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   Table of Contents - Current issue
Coverpage
January-March 2018
Volume 55 | Issue 1
Page Nos. 1-121

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EDITORIAL  

Medical Council of India's amended qualifications for Indian medical teachers: Well intended, yet half-hearted Highly accessed article p. 1
Sunita V. S. Bandewar, Amita Aggarwal, Rajeev Kumar, Rakesh Aggarwal, Peush Sahni, Sanjay A Pai
DOI:10.4103/ijc.IJC_654_17  PMID:30147085
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REVIEW ARTICLE Top

Implementing American Joint Committee on Cancer 8th edition for head-and-neck cancer in India: Context, feasibility, and practicality p. 4
Narayana Subramaniam, Krishnakumar Thankappan, Adharsh Anand, Deepak Balasubramanian, Subramania Iyer
DOI:10.4103/ijc.IJC_475_17  PMID:30147086
The American Joint Committee on Cancer (AJCC) 8th edition marks a paradigm shift in the staging of head-and-neck cancers. It introduces several novel considerations into the staging of head-and-neck cancer, with distinct therapeutic ramifications, to stage and prognosticate patients better. In oral cancer, it introduces the depth of invasion as a determinant of T-stage. The nodal staging recommendations have also upstaged extranodal extension, which has been shown to be a high-risk adverse feature associated with worse survival. In oropharyngeal cancer, human papillomavirus (HPV) expression of tumors has been used to reclassify tumors into two separate entities, with distinct staging systems. For HPV-positive tumors, nodal staging has been divided into clinical staging and pathological staging, for better prognostication of HPV-positive diseases treated with surgery. In carcinoma of unknown primaries with cervical nodal metastasis, immunohistochemical staining of nodal tissue for HPV and Epstein–Barr virus has been recommended in all cases. These recommendations are based on a high-quality evidence aimed at personalizing cancer therapy to optimize outcomes while minimizing morbidity. The new recommendations address many of the shortcomings of the previous editions. The practice of oncology in India, however, is markedly different from that in the Western world. Majority of these recommendations are universal; however, some are likely to have hurdles in implementation in India.
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HEMATOLYMPHOID MALIGNANCY OUTCOMES Top

Long term clinical outcomes of adult hematolymphoid malignancies treated at Tata Memorial Hospital: An institutional audit p. 9
Navin Khattry, Siddhartha Laskar, Manju Sengar, Venkatesh Rangarajan, Tanuja Shet, PG Subramanian, Sridhar Epari, Bhausaheb Bagal, Jayant Sastri Goda, Archi Agarwal, Hasmukh Jain, Prashant Tembhare, Nikhil Patkar, Nehal Khanna, Sachin Punatar, Anant Gokarn, Dhanlakshmi Shetty, Hemani Jain, Avinash Bonda, Vikram Gota, Syed Hasan, Jyoti Kode, Shilpee Dutt, Suyash Kulkarni, Nitin Shetty, Nilesh Sable, Jayita Deodhar, Sunita Jadhav, Preeti Pawaskar, libin Mathew, Hari Menon, Reena Nair, Sadhana Kannan, Shubhadha Chiplunkar, Sumeet Gujral
DOI:10.4103/ijc.IJC_656_17  PMID:30147087
Introduction: There is paucity of data from India about the outcomes of patients with various hematological malignancies. Since its formation in 2009, the adult hematolymphoid disease management group of the Tata Memorial Centre is dedicated to the treatment of hematological malignancies alone. In this report, we present the outcomes of patients treated at our centre over a 5 year period for various haematological malignancies in both transplant and non-transplant setting. Methods: This is a retrospective analysis of all patients registered in adult hematolymphoid disease management group between 1st January 2010 to 31st December 2014. Patients not treated at our centre were excluded from survival analysis. The cut off date for survival analysis was 31st January 2016. Results: Overall, 1869, 3633 and 544 patients with acute leukemias, various lymphomas and myeloma respectively were registered at our centre from 1st January 2010 to 31st December 2014. Of these, 1178 (63%), 3091 (85%) and 454 (83%) respectively received treatment at our centre. The cumulative probability of 5 year overall survival for patients with acute leukemias, Hodgkin's lymphoma, non-Hodgkin lymphoma and myeloma treated at our centre is 40%, 85%, 78% and 40% respectively. Four hundred and fifteen stem cell transplants were done between 14th November 2007 to 31st December 2014 with 46% being allogeneic and 54% being autologous. The 5 year overall survival of patients with allogenic and autologous transplant was 52% and 63% respectively. Conclusions: This is the largest single centre data on outcomes of various haematological malignancies from India. This real world data identifies areas which need further attention to improve outcomes.
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BREAST CANCER OUTCOMES Top

