Primary carcinoma of the vagina: Tata Memorial Hospital experience

PURPOSE: Carcinoma of the vagina is a rare gynecological malignancy comprising approximately 2% of all the gynecological malignancies. We have analyzed the treatment outcome of the patients treated at the Tata Memorial Hospital from January 1984 to December 1993. METHODS AND MATERIALS: In this 10-year period, 134 patients of primary vaginal cancers were registered at our hospital. Of these, 75 patients received complete treatment and are analyzed. RESULTS: Disease-free survival (DFS) for the whole group is 50%, and overall survival (OAS) is 60%. Most locoregional recurrences and distant failures are noted in the 2 years following treatment. DFS at 5 years is as follows: Stage I (5 patients), Stage IIA (37 patients), Stage IIB (15 patients), Stage III (14 patients), and Stage IV (4 patients); are 40%, 55%, 60%, 50%, and 25%, respectively. The DFS for patients with complete response (42 patients) to external radiation at 5 years is 68%, with partial response (25 patients) is 35%, and with poor or no response (6 patients) is 18% (p = 0.0000). We observed that brachytherapy was an important part of the treatment, and patients who received brachytherapy (59 patients), either with a vaginal intracavitary applicator (30 patients) or interstitial implant (29 patients) had a DFS of 53% and 56%, respectively, while 15 patients who received external radiation alone had a DFS of 30%. Patients receiving brachytherapy within 4 weeks of external radiation had a DFS of 60% as compared to 30% when the interval was more than 4 weeks. CONCLUSION: The factors indicating prognosis are: site and extent of involvement, presence of lymph nodes at presentation, technique of brachytherapy, and interval between external radiation and brachytherapy.     

Hypofractionated radiotherapy in carcinoma cervix IIIB: Tata Memorial Hospital experience

PURPOSE OF THE STUDY: To analyze the role of hypofractionated radiotherapy in advanced carcinoma of cervix. BASIC PROCEDURE: Medical records of 62 women with advanced carcinoma cervix III3 treated during 1994-1996 were reviewed. Patients were treated with standard pelvic portals to a total dose of 39Gy in 13 fractions over 17 days followed by intracavitary brachytherapy. Forty-eight patients completed the planned treatment and were considered suitable for analysis of late reactions and survival. MAIN FINDINGS: The 5-year disease free survival was 59% and the overall survival was 50% at the mean follow up of 40 months. Twenty-one (44%) patients developed acute gastrointestinal toxicity of which 5 patients had grade III and one patient had grade IV reaction. Ten patients (21%) developed acute genitourinary complications, 13 patients (27%) had late rectal reactions and 10 patients (20%) had late bladder complications. Three patients had grade I, five had grade II and five had grade III late rectal toxicity. CONCLUSION: Survival in patients treated hypofractionated radiotherapy appears comparable to that of standard fractionation. The acute gastrointestinal and skin reactions were mainly grade I or grade II. Hypofractionated radiotherapy can certainly be considered in a select group of patients where the local disease is extensive and is unsuitable for conventional treatment.     

Nasopharyngeal carcinoma in children: ten years' experience at the Tata Memorial Hospital, Mumbai

PURPOSE: To evaluate the disease characteristics and outcome of children with nasopharyngeal carcinoma treated at the Tata Memorial Hospital, Mumbai. METHODS AND MATERIALS: Between 1990 and 2000, 81 pediatric patients with a diagnosis of nasopharyngeal carcinoma were treated at the Tata Memorial Hospital. The median age was 14 years. The male/female ratio was 2.8:1. Of the 81 patients, 32 (39%), 21 (26%), and 28 (35%) had T1-T2, T3, and T4 (TNM International Union Against Cancer staging system, 1997), respectively. Ninety-one percent presented with nodal metastasis. Thirty patients (37%) had lymph nodes >6 cm, and 45 (56%) had bilateral nodes at presentation. Histologically, 77 patients (95%) had undifferentiated carcinoma. Eighty-five percent received neoadjuvant multiagent chemotherapy containing bleomycin, methotrexate, and cisplatin, followed by radiotherapy (RT). RESULTS: After a median follow-up of 50 months, the disease-free survival (DFS) and overall survival (OS) rate for the entire group was 45% and 54%, respectively. Kaplan-Meier curves were used for evaluation of prognostic factors and were compared using the log-rank test. Nodal status had a significant impact on DFS (p = 0.021) and OS (p = 0.006). Complete responders to chemotherapy had superior DFS (p = 0.000) and OS (p = 0.000). RT doses >60 Gy resulted in better DFS (p = 0.020) and OS (p = 0.012). Combined chemotherapy plus RT resulted in improved DFS (p = 0.457) and OS (p = 0.296), although the difference was not statistically significant. CONCLUSION: Combined modality management using chemotherapy and RT resulted in satisfactory locoregional control and OS in pediatric patients with nasopharyngeal carcinoma. Nodal involvement, response to chemotherapy, and RT dose were important prognostic factors.     

