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OBJECTIVES: To report the compliance of using vaginal dilator and reduction in the development of vaginal adhesions in patients receiving pelvic radiotherapy after providing an effective education of using a vaginal dilator. METHODS: A total of 287 patients receiving radiation therapy for gynecological malignancies from January 2008 to December 2014 were enrolled in the study. These patients were divided in two cohorts. In first cohort (Jan 2008 - Dec 2011), 111 patients were given verbal instructions and prescription of vaginal dilator to be purchased from market. In second cohort (Jan 2012 - Dec 2014), 176 patients were given a suitable sized dilator along with a written educational material and counseled by the nursing staff. Three months after completion of radiation, patients were called for vaginal examination by physician. The compliance of using the dilator was determined by interviewing the patient and the degree of development of vaginal adhesions were recorded according to RTOG Toxicity scale. RESULTS: Out of 287 patients, 195 (68%) had endometrial cancer, 90 (31%) had cervical cancer and 2 patients had vaginal melanoma and leiomyosarcoma of uterus. In first cohort 33 out of 111 patients (30%) followed the provided instructions and 55 out of 111 (50%) developed vaginal adhesions. All 55 patients had grade 3 vaginal adhesions. In second cohort 158 out of 176 patients (90%) were using vaginal dilators and 35 out of 176 (20%) developed vaginal adhesions. Only 9 out of 176 (5%) were found to have grade 3 adhesions. CONCLUSION: Effective patient education regarding the use of dilator after pelvic radiation is an important tool not only for better quality of life, but also for easy subsequent pelvic examination for early detection of recurrence. [ABSTRACT FROM AUTHOR]

BACKGROUND: Primary melanomas of central nervous system (CNS) are rare but aggressive neoplasms; accounts for approximately 1% of all cases of melanoma, among them, 3.6% arise in pineal region. Primary intracranial melanomas are thought to develop from melanocytes, normal elements of arachnoid covering brain, spinal cord, and pineal gland that originated at neural crest and migrated during embryogenesis. Generally, malignant melanomas are known as radio-resistant tumor and role of many treatment modalities are controversial. Here we report a rare case of primary malignant melanoma brain, over its feature of imaging studies, pathological findings, and management. CASE REPORT: 29 years old male, married, banker by profession presented with complains of generalized fits for one month and progressive right sided weakness for few days. On consultation with neurosurgeon, MRI Brain was advised which showed single space occupying lesion in medial cortex of left frontal lobe with hyper intense signals on T1 images associated with left intracranial bleed and significant mass effect. Desmoplastic neuro-epithelial tumor was radiological differential diagnosis. MRI spine advised was also normal. Then neuro navigation guided excision was done. Histologically, it revealed neoplastic lesion with spindle shaped cells and extensive hemorrhage. Immunohistochemistry showed S-100, Melan-A, HMB-45 stains positive and increased Ki-67 proliferative index while EMA, GFAP stains negative. All these features were suggestive of Malignant Melanoma. Post operatively CT scan was done after one week to rule out hydrocephalus which showed heterogeneous area in left frontal lobe that could be secondary to postsurgical changes however possibility of residual disease could not be excluded. Patient was then referred to oncologist for further management. Physical examination of skin and mucosa did not show any lesion suggestive of melanoma. Whole-body 18-fluorodeoxyglucose positron emission tomography was advised that did not demonstrate any sites with abnormal uptake. Then patient was treated with 36 Gy of whole-brain and 18 Gy of extended local boost irradiation. Surveillance was decided for chemotherapy. Follow-up was advised after eight weeks with MRI Brain. CONCLUSION: We report a rare case of young male patient with diagnosis of primary malignant melanoma of brain which was treated with surgical resection followed by whole-brain and extended local irradiation without chemotherapy. Long-term follow-up is needed to determine whether radiotherapy without chemotherapy is sufficient for the treatment of primary CNS melanoma. At present, there is no standardized treatment to address primary CNS malignant melanomas; therefore discussion in multidisciplinary tumor board meeting is mandatory for the management of patients with this type of rare disease. [ABSTRACT FROM AUTHOR]