Breast cancer in a tertiary cancer center in India - An audit, with outcome analysis p. 16
Nita Nair, Tanuja Shet, Vani Parmar, Rohini Havaldar, Sudeep Gupta, Ashwini Budrukkar, Rajiv Sarin, Meenakshi Thakur, Sangeeta Desai, Prabha Yadav, Rakesh jalali, Seema Gulia, Tabassum Wadasadawala, Jaya Gosh, Jyoti Bajpai, Seema Kembhavi, Asawari Patil, Shalaka Joshi, Palak Popat, Venkatesh Rangarajan, Sneha Shah, Vaibhav Vanmali, Shabina Siddiqui, Indraneel Mittra, Rajendra Badwe
DOI:10.4103/ijc.IJC_484_17  PMID:30147088
Background: Survival studies may serve as benchmarks to develop cancer-related policies and estimate baseline survival rates in a given patient population. Materials and Methods: We carried out a retrospective audit of cases managed in 2009 and now report the disease-free survival (DFS) in early breast cancer (EBC) and locally advanced breast cancer (LABC) in patients registered at a tertiary cancer center in India. Results: The study included 2192 patients with breast cancer with ages ranging from 18 years to 94 years with a median of 50 years. Of these, 888 (40.5%) were EBCs Stage I and II, 833 (38%) were LABCs (Stage III), and 471 (21.5%) were de novo metastatic or relapsed cancers at presentation. The 5-year DFS in the women with EBC was 85.5% and in LABC, it was 67.7%, P < 0.001. The factors adversely affecting DFS in EBC were node metastasis (P < 0.001), higher metastatic nodes (P < 0.001), hormone receptor negativity (P = 0.001), and human epidermal growth factor receptor 2 (Her2neu) positivity (P = 0.033). In the multivariate Cox regression analysis in EBC, node-positive status (hazard ratio [HR] 2.28, 95% confidence interval [CI] 1.51–3.45, P < 0.001) and hormone receptor negative tumors (HR 1.96, 95% CI 1.30–2.94, P = 0.001) significantly affected DFS in EBC. The factors adversely affecting DFS in LABC in the univariate analysis were node metastasis (P < 0.001), increasing numbers of nodes (P < 0.001), presence of lymphovascular emboli (LVE) (P < 0.01), mastectomy (P < 0.001), and Her2neu positivity (P = 0.03). In the multivariate Cox regression analysis, node positivity (HR 2.96, 95% CI 2.04–4.29, P < 0.0001), presence of LVE (HR 1.47, 95% CI 1.06–2.04, P = 0.023), and mastectomy (HR 1.49, 95% CI 1.06–2.10, P = 0.023) adversely impacted DFS in LABC. Conclusions: The survival rates in this study are equal to the documented global rates; nodal disease burden emerged as the most important prognostic factor. In addition, in EBCs, a lack of hormone receptor expression and in LABC, Her2neu overexpression appear to worsen the outcome.
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THYROID CANCER/HEAD AND NECK CANCER OUTCOMES Top

Surgical outcomes of thyroid cancer patients in a tertiary cancer center in India p. 23
Anuja Deshmukh, Kranthikumar Gangiti, Gouri Pantvaidya, Deepa Nair, Sandip Basu, Devendra Chaukar, Prathamesh Pai, Sudhir Nair, Rohini Hawaldar, Rohit Dusane, Pankaj Chaturvedi, Anil D'Cruz
DOI:10.4103/ijc.IJC_528_17  PMID:30147089
Background: Surgery is the mainstay in the management of thyroid cancer. Surgical outcomes need to be tempered against the excellent prognosis of the disease. Aims: This study aims to study the surgical outcomes including the 30-day morbidity and 5-year survival of thyroid cancer patients. Settings and Design: Retrospective analysis of a prospectively maintained surgical database in a tertiary cancer center in India. Materials and Methods: We analyzed 221 surgically treated patients in the year 2012. Statistical Analysis: Used IBM SPSS 24.0 (Armonk, NY) with p < 0.05. Results: The median age was 40 years with predominantly papillary thyroid carcinoma (55%). Localized disease in 47% of cases, locoregional disease in 42.5% and distant metastasis in 10.2% of cases at presentation was noted. Treatment naïve patients were 71% and revision surgeries were done in 29% patients. Extended thyroidectomy constituted 11% of the surgeries. Temporary hypocalcemia was seen in 30.8% of patients, 5% requiring intravenous calcium supplementation. Vocal cord palsy as per nerve at risk and chyle leak were seen in 4.5% and 3.1%, respectively. Aggressive histology, extended thyroidectomy, and inadvertent parathyroidectomy were significant factors associated with complications. Five year estimated overall survival with median follow-up of 50 months was 98%, and event-free survival was 84.8%. Advanced age, distant metastasis at presentation and aggressive histology connoted poor outcomes. Conclusion: Thyroid cancer, irrespective of the extent of disease, has good prognosis. Aggressive histology, the extent of thyroid surgery, distant metastasis and age are important factors, which should be factored in the algorithm of thyroid cancer management.
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SALIVARY GLAND CANCER/HEAD AND NECK CANCER OUTCOMES Top

Surgical morbidities and outcomes of major salivary gland neoplasms treated at a tertiary cancer center p. 33
Shivakumar Thiagarajan, Khuzema Fathehi, Deepa Nair, Anuja Deshmukh, Gouri Pantvaidya, Devendra Aravind Chaukar, Anil Keith D'Cruz
DOI:10.4103/ijc.IJC_466_17  PMID:30147090
Background and Objectives: Salivary gland neoplasms are relatively uncommon. They have a wide variety of histopathological types with diverse biological behavior. It involves all the major and minor salivary glands in the head and neck. This article focuses on the various types of major salivary gland tumors treated at a tertiary cancer center along with their surgical morbidities and outcomes. Materials and Methods: Data of all the salivary gland neoplasms operated in the head and neck services between January 2012 and December 2013 were retrieved from a prospectively collected database. The clinical, demographic data and types of surgeries along with the morbidities were collated from the database and the details regarding the follow-up were collected from the electronic medical record. Results: Out of 235. cases registered, 107. patients were treated at our institute. The parotid gland was most commonly involved; majority were malignant lesions. Sixty-two patients were treatment naive at presentation. Majority presented with advanced disease. Superficial parotidectomy was the most common surgery performed and neck dissection was done in 27. patients. Facial nerve palsy was the most common complication following surgery. (16%). Sixty patients received adjuvant treatment. All patients on follow-up were alive at their last visit, with 10. patients having recurrence. Factors influencing the disease-free survival were extracapsular spread, tumor grade, and perineural invasion. Conclusion: The postoperative morbidities and outcomes for major salivary gland neoplasms in our series were acceptable and comparable to the results available in the literature. Appropriate treatment of the salivary gland neoplasm will yield good outcomes with acceptable morbidity.
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BONE AND SOFT TISSUE SARCOMA OUTCOMES Top

