FIGO 2023 endometrial staging: a leap of faith into the new "prognostic based' rather than "anatomical based" staging-too fast too furious??

BACKGROUND

In 2023 FIGO revised the endometrial cancer staging system after 13 years. There is a lacuna of data regarding the performance and practicality of the revised 2023 FIGO staging schema for endometrial cancer from Low Middle-Income Countries (LMIC).

OBJECTIVE

To estimate the shift of stage and adjuvant management of endometrial cancer based on the FIGO 2023 system compared to the FIGO 2009 system and assess the predictive potential of the FIGO 2023 system.

MATERIAL AND METHODS

A retrospective study was conducted from 1st January 2017 to 31st December 2022. All patients with endometrial cancer were staged according to the FIGO 2023 and FIGO 2009 staging system. Follow-up of patients was done to determine recurrence.

RESULTS

A total of 152 patients were included. Aggressive histology was seen in 66 (45%) patients. Eighteen (11%) had subserosal involvement. Substantial LVSI was noted in 23 (15%) of patients. Twenty-four (47%) patients of FIGO 2009 Stage IA and 26 patients (63%) of FIGO 2009 Stage IB were upstaged. Eleven (50%) patients of FIGO 2009 Stage IIIA were down staged to IA3. Overall 23 patients (15%) had a shift of stage. Fifteen out of 152 patients (15%) would have had a possible risk stratification change which would imply 23 patients (15%) would have needed a more radical treatment. Molecular classification was done in 32 patients; however, only 2 patients could afford POLE testing. Kaplan-Meier curves showed significant PFS differences in FIGO 2009 Stage IB and Stage IIIA when restaged according to the FIGO 2023 system.

CONCLUSION

The FIGO 2023 endometrial staging is a more robust prognosticator; however, the practicality of molecular classification in LMICs is still a distant dream.

Patterns of failure in patients with nasopharyngeal cancer of Northeastern region of India: a retrospective observational study

PURPOSE

We aimed to analyze patterns of failure and disease volume-treatment outcomes in patients with Nasopharyngeal carcinoma (NPC) treated with definitive radiation with or without concurrent chemotherapy at a tertiary cancer centre in northeast India.

METHODS

From February 2018 to February 2022, 99 histopathologically proved non-metastatic NPC patients treated with curative-intent RT with or without chemotherapy were retrospectively analyzed. Locally advanced patients received neoadjuvant or adjuvant chemotherapy. The Cox proportional hazards model was used to investigate the impact of various prognostic factors on locoregional free survival (LRFS), distant metastasis free survival (DMFS), progression free survival (PFS) and overall survival (OS). The log-rank test and Kaplan-Meir curves compared outcome variables based on ROC analysis-classified tumor volume.

RESULTS

During a median follow up of 25.4 months (17.3-39.2), 35(35.4%) patients developed recurrence. Twenty-three patients developed locoregional failures, of which 11 were in-field; 12 patient showed an out-field failure. The 3-year LRFS, DMFS, PFS and OS was 71.10%, 70.90%, 64.10% and 74.10% respectively. There was statistically significant difference in LRFS according to T staging (p < 0.0001). Gross tumor volume (GTVp) and gross nodal volume (GTVn) were an independent prognostic factor for OS, PFS, LRFS and DMFS. The cut-off volumes for GTVp and GTVn for distant metastases and locoregional failure, respectively, were found to be 13 and 22.7 mL and 3.7 and 39.2 mL, respectively, by ROC curve analysis. Based on this, 99 patients were divided into three subgroups. OS demonstrated significant differences among patients in different volume subgroups for GTVp (p = 0.03) and GTVn (p = 0.00024).

CONCLUSIONS

For NPC patients who undergo curative IMRT, primary tumour and nodal volumes are independent prognostic indicators. GTVp and GTVn are highly predictive of local control, distant metastases, disease-free survival, and overall survival. This justifies their use as quantitative prognostic indicator for NPC.

Stereotactic Body Radiation Therapy in Recurrent Head and Neck Cancer: Where Do We Stand?

This review explores the difficulties encountered in the management of head and neck cancer (HNC), with special attention to the challenges presented by locoregional recurrences, which impact a substantial number of patients. While maximal surgical resection remains the gold standard for treatment, surgery is often not feasible due to various factors. In such cases, reirradiation has emerged as a potential strategy, albeit with a heightened risk of severe toxicity. Stereotactic Body Radiation Therapy (SBRT) is introduced as a promising approach for unresectable recurrent HNC. SBRT offers precise radiation doses and shorter treatment durations, making it a potentially optimal treatment modality. Despite the growing interest in SBRT, there is a lack of consensus guidelines for its use in HNC, particularly in India. Nevertheless, recommendations are provided for the benefit of SBRT in reirradiation settings, considering factors like tumour size, dose, and treatment duration. The article highlights the safety and effectiveness of SBRT-based reirradiation with existing evidence. The literature review discusses various studies and their findings, emphasizing the importance of high-dose SBRT for improved overall survival. The article also explores the combination of SBRT with systemic therapy as a potential synergistic approach to enhance patient outcomes. In conclusion, SBRT shows promise as a valuable therapeutic tool for patients with inoperable recurrent HNC, offering acceptable safety. However, further research and well-designed trials are needed to optimize its use and identify the most suitable patient cohorts. Establishing comprehensive working guidelines and a nationwide prospective database will be crucial in advancing this treatment approach.