Haematologic and immunophenotypic profile of acute myeloid leukemia: an experience of Tata Memorial Hospital

OBJECTIVES: To study the hematologic and immunophenotypic profile of 260 cases of acute myeloid leukemia at diagnosis. MATERIAL AND METHODS: This is a retrospective analysis of 260 cases of AML diagnosed at our institution between 1998 and 2000. Diagnosis was based on peripheral blood and bone marrow examination for morphology cytochemistry and immunophenotypic studies. SPSS software package, version 10, was used for statistical analysis. RESULTS: Seventy-six percent of our cases were adults. The age of the patients ranged from one year to 78 years with a median age of 27.2 years. There were 187 males and 73 females. The commonest FAB subtype, in both children and adults, was AML-M2. The highest WBC counts were seen in AML-M1 and the lowest in AML-M3 (10-97 x 10(9)/L, mean 53.8 x 10(9)/L). The mean values and range for hemoglobin was 6.8 gm/l (1.8 gm/l to 9.2 gm/l), platelet count 63.3 x 10(9)/L (32-83 x 10(9)/L), peripheral blood blasts 41.4% (5 to 77%) and bone marrow blasts 57.6% (34-96%). Myeloperoxidase positivity was highest in the M1, M2 and M3 subtypes. CD13 and CD33 were the most useful markers in the diagnosis of AML. CD14 and CD36 were most often seen in monocytic (38%) and myelomonocytic (44%) leukemias. Lymphoid antigen expression was seen in 15% of cases. CD7 expression was the commonest (11%). CONCLUSION: AML accounted for 39.8% of all acute leukemias at this institution. The most common subtype was AML-M2. Myeloperoxidase stain was a useful tool in the diagnosis of myeloid leukemias. CD13 and CD33 were the most diagnostic myeloid markers.     

Small cell carcinoma of the esophagus. The Memorial Hospital experience 1970 to 1987

During the period 1970 to 1987, 11 patients with small cell carcinoma of the esophagus were treated at Memorial Sloan-Kettering Cancer Center, New York. This rare tumor was responsible for 1.1% of all patients with esophageal tumors seen on the inpatient services during that period. Using a clinical staging system similar to that employed in small cell cancer of the lung, eight of 11 patients had extensive disease. Although responses were seen to multidrug combination chemotherapy regimens used alone or with sequential radiation, the overall prognosis for small cell esophageal cancer was poor, with a median survival of 7.5 months. Only one patient lived for greater than 2 years.     

Squamous cell carcinoma of the anal canal at The Queen Elizabeth Hospital: A local experience

Aim: Concurrent chemoradiotherapy is the standard treatment for squamous cell carcinoma of anal canal. We describe our experience of treating such patients at our center. Methods: Patients with anal squamous cell carcinoma were treated with a uniform sphincter preserving protocol at The Queen Elizabeth Hospital, South Australia. Standard radiotherapy along with 5‐fluorouracil (750 mg/m² on days 1–5 and days 29–32) and mitomycin C (12 mg/m² on day 1 only) was given to eligible patients. Results: Of the 34 patients included in this study, nearly 60% were women. Most (89.3%) had T1‐2 disease. One‐third had nodal involvement. Twenty‐seven had chemoradiotherapy, six had local excision alone and one had radiotherapy alone. Among those who had chemoradiation, 71.5% had a complete response and remained colostomy free until the last follow‐up. Most completed the treatment without major side‐effects. The 3 and 5‐year disease free survival rate was 62% and 53%, respectively. All patients who failed chemoradiation underwent salvage surgery with a median survival time of 32.5 months. Conclusion: Sphincter preservation is the goal for anal cancers. Chemoradiotherapy is an important modality to achieve this goal.     