BACKGROUND: Ewing's sarcoma (ES) belongs to the group of neuro-ectodermal tumors. It commonly occurs in ribs, pelvic girdle and diaphysis of long bones and is rare in head and neck area. ES is a primary malignant bone tumor found commonly in teen age, after leukemia and osteosarcomas, but it is rare in adults. This case is being reported for its rarity both in terms of age of presentation and nasal cavity as a site of origin. She was treated in a multimodal fashion, using surgery, chemotherapy and radiation therapy. CASE REPORT: A sixty year elderly lady known case of hypertension and rheumatoid arthritis, mother of 3 children presented with complains of right nasal obstruction and excessive watering from right eye. She was initially treated with antibiotics, but of no use. She then underwent dacryocysto-rhinostomy to treat epiphora, but without any benefit. Later on ENT evaluation revealed a firm fleshy mass filling right nasal cavity arising from lateral wall of nose and invading floor of nasal cavity and nasal septum. A contrast enhanced CT also showed the same findings with thickening of right maxillary antrum. She underwent endoscopic resection and histopathology confirmed it as a small round blue tumor consistent with Ewings' Sarcoma. Postoperative MRI head, neck and brain showed no evidence of residual disease and brain metastasis. PET/CT revealed no residual or metastatic disease. There was a delay of two months in initiating the treatment so MRI was repeated which showed recurrence of disease at medial canthus of right orbit. After discussing in ENT multidisciplinary meeting, she was advised for six cycles of chemotherapy with possible surgical resection at the completion of treatment. She received total four cycles of Vincristine, Adriamycin, Cyclophosphamide (VAC) and Ifosfamide, Etoposide (IE) chemotherapy. Her tolerance to chemotherapy was very poor, she had to be admitted in hospital multiple times for febrile neutropenia. A follow up CT scan showed significant reduction in size and it was appearing as only plaque like with subtle post contrast enhancement along medial canthus. She was then again discussed in tumor board meeting and recommended for local radiotherapy followed by 2 more cycles of chemotherapy. She received local radiotherapy 50Gy in 25 fractions. CONCLUSION: It is important to discuss every cancer case in a multidisciplinary setting, and especially the rare cases must be discussed with other disciplines of medicine. Here we treated this case of rare site of Ewings' sarcoma and on follow up scans after two months of radiation therapy no local disease was observed. [ABSTRACT FROM AUTHOR]

BACKGROUND: Hidradenocarcinoma is very rare malignant tumor of sweat gland. In literature it is reported for less than 0.001% of all malignant tumors. This rare tumor more frequently involves areas of face and scalp and very rarely on extremity. It is locally aggressive in nature can also metastasize to lymph node but rarely to distant sites. Usually these tumor treated by wide local excision but there is no definite treatment guideline for tumor with gross nodal disease. Role of radiation in this aggressive and advance stage disease is not clear. We are reporting a rare case of hidradenocarcinoma who presented with gross nodal involvement and treated with multimodality treatment including surgery and concurrent chemo radiation. CASE REPORT: A thirty eight year old male presented with history of right neck swelling for 3 month, also had a history of scalp lesion on right side of vertex which was there for more than 20 year. CT Scan Head and neck showed multiple enlarge lymph node on right side of neck, largest on level II of 4 cm in size, there is also a well-defined lobulated cystic mass over right side of scalp of 4 x 2.6 cm in size without any underlying bony erosion. The histopathology report of biopsy of right nodal mass suggest large cell carcinoma with AE1/AE3,CK7and P63 diffuse positive and CK20 and TTF1 negative on staining. Staging workup including CT scan chest, abdomen and pelvis and bone scan were negative for any distant metastasis. Pan endoscopy was done which was negative for any primary in head and neck region. He underwent wild local excision of scalp lesion with right neck dissection. Histopathology reported as Malignant Hidradenocarcinoma of scalp, size 4.2 x 3.5 x 2.2 cm, closest margin 0.1cm, 56 lymph node was recovered from right side of neck out of which 2 were positive for tumor at level II, largest deposit was 2.3cm. The case was discussed in multidisciplinary tumor board meeting where consensus was to give adjuvant concurrent chemo radiation. Radiation dose of 60 Gy in 30 Fractions was given along with Cisplatin 100 mg/m² 3 weekly. After completion of treatment he was followed up with clinical examination and serial CT scan of head and neck. Now he has completed his 2 year of follow up and remained disease free. CONCLUSION: We report a rare case of young male patient with diagnosis of malignant Hidradenocarcinoima of scalp with cervical nodal enlargement which was treated with local excision and neck dissection followed by chemo radiation to the scalp and right side of neck along with concurrent chemotherapy. Till date there is no evidence of local recurrent or systemic disease. [ABSTRACT FROM AUTHOR]