Household cooking fuel and gallbladder cancer risk: a multi-centre case-control study in India

PURPOSE

Gallbladder cancers (GBC), unique to certain geographical regions, are lethal digestive tract cancers, disproportionately affecting women, with limited information on risk factors.

METHODS

We evaluated the association between household cooking fuel and GBC risk in a hospital-based case-control study conducted in the North-East and East Indian states of Assam and Bihar. We explored the potential mediation by diet, fire-vents, 'daily exposure duration' and parity (among women). We recruited biopsy-confirmed GBC (n = 214) men and women aged 30-69 years between 2019 and 2021, and controls frequency-matched by age, sex and region (n = 166). Information about cooking fuel, lifestyle, personal and family history, female reproductive factors, socio-demographics, and anthropometrics was collected. We tested associations using multivariable logistic regression analyses.

RESULTS

All participants (73.4% women) were categorised based on predominant cooking fuel use. Group-1: LPG (Liquefied Petroleum Gas) users in the previous 20 years and above without concurrent biomass use (26.15%); Group-2: LPG users in the previous 20 years and above with concurrent secondary biomass use (15.9%); Group-3: Biomass users for ≥ 20 years (57.95%). Compared to group-1, accounting for confounders, GBC risk was higher in group-2 [OR: 2.02; 95% CI: 1.00-4.07] and group-3 [OR: 2.01; 95% CI: 1.08-3.73] (p-trend:0.020). These associations strengthened among women that attenuated with high daily consumption of fruits-vegetables but not with fire-vents, 'daily exposure duration' or parity.

CONCLUSION

Biomass burning was associated with a high-risk for GBC and should be considered as a modifiable risk factor for GBC. Clean cooking fuel can potentially mitigate, and a healthy diet can partially reduce the risk among women.

Definitive Radiotherapy in Locally Advanced Head and Neck Squamous Cell Cancer with Clinical Extranodal Extension

Purpose

The extranodal extension (ENE) in head and neck squamous cell carcinoma (HNSCC) is a potential poor prognostic factor. Clinical ENE (cENE) was incorporated in the HNSCC staging system in the 8th edition of AJCC. There is not much evidence to support the treatment of HNSCC with cN3b with radiotherapy in radical intent. This study aims to assess the treatment outcome in patients of HNSCC with cN3b disease treated with definitive radiotherapy.

Method

Forty-five HNSCC patients with cN3b disease treated with definitive radiotherapy with or without concurrent chemotherapy between January 2018 to December 2018 were retrospectively evaluated.

Results

The median age of the study patients was 60 years (40-75years). Only 35 patients (77.8%) could complete the prescribed course of treatment, and the leading common cause of non-completion was treatment-related toxicities. After a median follow-up period of 9.3 months (range 2-33), the median OS and PFS were 22.6 months and 7.2 months, respectively. Fourteen patients (31.1%) in our study developed grade III/IV mucositis, and 11 (24.4%) developed severe grade III/IV dermatitis. The locoregional failure constituted 24 patients (53.3%).

Conclusion

The treatment outcome of HNSCC with cN3b disease is inferior. A personalized and subjective approach should be undertaken before choosing radiotherapy with a radical intent in this group of patients.

Evaluation of Cardiac Substructures Dose Sparing in Single and Dual Isocenter RapidArc™ Radiotherapy Planning for Synchronous Bilateral Breast Cancer