Safety and feasibility of breast conserving therapy in Indian women: two decades of experience at Tata Memorial Hospital

PURPOSE: The NIH consensus statement on the management of breast cancer has highlighted the paucity of outcome data in non-Caucasian women. Treatment outcome and factors determining it in a large cohort of ethnic Indian women treated with breast conserving therapy (BCT) at Tata Memorial Hospital are reported here. MATERIALS AND METHODS: During 1980-2000, 1,022 pathological Stage I/II breast cancer patients (median age 43 years) underwent BCT (wide excision, complete axillary clearance, whole breast radiotherapy with 6 MV photons plus tumor bed boost, +/-systemic therapy). Median pathological tumor size was 3 cm (1-5 cm). Axillary node metastases were found in 39% women. Of the 938 patients with IDC, 70% were Grade III and in patients where receptor status was known, 209/625 (33%) were ER positive and 245/591 (41%) were PR positive. RESULTS: The 5- and 10-year actuarial overall survival was 87% and 77% and disease-free survival was 76% and 68%, respectively. Actuarial 5-year local and locoregional control rates were 91% and 87%, respectively. Cosmesis was good or excellent in 78% women. Independent adverse prognostic factors for local recurrence were, age<40 years, axillary node metastasis, lymphovascular invasion (LVI), and adjuvant systemic therapy; for locoregional recurrence-inner quadrant tumor, axillary node metastasis, and LVI; for survival-LVI and axillary node metastasis. CONCLUSION: Compared to Caucasians, these Indian women undergoing BCT were younger, had larger, higher grade, and receptor negative tumors. Comparable local control and survival was obtained by using stringent quality assurance in the diagnostic and therapeutic protocol. BCT, a resource intense treatment is safe for selected and motivated patients undergoing treatment at centers with adequate facilities and expertise even in countries with limited resources.     

The problem of carcinoma developing in a fibroadenoma: recent experience at Memorial Hospital.

Fourteen new cases of unsuspected carcinoma developing in fibroadenomas are reported with a detailed analysis of their preoperative findings; histopathology, the results of varying surgical procedures and a three month to twenty-six year follow-up. The majority of lesions were lobular carcinoma in situ (71%) and 29% of all cases were found to have carcinoma of the contralateral breast. Our study suggests that for invasive carcinoma within a fibroadenoma complete mastectomy is warranted in virtually all instances while noninvasive disease treated by complete mastectomy is essentially curative. Contralateral breast biopsy at the time of diagnosis with a careful life-time follow-up are appropriate because of the high risk of contralateral invasive coarcinoma. There seemed to be no evidence of striking or unusual epithelial hyperplasia in the breast tissue adjacent to fibroadenomas that contained carcinoma suggesting that the carcinomas are not intrinsically different from those not related to fibroadenomas.     

Treatment outcome of maxillary sinus squamous cell carcinoma.

BACKGROUND: Optimal treatment policies of maxillary sinus carcinoma remain to be defined. METHODS: Seventy-four patients with squamous cell carcinoma of maxillary sinus were treated at Department of Otolaryngology, Asahikawa Medical College between 1983 and 1997. The T classification according to the 1997 International Union Against Cancer was as follows: 9 with T2, 35 with T3, and 30 with T4. Eight patients had lymph node metastasis with N1 at diagnosis. Of 62 patients who started multimodality therapy that comprised preoperative radiochemotherapy including local irradiation with total dose of 50 grays along with concomitant intramaxillary arterial infusion of 5-fluorouracil with total dose of 5000 mg followed by total or partial maxillectomy, 59 received the complete therapy. Eleven patients had to be treated with radiotherapy alone, and 1 patient received postoperative radiotherapy. The median follow-up time for surviving patients was 117 months. RESULTS: The 5-year overall survival, disease free survival, and local control (LC) rates for all patients were 58.5%, 63.7%, and 73.6%, respectively. The patients who underwent multimodality therapy showed significantly better 5-year overall survival, disease free survival, and LC rates as compared with those who underwent radiotherapy alone (68.5% vs. 9.1%; 73.2% vs. 18.2%; 84.0% vs. 18.2%; P < 0.0001 each). Multivariate analysis revealed that T classification and treatment modality are independent predictors for disease free survival. CONCLUSIONS: The authors' treatment method, which did not include any complicated techniques, produced higher survival and LC rates because of high effectiveness of multimodality therapy. They concluded that their multimodality therapy could offer a better chance for cure from maxillary sinus carcinoma at many institutions.     

