapy to a dose of 36 Gy in 18 fractions; treating 200 cGy per fraction, 5 days a week. The late stage (stage-IIB, IIIA and IIIB, IVA) of disease were managed with initial external radiotherapy to a dose of 50 Gy, followed by a single intracavitary dose of 30 Gy to point-A. The median follow up was 33 months (range 12-72 months). The tumor volume less than 100 cc were associated with better survival than volume more than 100 cc (p < 0.05). The five year actuarial survival was 83%, 68% and 58% respectively in FIGO stage I-III disease. There were 0.33% and 2.6% late grade-III bladder and rectal complications. Our experience shows effectiveness of radiotherapy in the management of locally advanced cancer of the cervix.

Leptomeningeal carcinomatosis from carcinoma of the palatine tonsil

Distant metastases from carcinoma of the palatine tonsil are very uncommon. We encountered a case of a carcinoma involving the tonsillar region that resulted in subarachnoid mestastases following local radical radiotherapy. Metastases were diagnosed following magnetic resonance imaging and spinal fluid cytology. The patient succumbed to the disease after a rapid downhill course, 1 month following diagnosis of the secondary deposit. The present paper describes the rare site of distant metastasis and reviews the relevant literature.

Iridium-192 interstitial brachytherapy in carcinoma of the tongue. The importance of various tumor and physical parameters

A detailed analysis of host-tumor factors and interstitial physical factors influencing the disease-free control in carcinoma of the tongue was carried out. Twenty-eight cases of carcinoma of the tongue T1-3, NO-1, MO were treated radically with combined external irradiation and 192Iridium interstitial brachytherapy (one patient received brachytherapy only). The teletherapy dose ranged from 44 Gy to 56 Gy (average 48 Gy), the brachytherapy dose ranged from 16 Gy to 55 Gy (average 22 Gy). The interstitial practice involved loop technique in all the cases. Dose distribution analysis to assess factors influencing local control included indices of dose rate, source activity, inter-planar distance, and discontinuity in the prescribed isodose in other planes when compared to mid-plane. Two-year actuarial disease-free survival (DFS) was 46% with primary treatment and 63% when salvage treatment was also included. DFS was significantly poorer when the interplanar distance at mid-plane exceeded 10 mm (p < 0.05). Similarly, tumor control was poorer (p < 0.008) when there was discontinuity in the prescribed isodose in 1 or 2 planes (1 cm superior and inferior to mid-plane). Interplanar distance of around 10 mm, prescribed isodose continuity in all three planes and limiting the dose maximum within a factor of 2 will optimize the results of interstitial implants.

Results of definitive radiotherapy in T1 and T2 glottic carcinoma: Institute of Rotary Cancer Hospital experience

Early glottic carcinomas (T1 and T2) constitute only 2% of all laryngeal cancers in our data. Seventy patients were seen between 1985 and 1992. All patients were treated by cobalt-60 small field radiotherapy using a beam directed shell. The total dose delivered was 60-65 Gy in 31 patients and 66-70 Gy in 39 patients. The follow-up period ranged from 5 to 126 months, with a mean follow up of 37 months overall and 55 months in the surgical salvage group. Radiation therapy controlled disease in 71% (50 of 70) of patients overall; 75% with T1 and 67% with T2 lesions. Total laryngectomy as salvage surgery was performed in 70% (14 of 20) of patients whose disease recurred. Ultimate control including surgical salvage occurred in 64 (91%) of 70 patients in the present study. The actuarial 5 year survival was 83 and 80% in T1 and T2 tumours, respectively (statistically insignificant). This report supports the policy of definitive irradiation, reserving surgical salvage for radiation failures in early laryngeal cancers.

Palliative treatment of malignant pericardial effusion: report of two cases and a review of the literature

Malignancy accounts for 40%-60% of pericardial effusions. Two individuals with malignant pericardial effusions secondary to lung, cancer, managed with the help of a percutaneous balloon pericardial window (PBPW), are discussed in this report. Clinical benefits in terms of reduction of breathlessness and improved diastolic function of the heart were documented in both. There were no procedure-related complications. The PBPW provides quick relief, appears diagnostically superior to an invasive technique and has a low rate of recurrence and complications.

Aggressive bone metastases in urachal carcinoma

A 38-year-old female with urachal carcinoma showed extensive bone metastases 1 year after wide excision of the urachal tumor, including partial cystectomy. A combination of radiotherapy and systemic chemotherapy was offered. Local radiotherapy of 8 Gy as a single fraction or 10 Gy in two fractions was delivered to the painful regions of the skeletal system. Multiagent chemotherapy consisting of methotrexate, vinblastine, Adriamycin, and cisplatin was given for three cycles. The patient died 28 months after the initial presentation with progression of the disease to pelvis and skeletal sites. The problem of metastatic spread after initial resection should be considered in urachal carcinoma, and adjuvant chemoradiotherapy should improve the outcome in this rare neoplasm.

Incarcerated procidentia: a rare complication of carcinoma cervix

A rare case of a huge carcinoma of the cervix leading to sudden uterovaginal prolapse and incarcerated procidentia, in a postmenopausal woman is presented. The woman presented as an emergency with severe distress. The problem was successfully managed by reducing the uterovaginal prolapse under deep sedation and starting radiotherapy as an emergency procedure at the same sitting. The role of immediate radiotherapy in the management of such an emergency situation is discussed.

Carcinoma of the uterine cervix presenting as superior vena cava syndrome: report of three cases and a review of literature

We present three cases of superior vena cava syndrome secondary to carcinoma of the uterine cervix which manifested 2 to 7 years after the initial diagnosis and primary therapy. In two of these patients, tissue diagnosis could be obtained. Two patients expired within two months of presentation despite timely radiotherapy, and one case died after six months of diagnosis.