Purpose This study compares the dosimetry and dose sparing of cardiac substructures in single isocenter and dual isocenter RapidArc™ (Varian Medical Systems, Palo Alto, California, United States) radiotherapy planning for synchronous bilateral breast cancer. Methodology Six synchronous bilateral breast cancer (SBBC) patients received adjuvant radiation with the prescribed dose of 40.05 Gy in 15 fractions to the planning target volume (PTV) without local lymph nodal regions. PTVs and organs at risk (OARs), including both lungs, esophagus, spinal cord, heart, and left anterior descending coronary artery (LAD), both atria and ventricles were contoured. Single isocentric RapidArc (SIRA) and dual isocentric RapidArc (DIRA) plans were made for each patient and dosimetric differences between these two techniques were evaluated. Results There was no statistically significant difference in conformity index (CI) values between SIRA and DIRA plans, with 0.9681±0.01 and 0.9721±0.01 (p=0.505), respectively. SIRA planning showed superior homogeneity with homogeneity Index (HI) values of 0.0999±0.01 compared to DIRA planning with HI values of 0.1640±0.12 (p=0.230). The mean LAD dose of SIRA was valued higher than that of DIRA planning. Lower mean doses were obtained for both lungs in SIRA plans compared to DIRA plans. Meanwhile, doses to the right atrium, left atrium, left ventricle, right ventricle, and esophagus showed no statistical significance between these two techniques, except in the spinal cord. Conclusion Both SIRA and DIRA plans have satisfactory outcomes in sparing OARs. Meanwhile, SIRA techniques have less setup time and overall machine time.

Prognostic Significance of Neutrophil-Lymphocyte Ratio in Patients of High-Grade Glioma Undergoing Adjuvant Chemoradiation: A Prospective Study

PURPOSE

High-grade gliomas are highly fatal disease with poor prognosis despite multimodality management. Inflammatory biomarkers are widely used for prognostication in various solid malignancies to stratify high risk patients. The current research was conducted to investigate whether any change in neutrophil-lymphocyte ratio (NLR) during adjuvant chemoradiotherapy has any prognostic significance in high-grade glioma patients.

MATERIALS AND METHODS

Seventy-three biopsy proven high-grade glioma patients treated with adjuvant chemoradiotherapy were enrolled in this study. Haematological parameters were collected before treatment, weekly during treatment, and at 4th week after chemoradiotherapy along with baseline characteristics. Overall survival (OS) was determined using Kaplan-Meier curve. Variables found statistically significant in univariate analysis by Cox regression model were subjected to final multivariable analysis.

RESULTS

The median follow-up was around 17 months with a median OS of 17.2 months (95%CI 14.7-23). The best prognosis was seen in patients who had a baseline NLR< 3.5 with decline in NLR during treatment achieving a 1-year survival of 100% and median overall survival of 36.5 months. Patients who had baseline NLR ≥3.5 without a decline in NLR had worst prognosis with a 1-year survival of 25% (95%CI 9.4%-66.6%) and median OS of 7.1 months. On multivariate analysis, age [HR 1.025, p=0.040)], ECOG performance status≤1 [HR 0.089, p<0.001], extent of surgery [HR 0.305, p=0.001] and decline in NLR during treatment [HR 0.452, p=0.026] were found to be significant predictors of OS.

CONCLUSION

This study demonstrated that NLR is a cost-effective biomarker that has prognostic significance in predicting overall survival for high-grade glioma patients.

Intensity Modulated Radiotherapy in Head and Neck Cancer: Initial Experience of the First Treated Cases from North-East India

Head and neck cancer incidence is relatively higher in north-eastern states than in other parts of India. Intensity-modulated radiotherapy (IMRT) was first introduced in our institute in 2012 to cater the entire north-east. This study attempts to assess the treatment outcomes and prognostic factors of head and neck cancer patients who had been treated with definitive radiotherapy in our institute from 2012 to 2016 using IMRT. This is a single institutional retrospective study. Thirty-six patients of head and neck cancer other than nasopharynx primary treated with definitive radiotherapy using IMRT between 2012 to 2016 were evaluated. The survival was analyzed using the Kaplan-Meir method, and various clinicopathologic factors were compared. The median age of the study patients was 58 years (range 24-79 years). The majority of the patients (69.4%) were below the age of 50 years. Thirty-two patients (88.9%) were male, and only four (11.1%) were females. After a median follow-up time of 40 months (7-84 months), the 5-year overall survival (OS) was 42.1%. The stage at presentation and radiotherapy treatment time were found to be significant prognostic factors of the outcome. The treatment-related toxicities were within acceptable limits. This retrospective study has reported the outcome and treatment-related toxicities of initially treated HNC patients with IMRT from northeast India.

Factors Associated With Neurocognitive Impairment Following Chemoradiotherapy in Patients With High-Grade Glioma: Results of a Prospective Trial

BACKGROUND

High-grade gliomas (HGG) are highly fatal tumors despite advanced multimodality management. They are also associated with neurocognitive impairment, both due to disease pathology and treatment. We aimed to assess various risk factors responsible for neurocognitive decline in HGG patients undergoing adjuvant chemoradiation.