Analysis of bone and soft-tissue sarcomas registered during the year 2012 at Tata Memorial Hospital, Mumbai, with clinical outcomes p. 37
Jyoti Bajpai, Nehal Khanna, Tushar Vora, Ashish Gulia, Siddhartha Laskar, Ajay Puri, Bhanupriya Sanduptla, Girish Chinnaswamy, Prakash Nayak, Shashikant L Juvekar, Amit Janu, Subhash Desai, Jaya Ghosh, Nilendu Purandare, Mukta Ramadwar, Venkatesh Rangarajan, Bharat Rekhi
DOI:10.4103/ijc.IJC_481_17  PMID:30147091
Introduction: Primary bone and soft tissue sarcomas are rare, but diagnostically and therapeutically challenging group of tumors, requiring multidisciplinary management. There are limited documented studies from multidisciplinary teams , in the form of comprehensive analysis of these tumors, from our country. This study is an analysis of cases of osteosarcomas, Ewing sarcomas (ESs), chondrosarcomas (CSs), and soft-tissue sarcomas (STSs), registered at our institution during 2012. Methods: Clinical details, including outcomes of cases of bone and STSs, during the year 2012, were retrieved from the medical records of our institution and were further analyzed. Results: Ninety-five high-grade, extremity-based, treatment-naïve cases of osteosarcomas were treated with a novel, dose-dense, nonhigh-dose methotrexate-based OGS-12 protocol. Good histopathologic response (necrosis ≥90%) was achieved in 59% nonmetastatic and 56% metastatic patients. At a median follow-up of 48 months, the estimated 5-year event-free survival and overall survival (OS) were 67% and 78%, respectively. In the metastatic cohort at a median follow-up of 51 months, the 5-year estimated progression-free survival was 24% and OS was 26%. Among 87 (73.2%) nonmetastatic and 32 (26.8%) metastatic, analyzable cases of ES, at a median follow-up of 40 months, the disease-free survival (DFS) and OS in the nonmetastatic group were 62% and 83%; in the metastatic group, they were 37.5% and 65.6%, respectively. Among 40 cases of CSs (33 nonmetastatic and 7 metastatic), 21 had limb salvage surgery while 5 had amputation. Microscopically, 90.4% were Grade II CSs. Five-year OS and DFS were 84.6% and 71%, respectively. Among 189 high-grade, extremity-based STSs (89% nonmetastatic), synovial sarcoma was the most common subtype (31%). Eighty-five percent had limb preservation surgery; a majority were offered adjuvant radiation with or without chemotherapy. At a median follow-up of 51 (1–63) months, 3-year local control, DFS, and OS were 81%, 48%, and 64%, respectively. Conclusions: The novel OGS 12 and Ewing Family of Tumors 2001 protocols have shown comparable outcomes to international standards in cases of osteosarcoma and ES, respectively, and merit wider applications, especially in low- and middle-income countries (LMICs). Outcomes in STS and CSs were also comparable and underscore the importance of a multidisciplinary approach for the management of sarcomas in LMICS.
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FEMALE GENITAL TRACT CANCER OUTCOMES Top