Squamous carcinoma arising in a pilonidal sinus

A patient with squamous cell carcinoma arising from an extensive pilonidal sinus was treated with wide local excision, resulting in an apparent cure over a 1-year follow-up period. Review of the literature revealed 32 previously reported cases of this entity. Forty-four percent of these patients developed recurrences or metastases, and 22% died of their disease. The largest historical treatment group with at least 1-year follow-up (19 patients with localized disease) underwent wide excision. Forty-two percent of these patients recurred or developed metastases. Ultimately, 89.5% of these patients were reported cured, but only five survivors were followed for as long as 5 years. Historical experience appears to identify pilonidal tract squamous carcinoma as an aggressive tumor. The reported success of wide local excision is based on a small number of patients followed for short periods of time. Continued experience with this disease should be reported to verify the adequacy of local excision or identify the need for adjunctive therapy.     

Squamous cell carcinoma of the pyriform sinus treated with radical radiation therapy

This is an analysis of 54 patients with squamous cell carcinoma of the pyriform sinus treated with radical irradiation at the University of Florida between October 1964 and March 1984. There is a 2-year minimum follow-up on all patients and 85% have at least 5 years of follow-up. Patients were excluded from analysis of disease control at the primary site, neck, and/or above the clavicles if they died less than 2 years from treatment with the site(s) continuously disease-free. All patients were included in the analysis of complications and survival. The rates of local control following initial treatment with irradiation and the ultimate local control rates, including surgical salvage of irradiation failures, were as follows: T1, 8/9 and 8/9; T2, 15/20 (75%) and 18/20 (90%); T3, 2/5 and 3/5; and T4, 0/4 and 0/4. The 5-year determinate survival rates as a function of modified AJCC stage were I, 1/1; II, 3/3; III, 5/8; IVA, 7/12; and IVB, 2/8.     

Prognostic factors influencing relapse of squamous cell carcinoma of the maxillary sinus

In 95 surgically staged patients with squamous cell carcinoma of the maxillary sinus, multivariate regression analyses were employed to identify prognostic factors. Possible prognostic factors for local control were TNM stage and type of surgical procedures: T2 or T3 tumors and use of total maxillectomy showed better local control rates (P less than 0.01). High radiation doses of 40 Gy or more also seemed to be of prognostic significance: P less than 0.2 for 40 to 60 Gy, and P less than 0.1 for 60 Gy or more. The risk of cervical relapse increased when the cheek or alveolus was grossly involved (P less than 0.2). However, since cervical relapse frequently accompanied uncontrollable primary recurrence or distant spread, and since cervical relapse alone was frequently salvaged by radical neck dissection, prophylactic irradiation to the neck is not recommended. Sex, age, nodal state, addition of chemotherapy, total doses of bleomycin or 5-fluorouracil (5-FU), or intra-arterial administration of chemotherapeutic agents did not appear to be of prognostic significance.     

Leukoplakia--an epidemiologic study of 1504 cases observed at the Tata Memorial Hospital, Bombay, India

An epidemiological study of 1504 cases of leukoplakia seen at the Tata Memorial Hospital, Bombay, indicates that the oral cavity was the site of the disease in 95% of the cases. The buccal mucosa was the commonest site affected in all religious communities of Western India except among Parsis. Parsis, a majority of whom are non-smokers and non-chewers of tobacco, had leukoplakia more often on the anterior 2/3rd tongue than on the buccal mucosa and this pattern persisted in the distribution of cancer also, whereas people from Gujarat more often smoke; in these the buccal mucosa was commonly affected with leukoplakia, but cancer was not so frequent in this site. Statistical computation of the risk of malignant transformation indicates that males have a 4·8 times higher risk of developing cancer when they have leukoplakia than the normal population, and the females have 7 times higher risk of developing cancer in the presence of leukoplakia. It was felt that leukoplakia not associated with smoking habits had a greater chance of malignant transformation.     