BACKGROUND: Mycosis fungoides (MF) is classically evolved through cutaneous manifestations including patches/plaques, tumors, and generalized erythroderma. Staging classification system for MF and SS is TNMB system, based upon an evaluation of the skin, lymph nodes, visceral involvement, and blood. Treatment modalities includes Topical treatments, Radiotherapy, Phototherapy, chemotherapy, and novel targeted agents CASE REPORT: 36 years old female presented to us with complain of multiple crusted skin lesions, progressively increasing in size. On examination she had generalized patchy erytheroderma, crusted tumor lesion with axillary lymphadenopathy. Biopsy revealed T cell lymphoma. Computed tomography scans revealed multiple enlarged lymph nodes in axilla, and lymph node mass at L1 level. Blood tests showed no atypical cells. Her TNMB stage was T4 Nx M0 B0. Multi-disciplinary tumor board meeting consensus decision comprised of skin-directed therapy and systemic chemotherapy. Due to depth and size of skin tumors, total skin electron therapy (TSET) was recommended for this case with weekly oral methotrexate. Treatment was delivered with extended SSD technique, 350 cm. Prescribed dose was 3600cGy in 24 fractions with 150 cGy dose/fraction. After 1 month follow up visit, patient had no clinical evidence of disease over skin. DISCUSSION: Mycosis fungoides is T cell lymph proliferative disorder that arises primarily in skin. Radiotherapy with electrons of all skin is normally used in patients with history of quick progression of disease with complete response rates after 3 months of treatment vary from 80 to 97%. [ABSTRACT FROM AUTHOR]

BACKGROUND: Globally cancer burden is growing at an alarming pace and it is second leading cause of death. In our current state of cancer care globally, around half of the approximately 28 million cancer survivors worldwide underwent radiotherapy (RT) at some point in their treatment. To improve quality of cancer care clinical practitioners have an important tool in the form of clinical audits, which can remarkably help in clinical practice modification. After keen observation in our clinical set up that few of our patients takes expert options from clinician but never come back for treatment so we aim to audit that what factors are major hindrance for patients being non-compliant to treatment in our clinical set up OBJECTIVES: To evaluate factors which are major hindrance for patients being non-compliant to treatment advised by clinicians. METHODS: This retrospective audit includes patients booked in clinic from March 2014 to August 2014 for radiotherapy. Almost all patients who were seen in clinic further discussed in respective site specific multidisciplinary tumor board meeting (MDT) to make an appropriate treatment plan. Afterwards patients were registered for radiation therapy either with radicle or palliative intent. Total 52 Patients who were recommended for radiotherapy in clinic but refused to come for treatment were selected for this audit. We took telephonic interview of those patients and evaluated reason for not pursuing treatment at AKUH. A Performa was filled for every patient to document the cause. RESULTS: Total 52 patient's simulation forms were taken for audit out of which 36 patients gave telephonic interview while 16 patients did not respond to phone call. Analysis of 52 patients showed that 49 patients were booked with curative intent while 3 patients with palliative intent. Results showed that 27/36 patients (75%) refused treatment due to financial issues and choose treatment in other hospitals. 6/36 (16.6%) patients refused recommended treatment due to multiple radiation related myths. One patient's treatment plan changed in MDT 1/36 patients (2.7%), one patent was unsatisfied with clinician counseling 1/36 patients (2.7%)and one patient's disease upstaged 1/36 (2.7%) and he no longer remained candidate for radicle radiation therapy. CONCLUSION: Financial constraint and misconceptions are the two most important factors found to be hindering the acquisition of recommended cancer treatment. Further efforts are required to overcome cost issues. Physicians need to work on patient's education and quality of life while delivering the standard treatment. [ABSTRACT FROM AUTHOR]