METHODS

Newly diagnosed HGG patients who underwent maximal safe resection were included. Patients received volumetric modulated arc therapy to a dose of 60 Gy in 30 fractions, along with concurrent temozolomide (TMZ) at a dose of 75 mg/m²/day orally; thereafter adjuvant TMZ (150-200 mg/m² for 5 days), given every 28 days for 6 to 8 cycles. The Mini-Mental State Examination questionnaire was used to measure cognitive impairment of each study patient at various time points. Cox regression model was used for univariate and multivariable analysis of data to establish possible risk factors.

RESULTS

Fifty-three patients were enrolled and analyzed. At a median follow-up of 15 months, 30 patients (56.6%) developed cognitive impairment, and 23 patients (43.4%) did not. On univariate analysis, HGG with WHO grade 4, glioblastoma and diffuse midline glioma histology, IDH-wild type, recursive partitioning analysis class IV/V, and only biopsy of primary tumor were significantly associated with neurocognitive impairment, but none of them were independent risk factors on multivariable analysis. Planning target volume and dose received by ipsilateral hippocampus were also significantly correlated with cognitive decline in HGG patients.

CONCLUSION

Decline in neurocognitive functions in HGG patients is multifactorial and can be attributed to an amalgam of various tumor, patient, and treatment-related factors.

Clinical Outcomes and Prognostic Factors of Locally Advanced Nasopharyngeal Cancer Treated with Intensity Modulated Radiotherapy: First Experience Report from Northeast India

The aim is to retrospectively evaluate the clinical outcomes and prognostic factors in patients of locally advanced nasopharyngeal cancer (NPC) treated with intensity-modulated radiotherapy (IMRT). The northeastern states report relatively more NPC cases in comparison to other states of India. This study is an attempt to assess the treatment outcomes and prognostic factors of locally advanced NPC who had been treated with definitive radiotherapy with or without chemotherapy in our institute from 2012 to 2016 using IMRT. This is a single institutional retrospective study. Thirty-one consecutive patients of locally advanced NPC treated with definitive chemoradiation using the IMRT technique between 2012 to 2016 were evaluated. The survival was analyzed using Kaplan-Meir method and their relations with various clinicopathologic parameters were compared. After a median follow-up time of 36 months, the 5-year overall survival (OS) and disease-free survival (DFS) was 47.3% and 26.1% respectively. The younger patients of < 50 years had improved OS (p = 0.05). Patients of stage IVA had inferior 5-year OS (p = 0.1) and 5-years DFS (0.02) than those of stage III. The patients who received neoadjuvant chemotherapy showed improved DFS at 5 years (p = 0.09). The treatment-related toxicities were within acceptable limit. This retrospective analysis has reported outcomes of locally advanced NPC patients treated with IMRT with concurrent chemotherapy when IMRT was first introduced in our institute. This is the first of its kind from the Northeastern region of India.

Analysis of Biochemical and Hematological Parameters During the First and Second Wave of SARS-CoV-2 Infection among North-East Indian Cancer Patients

Introduction: SARS-CoV-2 (COVID-19) affects respiratory airways as well as the kidneys, hearts etc. This study aims to demonstrate the impact of COVID-19 infection on biochemical and hematological parameters in cancer patients of North-East India. Methods: The study includes biochemical parameters for 907 and hematological parameters for 1103 cancer patients who were tested for COVID-19 between 1st June 2020 and 1st June 2021. All the data were analyzed by the statistical software SPSS (ver20). Results: AST (p = 0.023), GGT (p = 0.026) and Urea (p = 0.004) significantly increased in COVID-19 positive cancer patients compared to negative cancer patients. Eosinophils (p=0.01), eosinophils absolute (p=0.01), monocyte (p=0.04) and MCHC (p=0.01) were significantly decreased in COVID-19 positive cancer patients compared to negative. Various biochemical and haematological parameters analysed in our study were found to be altered between the COVID-19 positive and negative group but their association was not found to be statistically significant. Conclusion: We conclude that in cancer patients of North-East India, significant alterations of biochemical and hematological parameters AST, GGT, Urea, Eosinophils, eosinophils absolute, monocyte and MCHC were found in COVID-19 positive cancer patients compared to negative cancer patients.

Subjective Global Assessment of Nutritional Status in Head and Neck Cancer Patients Treated with Radiotherapy - A Prospective Observational Study from North East India

Head and neck cancer (HNC) patients undergoing curative radiotherapy (RT) are at risk of malnutrition due to disease process as well as effects of therapy. Identifying the nutritional status of these patients at the earliest, helps to introduce adequate and timely interventions that can improve compliance and outcomes of treatment. Various tools for nutritional assessment in cancer patients have been proposed. In this prospective observational study we used the Subjective Global Assessment (SGA) questionnaire in a cohort of HNC patients receiving definitive RT at a regional cancer center of North East India. Recording of data was done at baseline, at two weekly intervals during treatment, at end of radiotherapy (EORT) and at follow-up upto 6 months. We observed that despite proper nutrition counseling, our patients suffered from malnutrition throughout their course of RT, which was at its peak by EORT but gradually improved over six months of follow-up. Pain on eating and swallowing were the most debilitating symptoms which caused significant decline of nutrient intake, body fat and muscle mass among patients together with deteriorating SGA ratings. Our results will hopefully help us design better strategies for nutrition management while delivering curative (chemo)radiotherapy for HNC patients of this region- which has one of the highest incidences of HNC in the world.