Locally advanced cervical cancer: A study of 5-year outcomes p. 45
Supriya Chopra, Meetakshi Gupta, Ashwathy Mathew, Umesh Mahantshetty, Reena Engineer, G Lavanya, Sudeep Gupta, Jaya Ghosh, Meenakshi Thakur, Kedar Deodhar, Santosh Menon, Bharat Rekhi, Jyoti Bajpai, Seema Gulia, Amita Maheshwari, Rajendra Kerkar, TS Shylasree, SK Shrivastava
DOI:10.4103/ijc.IJC_428_17  PMID:30147092
Background: Cervical cancer is the second most common cancer among Indian women. This present retrospective study was conducted to report patient outcomes with locally advanced cervical cancer treated in the year 2010. Materials and Methods: Case records of cervical cancer patients registered from January 1, 2010, to December 31, 2010 were retrieved. A total of 1200 patients were registered, of which 583 received either definitive or adjuvant radiotherapy (RT). Of these, 345 patients who received complete treatment at our hospital were included for outcome analysis. Descriptive statistics were used to summarize patient- and treatment-related variables, and Kaplan–Meier analysis was performed for survival analysis. Results: The median age was 56 years (range: 33–90). Squamous carcinoma was the most common histology (91.4%) and the majority were FIGO Stage III (45.4%). Median follow-up of the cohort was 44 months (1–85 months). The 5-year disease-free survival (DFS) across stages was 50%. Most important predictor of DFS was FIGO staging (Stage II vs. Stage III: 62% vs. 45%) and use of concurrent chemoradiotherapy (CTRT) l (RT vs. CTRT: 32% vs. 57%, respectively). Patients aged >70 years had a significantly poor DFS at 5 years; however, did not have any effect on survival. Grade 3 or more late toxicity was seen in only 5% of the patients. Conclusion: Five-year DFS of 62% and 45% of Stage II and III patients treated under routine care represents comparable stage-matched results to the rest of the world, respectively.
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Outcomes of advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy p. 50
Amita Maheshwari, Neha Kumar, Sudeep Gupta, Bharat Rekhi, TS Shylasree, Rohit Dusane, Jyoti Bajpai, Jaya Ghosh, Seema Gulia, Kedar Deodhar, Santosh Menon, Palak Popat, Nilesh Sable, Meenakshi Thakur, Rajendra Kerkar
DOI:10.4103/ijc.IJC_468_17  PMID:30147093
Background: Ovarian cancer is the fourth most common cancer in Indian women. Majority of these are epithelial ovarian cancers (EOCs), most of which present in advanced stage. Women with poor performance status and/or those unlikely to achieve optimal debulking at upfront surgery, benefit from neoadjuvant chemotherapy (NACT) followed by interval cytoreduction, with lesser surgical morbidity and equal survival rates as compared to primary cytoreduction. Methodology: This was a retrospective analysis of patients with advanced ovarian cancer, treated with NACT followed by interval debulking surgery at Tata Memorial Hospital from January 2014 to December 2014. Results: Epithelial cancers constituted 84.4% (n = 406) of all cases of ovarian malignancies. Of these, overwhelming majority (84.3%, n = 342) were in the advanced stage. Sixty percent of all EOC patients received NACT. The mean baseline serum CA-125 level in women treated with NACT was 4294.7 U/ml (range, 11–151,200 U/ml). The median number of NACT cycles (paclitaxel + carboplatin) was 3. Optimal cytoreduction was achieved in 81.5% cases. The rates of Grade 3 or 4 intraoperative and postoperative complications were 4% each. The median postoperative stay was 5 days and the median time between surgery and adjuvant chemotherapy was 20 days. The median progression-free survival (PFS) was 15.15 months (95% confidence interval [CI]: 12.95–17.34), and the median overall survival (OS) was 34.73 months. Multivariate analysis revealed that optimal cytoreduction (hazard ratio [HR] = 2.04 [95% CI: 1.15–3.62]; P = 0.015) and number of NACT cycles (3 vs. >3; HR = 1.51 [95% CI: 1.06–2.16]; P = 0.022) were significantly associated with PFS, and optimal cytoreduction (HR = 3.21 [95% CI: 1.53–6.73]; P = 0.002) and ECOG status (0–1 vs. ≥2; HR = 2.64 [95% CI: 1.25–5.55]; P = 0.011) with OS. Conclusions: High rates of optimal cytoreduction were achieved at interval cytoreductive surgery after NACT, with acceptable surgical morbidity, early start of adjuvant chemotherapy, and survival outcomes comparable to international standards.
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PEDIATRIC ONCOLOGY OUTCOMES Top

A cross-sectional study of the distribution of pediatric solid tumors at an Indian tertiary cancer center p. 55
Sajid S Qureshi, Monica G Bhagat, Seema A Kembhavi, Girish Chinnaswamy, Tushar Vora, Maya Prasad, Siddarth Laskar, Nehal Khanna, Mukta R Ramadwar, Sneha Shah, Navin Salins, Sanjay Talole
DOI:10.4103/ijc.IJC_610_17  PMID:30147094
Context: Pediatric solid tumors include a heterogeneous group of tumors, and the burden of these tumors, especially from resource-challenged countries, is not well described. AIMS: The aim of this study was to describe the distribution of solid tumors in children and the treatment outcome of Wilms tumor and hepatoblastoma. Patients and Methods: All patients under 15 years of age with histologically confirmed tumors presenting at a tertiary cancer center from January 2012 to December 2016 were identified from the hospital database. Patients with lymphomas, bone, and central nervous tumors were excluded. The demographic profile including age, sex distribution, and the treatment received were recorded for all patients. Results: The mean age of the eligible 1944 patients was 5.7 years with majority (57.3%) in the 0–4 years age group. The male-to-female ratio was 1.4:1 with a male predominance in all tumors except germ cell tumors. Soft tissue tumors were the most common tumors followed by neuroblastoma and renal tumors, whereas liver tumors formed only 6.7% of all tumors. Seventy percent of the patients received treatment completely or partially at our institute, whereas 18.3% had no cancer-directed treatment. The 3-year overall survival of patients with Wilms tumor and hepatoblastoma was 85.4 and 78.5%, respectively. Conclusions: Extracranial and extraosseous pediatric solid tumors include a wide range of tumors with a predilection for male sex and children below 4 years of age. Soft tissue tumors, neuroblastoma, and renal tumors are the most common; the outcomes of Wilms tumor and hepatoblastoma are favorable.
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LUNG CANCER Top