Results of multimodality therapy for squamous cell carcinoma of maxillary sinus

BACKGROUND: A wide variety of modalities, including surgery, radiation therapy, and chemotherapy, alone or in combination, have been used for the treatment of squamous cell carcinoma (SCC) of the maxillary sinus to obtain better local control and maintain functions. However, there is still much controversy with regard to the optimum treatment. METHODS: From 1987 to 1999, 33 patients with SCC of maxillary sinus were treated at the Department of Otolaryngology-Head and Neck Surgery, University of Tokyo Hospital. The treatment consisted of 30-40 grays (Gy) of preoperative radiotherapy with concomitant intraarterial infusion of 5-fluorouracil and cisplatin followed by surgery and 30-40 Gy of postoperative radiotherapy, for tumors without skull base invasion. For tumors invading the skull base, preoperative systemic chemotherapy with or without radiotherapy was performed, instead of intraarterial chemotherapy, then followed by skull base surgery. The surgical procedures varied according to the extent of tumor. Results were compared with those of the 108 patients treated in our hospital from 1976 to 1982. RESULTS: Partial maxillectomy was performed in 2 T2 patients and 12 T3 patients. Total maxillectomy was performed in 1 T2 patient, 3 T2 patients, and 7 T4 patients. Skull base surgery was performed in eight T4 patients. Orbital content and hard palate were preserved in 22 patients and 18 patients, respectively. The overall 5-year survival rates were 86% in T 3 patients and 67 % in T4 patients, respectively. CONCLUSIONS: Our multimodal treatment has provided favorable local control and survival outcome with good functional results.     

Clinicopathological study of maxillary sinus carcinoma

Autopsy was performed on 67 patients who had squamous cell carcinoma of the maxillary sinus. These patients had undergone radiotherapy and died during a 30 year period, which ended for this study in 1982. The clinicopathological picture showed several differences according to changes of the mode of therapy and to the rise in local control rate. Postmortem examinations have shown a decreased death rate from extensive carcinoma, and increased distant metastases after the introduction of megavoltage irradiation and trimodal combination therapy (radiotherapy + surgery + intraarterial infusion of antimetabolites). In addition, the introduction of aggressive chemotherapy with antimetabolites and antibiotics has given rise to several gastrointestinal complications.     

Multidisciplinary treatment of maxillary sinus carcinoma

The history of treatment of maxillary sinus carcinoma is divided into four characteristic periods, with the corresponding 5-year cumulative survival rates of: 20% of 282 patients for 1957 to 1966; 25% of 191 patients for 1967 to 1971; 39% of 166 patients for 1972 to 1975; and 54% of 134 patients for 1976 to 1979. The best treatment at present consists of 60Co gamma ray (5000 rad/25 fractions/5 weeks), continuous intra-arterial 5-FU infusion (2000 mg during the radiotherapy), tumor reduction mainly by weekly cryosurgery, and immunotherapy with cell wall skeleton of Nocardia rubra in appropriate combination. Early antrostomy and final curettage are mandatory. Maxillectomy should be resorted to when recurrence is histologically confirmed. Multidisciplinary treatment of maxillary sinus carcinoma based on this conception has successfully increased the survival rates and reduced the need for maxillectomy.     

Radiotherapy in trimodal combination therapy of maxillary sinus squamous cell carcinoma

From May 1979 to December 1982, 31 patients with reappraisable preoperative CT were treated with trimodal combination therapy for maxillary sinus squamous cell carcinoma. The three-year cumulative survival rate of all cases was 43% and the two-year cumulative local control rate was 44%. The 5-FU distribution in infusion chemotherapy was reappraised by the dye method and the radiation field was reappraised on the basis of preoperative CT. Only patients who received suitable infusion chemotherapy and radiotherapy showed a good local control rate. Suitably performed infusion chemotherapy and radiotherapy were essential in our trimodal combination therapy. Radiotherapy must be planned according to the individual patient on the basis of the preoperative CT and surgical findings.     

Sarcomatoid carcinoma of the maxillary sinus: a rare head and neck tumor

Sarcomatoid carcinomas are rare tumors. These tumors have been reported at other sites, but head and neck origin is extremely uncommon. We report here a rare case of sarcomatoid carcinoma involving the maxilla. Only four such cases with maxillary origin have been discussed in English literature earlier. As compared to squamous cell carcinoma of maxilla, this variant is associated with poor prognosis and advanced disease at presentation, as was also seen in our case. There are no standard recommendations for management owing to the rarity of this histology. Surgery and radiotherapy form the mainstays of treatment. Exploration of the role of chemotherapy and novel targeted therapy agents is warranted in order to improve treatment results.