Knowledge, Attitude and Level of Involvement of Married Males in Family Planning

Background There is an age-old notion that family planning is women's responsibility disregarding the fact that men have equal responsibility in fertility regulation. Although male involvement is getting more recognition, studies on men's role in family planning are very few in the number in this part of the world. Objective To assess the knowledge, attitude and level of male involvement in family planning and to find out the factors associated with male involvement by contraceptive usage. Method A community based cross-sectional study was done from May to July 2021 among 165 currently married male, who had at least one child, living in Singur district of West Bengal. Cluster sampling method was done to select study participants and data were collected by pre-designed pretested questionnaire. Descriptive statistics, multivariable logistic regression was applied and data were analysed applying SPSS software. Result Only 36.4% participants were directly involved in family planning either by using condom or by withdrawal method but 65.5% participants were indirectly involved in family planning through spousal communication either by approving contraceptive use to their spouse or by decision making regarding family planning. Moreover, barrier of contraceptives usage were side effect (27%) and fear of impotence (25.5%). Male involvement was significantly associated with participant's education [AOR (95% CI= 3.63 (1.45-9.05)], caste [AOR (95% CI= 7.06 (2.55-19.51)], number of living children [AOR (95%CI= 5.01(1.95-12.87)], desire for more child [AOR (95% CI=0.34 (.13-.87)] and attitude on family planning [AOR (95% CI= 3.55 (1.41-8.94)]. Conclusion This study identified the prevailing gender norms in rural areas. Advocacy for male involvement in family planning by health personnel during counselling of eligible couples should help in increasing contraceptive coverage in the long run.

Cancer in patients of and above 90 years: A hospital-based retrospective study

Background and Objective

Cancers in a nonagenarian patient are rarely seen, and there is always a moral dilemma for the family members and patient of whether to opt for the treatment or not. The main objective was to identify the survival differences between treated and not treated nonagenarian cancer patients.

Materials and Methods

This was a retrospective study of Hospital-Based Cancer Registry data from 2010 to 2016. The data of all nonagenarian cancer patients were analyzed for gender distribution, leading sites of cancer, stage distribution, types of treatment received, and survival. The survival was calculated from the date of the first diagnosis. Kaplan-Meier analysis was done to present the survival.

Results

Of 60,087 patients, 146 (0.2%) patients were of 90 years and above. Hypopharynx in males (20.5%) and tongue (20.5%) in females were the top cancer sites, 60% patient data were in Stages III and IV, 37 (25.3%) patients received treatment, and 86% patients were treated by radiotherapy. The overall survival (OS) was 14.3%. OS in the treatment group was 21.3% versus 7.7% (P = 0.001) in the no treatment group. The unadjusted hazard ratio for no treatment group was 3.8 (P = 0.003, confidence interval = 1.5-9.7).

Conclusion

Selected nonagenarian cancer patients from our population with a good performance status should receive curative treatments in all possible ways.

Standard-dose versus high-dose radiotherapy with concurrent chemotherapy in esophageal cancer: A prospective randomized study

Objective:

The objective of this study is comparision of local and distant control rates with high-dose versus standard-dose radiotherapy along with concurrent chemotherapy in esophageal cancer – a prospective randomized study.

Materials and Methods:

Histologically proven Stage I–III patients with carcinoma esophagus were randomized into two groups. One group has been treated with standard-dose radiotherapy, i.e., a total dose of 50.4 Gy (1.8 Gy/day, 28#, 5 days/week). The other group (study arm) has received high-dose radiotherapy, i.e. a total dose of 64.8 Gy (1.8 Gy/day, 36#, 5 days/week). Both groups have received 2 cycles of 3 weekly concurrent chemotherapy (cisplatin 75 mg/m^[2] on day 1 and 5-fluorouracil 750 mg/m^[2] continuous intravenous infusion over 24 h on day 1–4). Follow-up response evaluation was done by both endoscopy and computed tomography scan after 6–8 weeks and after 2 months thereafter.

Results:

Out of a total of 28 patients, 68% showed a complete response, 14% showed partial response, and 18% patients developed progressive disease at first and subsequent follow up (median follow-up of 21 months). Among the complete response patients, rates were higher in high-dose group compared to standard-dose radiotherapy group (71% vs. 64%, P = 0.38). Treatment-related toxicities were acceptable in both groups.