Time-domain heart rate variability-based computer-aided prognosis of lung cancer p. 61
Reema Shyamsunder Shukla, Yogender Aggarwal
DOI:10.4103/ijc.IJC_395_17  PMID:30147095
Objective: Incidence of lung cancer (LC) is increasing day by day with exposure to smoke, radiation, and chemicals; LC is one of the leading causes of death. The major difficulty in treatment was delayed diagnosis. This study aims to propose a time-domain heart rate variability (HRV) feature-based automated system in LC prediction and its staging. Materials and Methods: HRV analysis was done using recorded electrocardiographic signal from 104 LC participants and 30 control volunteers. Artificial neural network (ANN) and support vector machine (SVM) were implemented on HRV time-domain features for early prognosis of the disorder. Statistical significance of HRV parameters was tested, and graphical user interface (GUI) was also implemented. Results: It was revealed that progression of cancer causes low HRV. An accuracy of 89.64% and 100% was obtained with ANN and SVM, respectively, in automated cancer prediction. Statistical analysis suggested the significance of data at P < 0.05 between different performance statuses among patients. Conclusion: The severity of LC alters the sympathovagal balance through autonomic dysfunction. HRV analysis with an expert system was found useful for the early diagnosis of the disease, and thus, a noninvasive technique is of prognostic importance in classifying LC stages. The GUI designed for clinicians can help them to diagnose the Eastern Cooperative Oncology Group performance status scale of future patients.
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HEMATOLYMPHOID MALIGNANCY Top

Diffuse large B-cell lymphoma: A retrospective study from a regional care center in South India p. 66
Suresh MC Babu, Sunny Garg, Govinda Babu Kanakasetty, Lakshmaiah Chinnagiriyappa Kuntegowdanahalli, Lokanatha Dasappa, Suparna Ajit Rao
DOI:10.4103/ijc.IJC_450_16  PMID:30147096
Introduction: Diffuse large B-cell lymphoma (DLBCL) is an aggressive lymphoma whose outcomes have significantly improved with rituximab in addition to anthracycline-based chemotherapy. Objective: This study aimed to study the epidemiology, treatment, and outcomes of patients with DLBCL. Materials and Methods: A total of 526 patients diagnosed with DLBCL between 2006 and 2015 were retrospectively analyzed. Results: The median age was 50 years with a male preponderance. Two hundred and twenty-three (42.39%) patients presented with B symptoms. A total of 53 (10.07%) patients presented with bulky disease and 202 (31.40%) with extranodal disease. The most common extranodal sites involved were the stomach (20.79%) and the bone marrow (10.89%). Bone marrow involvement was seen in only 22 (4.18%) cases. The distribution of patients presenting in low, low-intermediate, high-intermediate, and high-risk International Prognostic Index (IPI) were 148 (28.13%), 191 (36.31%), 124 (23.57%), and 63 (11.97%), respectively. The median survival of the entire cohort was 22 months. Survival of patients that compared the two groups with respect to the IPI – one having clubbed patients in low and low/intermediate risk and the other clubbing high/intermediate and high risk showed significantly improved survival in the lower risk groups – 24 versus 18 months (P = 0). The survival of those who received chemoimmunotherapy i.e R – CHOP was significantly better than those who received chemotherapy (CHOP) alone – 33 versus 21 months (P = 2.22e–16). Conclusions: DLBCL is one of the most common lymphomas seen in our daily practice. Outcomes are significantly inferior compared to western countries. Biological and patient-related factors such as nongerminal center B subtype, higher extranodal involvement, and poor tolerability to treatment could contribute to inferior outcomes.
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GYNECOLOGIC CANCER Top

Retrospective analysis of patients of cervical cancer a tertiary center in Bihar p. 70
Anita Kumari, Sangeeta Pankaj, Vijayanand Choudhary, Anjili Kumari, Syed Nazneen, Jaya Kumari, Shishir Kumar
DOI:10.4103/ijc.IJC_482_17  PMID:30147097
Objective: A retrospective analysis of all patients with cancer of the cervix attending regional cancer center of Indira Gandhi Institute of Medical Sciences, Patna, from June 2015 to June 2017. The aim of this study was to know patient demographics, histology, age, stage and status of presentation, compliance with treatment and follow-up. Materials and Methods: Five hundred and eighteen consecutively registered patients with cancer of the cervix were included in the study. Results: The prevalence of cervical cancer among gynecological malignancy was 52%. It is the second most common cancer after breast cancer at our center. Patients hailed from the various districts of Bihar (89%), India, and from Nepal (10.61%). The majority (>50%) were aged 40–59 years. Stage information was available for 71.81% of the patients, of which Stage I comprised 12.36%, Stage II, 35.21%; Stage III, 50%; and Stage IV, 2.41%. Squamous cell carcinoma was the most common reported histopathology (~90%). A significant proportion of the women defaulted after registration, or after undergoing investigations (17%). Of the 68% cases planned for treatment, 50% initiated it, but only 38% completed it, About 11% of cases underwent Wertheim's hysterectomy and rest of patients were treated by radiotherapy with or without chemotherapy. Conclusion: The incidence of cervical cancer is still unacceptably high at our center. Organized cervical cancer screening needs to be adopted for early diagnosis.
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GYNECOLOGIC CANCER/RADIOTHERAPY Top