Conclusion:

High-dose radiotherapy with concurrent chemotherapy seems to be more effective with acceptable toxicity in our study. However, further follow-up and large sample size may be required to validate the current study conclusion.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Determination of Optimal Clinical Target Volume to Planning Target Volume Margins for Conformal Radiotherapy Planning using Image Guidance System in Rectal Cancer in Prone Position

Context:

In advanced radiotherapy techniques such as three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT), geometrical uncertainties are very crucial as they may lead to under dosing of tumor and over dosing of the nearby critical structures and hence, it is important to determine planning target volume (PTV) margins which are specific for every center.

Aims:

The aim of this study is to determine adequate clinical target volume (CTV) to PTV margins specific to our radiotherapy center.

Settings and Design:

To calculate CTV to PTV margins for rectal cancer patients in prone position using kV cone beam CBCT data sets.

Materials and Methods:

With the Patient immobilized in prone position using thermoplastic mask, a CT simulation was done and a comprehensive 3DCRT plan was generated. Daily kV CBCT was done to check the patient setup error. Daily setup errors were recorded and evaluated retrospectively.

Results:

CTV-PTV margin calculated for pelvis in the prone position was calculated using van Herk Formula and were found to be 0.5, 1.8, 0.7 cm in the lateral, longitudinal, and vertical directions, respectively.

Conclusions:

Image guidance is an effective method to evaluate patient setup errors. Good quality immobilization devices and stringent patient setup policies can help to reduce PTV margins further.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.

CONCLUSIONS

Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

DNA damage-induced ephrin-B2 reverse signaling promotes chemoresistance and drives EMT in colorectal carcinoma harboring mutant p53

Mutation in the TP53 gene positively correlates with increased incidence of chemoresistance in different cancers. In this study, we investigated the mechanism of chemoresistance and epithelial-to-mesenchymal transition (EMT) in colorectal cancer involving the gain-of-function (GOF) mutant p53/ephrin-B2 signaling axis. Bioinformatic analysis of the NCI-60 data set and subsequent hub prediction identified EFNB2 as a possible GOF mutant p53 target gene, responsible for chemoresistance. We show that the mutant p53-NF-Y complex transcriptionally upregulates EFNB2 expression in response to DNA damage. Moreover, the acetylated form of mutant p53 protein is recruited on the EFNB2 promoter and positively regulates its expression in conjunction with coactivator p300. In vitro cell line and in vivo nude mice data show that EFNB2 silencing restores chemosensitivity in mutant p53-harboring tumors. In addition, we observed high expression of EFNB2 in patients having neoadjuvant non-responder colorectal carcinoma compared with those having responder version of the disease. In the course of deciphering the drug resistance mechanism, we also show that ephrin-B2 reverse signaling induces ABCG2 expression after drug treatment that involves JNK-c-Jun signaling in mutant p53 cells. Moreover, 5-fluorouracil-induced ephrin-B2 reverse signaling promotes tumorigenesis through the Src-ERK pathway, and drives EMT via the Src-FAK pathway. We thus conclude that targeting ephrin-B2 might enhance the therapeutic potential of DNA-damaging chemotherapeutic agents in mutant p53-bearing human tumors.

Brief descriptive epidemiology of primary malignant brain tumors from North-East India

Brain tumors are a mixed group of neoplasms that originate from the intracranial tissues and the meninges with degrees of malignancy varying greatly from benign to aggressive. Not much is known about the epidemiology of primary malignant brain tumors (PMBTs) in our population in North-East India. In this analysis, an attempt was made to identify the age groups, gender distribution, topography and different histological types of PMBT with data from a hospital cancer registry. A total of 231 cases of PMBT were identified and included for the present analysis. Our analysis has shown that most of PMBT occur at 20-60 years of age, with a male to female ratio of 2.3:1. Some 70.5% of cases occurred in cerebral lobes except for the occipital lobe, and astrocytic tumors were the most common broad histological type. In our population the prevalence of PMBT is 1% of all cancers, mostly affecting young and middle aged patients. As brain tumors are rare, so case-control analytic epidemiological studies will be required to establish the risk factors prevalent in our population.

Radiotherapy and Concurrent Chemo-Radiotherapy in Locally Advanced Hypopharyngeal Cancers--A Hospital Registry Based Analysis

BACKGROUND

The survival of patients with hypopharyngeal cancer is low amongst head and neck cancer cases. The incidence rates of hypopharyngeal cancers in our population are amongst the highest in the world and there are limited data available on the literature on varied responses to first course of treatment with radiotherapy (RT) and concurrent chemo-radiotherapy (CRT) in our population.

MATERIALS AND METHODS

Clinical characteristics and initial responses to treatment in patients who had received radiotherapy and chemo-radiotherapy in a regional cancer center from January 2010 to December 2013 were evaluated. The data were obtained from the hospital cancer registry, and analysis was carried using descriptive statistics. Pearson's chi-square was used to test for differences in the variables and p<0.05 was considered statistically significant.

RESULTS

A total of 554 patients were included in the analysis, 411 (74.2%) receiving RT and 143 (25.8%) being given CRT. There was significantly lower number of patients above 70 years with a higher proportion of patients below 50 years who had received CRT (p<0.05). Some 79.3% and 84.6% of patients in the RT and CRT groups respectively presented with a favorable performance status, and in the RT group 240 (58.4%) showed complete response (CR), and in the CRT group 103 (72.0%) showed CR at the first follow-up (p<0.05).

CONCLUSIONS

Concurrent chemo-radiotherapy gives better short term response to treatment in locally advanced hypopharyngeal cancers.

Prognosis of vulval cancer with lymph node status and size of primary lesion: A survival study

Introduction:

Squamous cell cancer of the vulva is a rare disease with an annual incidence of two to three per 100,000 women. Lymph node metastasis is the most important prognostic factor for the recurrence and survival in vulval carcinoma.

Materials and Methods:

It is a retrospective study of 18 cases, operated in our institute from 2006 to 2009 and followed up till July, 2012. These patients were divided into two group of node positive and node negative and compared for recurrence and survival.

Result:

Ten patients had lymph node metastasis and eight had no lymph node metastasis. Recurrence rate was 40% and 12.5% in node positive and negative groups, respectively. Adjuvant radiation when given to node negative bulky tumor showed no recurrence compared to one out of two in the non-irradiated group. Survival was only 25% in node positive recurrent cases.

Conclusion:

Lymph node positivity added a great risk for future recurrence. Prophylactic radiation in node negative, bulky tumor is helpful.

Evaluation of hypopharyngeal carcinoma using high-resolution ultrasound: comparison with CT

BACKGROUND

To evaluate the role of sonography (US) in assessing hypopharyngeal carcinoma when compared with CT.

METHODS

A randomized prospective study was performed on 40 biopsy-proven cases of hypopharyngeal carcinoma.Contrast-enhanced CT of the neck was performed in all patients, followed by US. Sonographic identification of any tumor extension into the extralaryngeal soft tissues, postcricoid space, subglottis, thyroid gland, esophagus, and across the midline was recorded. US observations and CT findings were compared and then correlated with the histopathologic findings in 14 operative cases. In the remaining 26 inoperable cases, US was compared only with CT.

RESULTS

Our cohort was composed of 38 men and 2 women ranging in age from 36 to 59 years. In a subset of 14 operative patients, US had a sensitivity of 71.4% (10/14), while CT achieved a sensitivity of 92.8% (13/14), and the difference was not statistically significant (p > 0.05). US and CT findings concurred in 67.5% (27/40) of cases.

CONCLUSIONS

Even though small tumors are difficult to visualize, US can play a significant role in the assessment of tumor extension within and beyond the larynx, especially when cross-sectional imaging is either unavailable or unaffordable.

Prospective observational evaluation of incidences and implications of drug-drug interactions induced adverse drug reactions in critically ill patients

The primary aim of this study is to identify and analyze the importance of adverse drug reaction due to drug-drug interaction as a contributing factor towards drug safety. Patients more than 18 years of age admitted in multidisciplinary intensive care unit of a tertiary care hospital were included in this study. Patients who stayed less than 48 h and patients in whom all treatment modalities have been withdrawn and were on comfort measures only (no drugs were prescribed), were excluded. All the drugs that were given during intensive care unit stay were checked for presence of potential interactions which led to adverse drug reaction. Drug-drug interactions that were detected clinically or through investigations were recorded and also any therapeutic actions taken for drug-drug interactions were noted. From June 2006 to April 2007, 400 patients-prescriptions were analyzed. Adverse drug reactions due to drug-drug interactions were identified in 64% patients. Among those patients 38.67% had a single drug-drug interaction. Potential drug-drug interactions were 602. Clinically significant drug-drug interactions among the potential were 208 (34.55%). Clinically relevant drug-drug interactions were 103 (49.52% of 208 episodes). The adverse drug reactions due to drug-drug interactions in our sample were managed either by substituting another drug (50.48% of 103 episodes) or by adjusting the dose (1% of 103 episodes) or by omitting the drug (48.54% of 103 episodes). Among the 208 observed drug-drug interactions induced adverse drug reactions 21.63% was severe drug-drug interactions induced adverse drug reactions, 23.08% was moderate drug-drug interactions induced adverse drug reactions and 55.29% was minor drug-drug interactions induced adverse drug reactions. The interactions which were life threatening and/ or require medical intervention to minimize or prevent serious adverse effects were considered as severe drug-drug interactions and those interaction which resulted in an exacerbation of the patient's condition and/ or require an alteration in therapy were considered as moderate drug-drug interactions. The interactions which were limited clinical effects and manifestations may include an increase in the frequency or severity of side effects but generally would not require a major alteration in therapy were classified as minor drug-drug interactions. The correlation coefficient was 0.86 between the number of drugs given to the patient & number of average potential adverse drug reactions found among the patients. Increase in number of prescribed drug significantly (one way) increases number of potential adverse drug reaction due to drug-drug interaction (p<0.0001). Critically ill patients are more susceptible to drug-drug interactions due to the administration of multiple drugs and complex drug combinations. Several drug-drug interactions were clinically irrelevant.