A comparative study of RapidArc and intensity-modulated radiotherapy plan quality for cervical cancer treatment p. 74
Atia Atiq, Maria Atiq, Khalid Iqbal, Manzar A Sial, Saima Altaf, Quratul Ain Shamsi, Saeed A Buzdar
DOI:10.4103/ijc.IJC_609_17  PMID:30147098
Background: RapidArc therapy, a complex form of intensity-modulated radiotherapy (IMRT), is now widely used to treat cancer patients. Aims: This study aimed to investigate and compare the plan quality of IMRT and RapidArc techniques using various dosimetric indices to find the better treatment modality for treating patients with cervix cancer. Materials and Methods: Thirteen cervical cancer patients treated with IMRT were selected for analysis and original plans were subsequently re-optimized using the RapidArc technique. Plans were generated such that dose of 5000 cGy was delivered in 25 equal fractions. Inverse planning was done by Eclipse (Varian Medical Systems, Palo Alto, CA) treatment planning system for 15 MV photon beams from computed tomographic data. Double arcs were used for RapidArc plans. Quality of treatment plans was evaluated by calculating conformity index (CI), homogeneity index (HI), gradient index (GI), coverage, and unified dosimetry index (UDI) for each plan. Results and Conclusion: RapidArc resulted in better planning target volume (PTV) coverage as is evident from its superior conformation number, coverage, CI, HI, GI, and UDI. Regarding organs at risk (OARs), RapidArc plans exhibit superior organ sparing as is evident from integral dose comparison. Difference between both techniques was determined by statistical analysis. For all cases under study, modest differences between IMRT and RapidArc treatment were observed. RapidArc-based treatment planning is safer with similar planning goals compared to the standard fixed IMRT technique. This study clearly demonstrated that favorable dose distribution in PTV and OARs was achieved using RapidArc technique, and hence, the risk of damage to normal tissues is reduced.
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EXFOLIATIVE CYTOLOGY/GYNAECOLOGIC CANCER/SCREENING Top

Comparison of conventional Pap smear and liquid-based cytology: A study of cervical cancer screening at a tertiary care center in Bihar p. 80
Sangeeta Pankaj, Syed Nazneen, Simi Kumari, Anjili Kumari, Anita Kumari, Jaya Kumari, Vijayanand Choudhary, Shishir Kumar
DOI:10.4103/ijc.IJC_352_17  PMID:30147099
Background: Cervical cancer is the fourth leading cause of cancer in women in the world and it is the second most common cancer in women 15–44 years of age. Strict implementation of screening programs has led to a large decrease in cervical cancer incidence and mortality in the developed countries. In contrast, cervical cancer remains largely uncontrolled in high-risk developing countries because of ineffective or no screening programs. Conventional Pap smear method has been the mainstay of most of the screening programs for many decades. However, this technique is not without limitations, and the sensitivity and specificity of cervical cytology are relatively low. To overcome the limitations of conventional Pap smear (CPS), liquid-based cytology (LBC) was introduced in 1990s as a better tool for processing cervical samples. Objectives: This study was undertaken to compare CPS with liquid-based methods, to assess the effectiveness and feasibility of LBC over CPS in our setting, and also to evaluate the prevalence of human papillomavirus (HPV) in our population. Materials and Methods: This study was conducted in Gynecological Oncology Unit of Regional Cancer Center at Indira Gandhi Institute of Medical Sciences, Patna, Bihar. About 310 women were enrolled in this study and the sample was taken for both conventional cytology and LBC. The smears were studied in detail and were interpreted as per the Bethesda system of reporting Pap smears. The results were compared and analyzed statistically. Results: Unsatisfactory smears were more commonly reported by conventional method (7.1%) than with liquid-based method (1.61%), and this difference is statistically significant. There was no difference in the detection of epithelial cell abnormalities using both the methods. HPV DNA for high-risk oncogenic strains (16 and 18) was detected in 6.45% of women in this study. Conclusion: LBC has been found to be more superior to conventional smears only with respect to lesser number of unsatisfactory smears, but considering the economic implications of LBC, conventional Pap is more feasible in our setting.
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BREAST CANCER SCREENING Top

Assessment of breast cancer early detection program in Iraq-Sulaimania: Measuring the cancer detection rate p. 84
Jamal K Shakor, Atiya K Mohammed
DOI:10.4103/ijc.IJC_633_17  PMID:30147100
Background: Low- and middle-income countries require to specify early detection programs and intervention models for breast cancer. The aim of this study was to assess the performance efficacy of an Iraqi early detection model in terms of cancer detection rate (CDR) and the method of participation in this program. Materials and Methods: Data from June 2007 to August 2016 was collected from the Breast Disease Treatment Center in the Sulaimani province in Iraq. A total of 40,491 women had registered at the center during that period for breast cancer screening, and cancer was detected in 793 women. Results: The CDR of the Iraqi program was 8.2 per 1000 screened women, and that of the mammograms was 42.02 per 1000 mammograms. Women mostly participated in the program by the self-referral method (77.54%). Conclusion: The performance of the Iraqi early detection model was effective with a high CDR, and most women participated by self-referral. This program could, therefore, be effective in low- and middle-income countries.
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GI CANCER Top

Docetaxel/Oxaliplatin/Capecitabine (TEX) triplet followed by continuation monotherapy in advanced gastric cancer p. 88
Vikas Ostwal, Subhadeep Bose, Bhawna Sirohi, Bhavesh Poladia, Arvind Sahu, Prabhat Bhargava, Vipul Doshi, Rohit Dusane, Chaitali Nashikkar, Shailesh V Shrikhande, Anant Ramaswamy
DOI:10.4103/ijc.IJC_353_17  PMID:30147101
Introduction: Docetaxel/oxaliplatin/capecitabine (TEX) is a commonly used combination chemotherapeutic regimen in advanced gastric cancer (AGC). Application strategies in routine clinical practice are reported in this study. Materials and Methods: Patients diagnosed with AGC, receiving biweekly TEX (docetaxel - 60 mg/m (2)-D1; oxaliplatin - 85 mg/m (2)-D1, and capecitabine 500–625 mg/m (2) orally twice daily for 14 days) between July 2012 and May 2016 were retrospectively analyzed for tolerance, prognostic factors, event-free survival (EFS), and overall survival (OS). The proportion of patients continuing and terminating chemotherapy at various time-points was enumerated. Results: Overall, 208 patients were started on TEX. Median EFS was 6.34 months (95% confidence interval [CI] 5.80–6.87), and median OS was 15.31 (95% CI 12.65–17.96). Post 8 cycles of TEX, further 30 patients (14.4%) were continued on chemotherapy (docetaxel, capecitabine, or TEX) whereas 47 patients (22.6%) were on observation only, and there was a statistically significant difference in the median OS of these two groups (22.55 months vs. 14.89 months; P = 0.028). Raised serum alkaline phosphatase (SAP) levels (>100 U/L) predicted inferior survival (P = 0.006). Conclusion: TEX chemotherapy is a feasible, efficacious triplet regimen that can be used in clinical practice. SAP levels >100 U/L is a poor prognostic factor, as observed in this study. An initial “induction” such as combination chemotherapy regimen followed by monotherapy as continuation requires further evaluation.
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UROLOGIC CANCER Top

Metronomic therapy in metastatic castrate-resistant prostate cancer: Experience from a tertiary cancer care center p. 94
Deepak Dabkara, Sandip Ganguly, Bivas Biswas, Joydeep Ghosh
DOI:10.4103/ijc.IJC_346_17  PMID:30147102
Background: Many agents have shown survival advantage in metastatic castrate-resistant prostate cancer (mCRPC). Despite this improvement, survival is poor, especially in subgroup of elderly patients who are not fit for cytotoxic chemotherapy. Materials and Methods: This is a single-institutional data review of mCRPC treated between December 2012 and May 2016 with oral cyclophosphamide (50–100 mg/day) ± oral prednisolone. mCRPCs failed or not fit for docetaxel and/or abiraterone were included in this study. Monthly prostate-specific antigen (PSA) was monitored, and toxicity of cyclophosphamide was recorded. PSA response was defined as ≥50% reduction from precyclophosphamide value. The median follow-up was calculated from the day of starting cyclophosphamide and the last date of follow-up or death, whichever is later. Results: Eighteen patients were included with a median age of 74.5 years (range: 59–83). The site of metastasis was bone in 15, bone and distant lymph nodes in 2, and rectum in 1 patient. The median duration of androgen deprivation was 21 months (range: 3–42.9 months). The median cyclophosphamide exposure was 2 months (range: 0.9–13.5 months) after a median follow-up of 5.8 months. Overall PSA response rate was 44%. The median PSA progression-free survival with cyclophosphamide was 4.7 months (range: 0.9–13.5 months). Five patients had durable PSA response of 9.9, 10.1, 10.5, 12.1, and 13.5 months, respectively. No Grade 3 or 4 toxicity was observed with cyclophosphamide. Conclusion: Oral metronomic cyclophosphamide was found to be an effective and well-tolerated therapy in mCRPC after failure or not fit for docetaxel and/or abiraterone. In few patients, cyclophosphamide induced durable PSA response. This finding needs further evaluation in a prospective manner.
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HEAD AND NECK CANCER Top

Prognostic factors in parotid cancers: Clinicopathological and treatment factors influencing outcomes p. 98
Swagnik Chakrabarti, Deepa Nair, Akshat Malik, Burhanuddin Qayyumi, Sudhir Nair, Jai Prakash Agrawal, Pankaj Chaturvedi
DOI:10.4103/ijc.IJC_503_17  PMID:30147103
Background: Parotid cancers are uncommon and have a relatively long natural history. Determination of prognostic factors affecting the outcome is difficult. Materials and Methods: The primary objective was to determine the demographic, clinical, histopathology and treatment-related factors affecting overall survival (OS) in parotid cancers. The secondary objective was to study the impact of these factors on disease-free survival (DFS) and patterns of failure. Data of consecutive patients who underwent parotidectomy for primary parotid malignancy between July 2006 and April 2015 with at least 6 months of posttreatment follow-up were retrospectively retrieved. Patients whose follow-up status was known at the time of analysis were included. One hundred and sixty-five patients met the inclusion criteria. Results: The median follow-up was 38 months. The mean OS and DFS were 141.03 and 124.38 months, respectively. Age > 45 years affected both OS and DFS (P = 0.00 and 0.002 respectively) adversely. Advanced T stage affected adversely OS in univariate (P = 0.00) but not in multivariate analysis (P = 0.91) and DFS in both univariate (P = 0.00) and multivariate analysis (P = 0.005). Nodal positivity adversely affected survival adversely in univariate (P = 0.00 for OS and DFS) and multivariate analysis (P = 0.022 for OS and P = 0.001 for DFS). Resection margin of < 5mm affected OS as compared to a margin of ≥5mm (P = 0.03). Conclusions: Nodal positivity is the single most important factor affecting survival in parotid cancers. A histopathological resection margin of at least 5 mm is desirable. Advanced age along with high grade, advanced T and N stages need to be considered for adjuvant treatment.
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HEAD AND NECK CANCER/PEDIATRIC ONCOLOGY Top