An oncolytic adenovirus defective in pRb-binding (dl922-947) can efficiently eliminate pancreatic cancer cells and tumors in vivo in combination with 5-FU or gemcitabine

Pancreatic adenocarcinoma has a poor prognosis and frequently develops resistance to standard chemotherapeutics. Oncolytic adenoviruses represent a promising approach to overcome treatment resistance. The replication-selective dl922-947 adenovirus, defective in pRb binding, targets cancers with deregulated cell cycle control, such as the majority of pancreatic tumors. Cell killing efficacy was higher for dl922-947 than for adenovirus type 5 (Ad5) and the clinically approved dl1520 in pancreatic cancer cells with K-ras, p16 and p53 mutations. Combinations of dl922-947 and 5-fluorouracil or gemcitabine (2'2'-difluoro-2-deoxytidine) resulted in strong synergistic cell killing in Suit-2 and the highly drug- and virus-resistant Hs766T cells. Viral uptake increased in response to drugs, but was independent of the expression levels of the viral attachment receptor coxsackie and adenovirus receptor (CAR), whereas expression levels of the internalization receptors α(v)β(3)- and α(v)β(5)-integrins were increased. Early viral E1A expression was potently induced with drugs contributing to the synergistic effects. The dl922-947 mutant was more efficacious than Ad5 in vivo in Hs766T and Suit-2 xenograft models. In combination with gemcitabine, median survival was further prolonged. We demonstrate that dl922-947 is highly efficacious in pancreatic cancers and conclude that oncolytic adenoviruses harboring the E1ACR2 deletion have great potential for development into future clinical candidates for pancreatic cancer.

Microalbuminuria: An inexpensive, non invasive bedside tool to predict outcome in critically ill patients

This study was conducted to evaluate whether microalbuminuria on admission and after 24 hrs of admission to intensive care unit (ICU) predicts outcome as well as the Acute Physiology and Chronic Health Evaluation (APACHE) II severity illness score, the current accepted method of doing so. The study was carried out in a 20 bed mixed medical-surgical ICU of a tertiary care hospital. Of 525 consecutive adult patients with ICU stay of more than 24 hrs, 238 were included for the study. Patients with pregnancy, menstruation, anuria, macroscopic hematuria, urinary tract infection, marked proteinuria due to renal and post-renal structural diseases, were excluded. Spot urine samples were collected on admission to ICU and 24 hrs thereafter. Urine albumincreatinine ratio (ACR) was measured on ICU admission (ACR1) and after 24 hrs (ACR2) and expressed in mg/g. Patient demographics were noted on admission. For disease severity scoring, APACHE II scores were calculated. Each patient was followed up throughout their ICU stay for a maximum of 28 days and the following outcome data were obtained: ICU length of stay and ICU mortality. Of the 238 patients, 196 survived while 42 patients died in the ICU. Non-survivors had a significantly higher median ACR2 [162.7 mg/g (IQR 69.5-344.3)] in comparison to the survivors who had a median ACR2 = 54.4 mg/g (IQR 19.0-129.1) (P< 0.0001). The median ACR1 [161.0 mg/g (IQR 29.0-369.3)] of non-survivors was higher than the median ACR1 [80.4 mg/g (IQR 35.1-167.6)] of survivors but failed to reach statistical significance (P= 0.0948). In a receiver operating characteristic curve (ROC) analysis, ACR2 emerged as the best indicator of mortality [(area under curve (AUC) of ACR2 = 0.71 > AUC (ACR1) =0.58 > AUC (ΔACR) =0.55] similar to the currently used APACHE II scores (AUC = 0.78) (P=0.3). At a cutoff of 101 mg/g, ACR2 had a sensitivity of 69%, specificity of 67%, positive predictive value of 31% and a negative predictive value of 91% for predicting mortality in the critically ill patients. Absence of significant microalbuminuria at 24 hrs of ICU admission may help to predict survival in the ICU.