Management outcomes of pediatric and adolescent papillary thyroid cancers with a brief review of literature p. 105
Ravishankar Palaniappan, Arvind Krishnamurthy, S Swaminathan Rajaraman, R Krishna Kumar
DOI:10.4103/ijc.IJC_486_17  PMID:30147104
Background: Papillary carcinoma of thyroid (PTC) is a rare disease in children and adolescents and contributes to about 1.5%–3% of all pediatric malignancies. To date, no randomized trial has ever been performed in the pediatric population and management of these patients has been extrapolated from adult practice. Materials and Methods: Retrospective analysis of the patients treated for PTC in the age <21 years, between the years 1998–2013 at a tertiary cancer center from India. Results: Sixty-seven patients were treated in the above said period with a male:female ratio of 1:1.6 and a median age of 18 years. Fifty-two (77.6%) patients clinically presented as a thyroid swelling with or without nodal swelling while 13 (19.4%) presented with isolated nodal swelling. Surgery was performed in 30 patients at a nononcological hospital and was subsequently referred to our center; more than half of them needed a completion surgery at our center. Pathologically, multifocal tumors were found in close to a quarter of the patients. Among the pathological variants, classical, follicular, and tall cell variants comprised 65.7%, 28.4%, and 5.9% of the cases, respectively. Nodal positivity was noted 71.6% of the cases of which 14.5% were N1a disease and the vast majority (85.5%) harboring N1b disease. The median follow-up period of the study cohort was 104 months during which there were 3 local, 6 nodal, and 2 systemic recurrences. The 5- and 10-year disease-free survival were found to be 85.9% and 81.4%, respectively. Univariate and multivariate analysis has shown no significant clinical and pathological feature defining the disease outcomes except for the T-stage. Logistic regression revealed extrathyroidal invasion and the age ≤ 15 years correlated with nodal positivity. Conclusion: Being a rare malignancy, pediatric and adolescent PTCs tend to behave differently from adult PTC with a seemingly aggressive clinical presentation; however, they are associated with excellent survival outcomes.
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AUDIT, CHEMOTHERAPY DELAYS Top

Clinical audit to assess delays in chemotherapy administration at daycare oncology center at a tertiary care hospital in Karachi, Pakistan p. 111
Arifa Aziz, Zarka Samoon, Mohammad Khurshid, Afsheen Feroz, Nadia Ayoub, Safia Awan, Madhia Beg
DOI:10.4103/ijc.IJC_493_17  PMID:30147105
Aim: There were delays reported by patients in chemotherapy administration in daycare oncology. Therefore, we decided to audit all processes which are involved in chemotherapy administration. The objective was to improve our service by decreasing the time between admission and initiation of chemotherapy and identify the reasons for delays. Materials and Methods: The audit was conducted in three parts. In Review I, audit tool was developed and information documented of 109 patients receiving chemotherapy at daycare center from April 14 to May 13, 2015. Five processes were assessed out of which delay in initial assessment by the nurse was the only factor identified leading to delay in chemotherapy. Review II was done from March 1 to 31, 2016 of 208 patients after increasing the number of nurses and Review III from June 7 to August 25, 2016 of 287 patients by dividing the initial assessment process at two different areas to decrease delay in initial assessment. Results: Seventy-two percent of patients had their initial assessment done within 15 min of arrival in daycare in the first audit. In the second part of audit this percentage decreased to 55%, and finally, in the third part of the audit, percentage was improved and increased to 75% after separating initial assessment process into two areas (P < 0.001, Kruskal–Wallis test). Conclusion: After separating initial assessment process into two different areas, delays in chemotherapy administration were reduced.
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PATIENT SATISFACTION, CHEMOTHERAPY Top

Influence of supportive care on chemotherapy patients' self-care behaviour and satisfaction: A pilot study conducted in Karachi, Pakistan p. 115
Salima Shams, Adnan A Jabbar, Kashmira Nanji, Rafat Jan, Ambreen Tharani
DOI:10.4103/ijc.IJC_621_17  PMID:30147106
Background and Aim: Cancer is a daunting illness affecting a vast number of people globally. During the illness trajectory, cancer patients suffer from physical and/or psychosocial issues. These physical and psychosocial issues demand conscious actions by patients to maintain their well-being. Hence, the objective of the pilot study was to evaluate the level of self-care behaviors and satisfaction in women suffering from cancer after exposure to supportive care (education and mind diversion activities) delivered via a patient help group program. Methods: The study was conducted at the chemotherapy day care unit of one of the tertiary care hospitals located in Karachi, Pakistan. In this study, supportive care interventions were offered via the patient help group program over a 5-week period, and in the 6th week, data were collected. The total sample size of this pilot study was n = 17. Female cancer patients receiving weekly chemotherapy regimen and diagnosed with breast or gynecological cancers were a part of the study. Outcome variables, self-care behavior and satisfaction, were assessed via a self-developed questionnaire. Content validity index of the questionnaire was calculated on the basis of expert review and was found to be 96% for relevancy and 94% for clarity. Frequencies were calculated to evaluate outcome variables. Outcome variable satisfaction was also assessed via few open-ended questions. Results: Participants reported moderate-to-high self-care behaviors and satisfaction after exposure to supportive care interventions delivered via the patient help group program. Conclusion: Counseling and mind diversion activities are effective in producing a positive change in chemotherapy patients' self-care behaviors and satisfaction. Therefore, oncology nurses must utilize them in chemotherapy patient care. Future studies should evaluate the effectiveness of these interventions with larger sample size and comparative analysis.
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