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This study aimed to compare the impact of 3 versus 6 cycles of neoadjuvant chemotherapy (NACT) on the optimal cytoreduction in patients of advanced ovarian malignancy during interval debulking surgery (IDS). Thirty patients with advanced-stage IIIc/IV epithelial ovarian cancer, fallopian tube cancer, and primary peritoneal cancer were randomly allocated to receive 6 cycles in the late IDS group versus 3 cycles in early IDS before undergoing interval debulking surgery. A higher percentage of patients achieved optimal cytoreduction in the late IDS group compared to the early IDS group (60 versus 23%) which was statistically significant (p =.010). Giving 6 cycles of NACT before surgery increased the odd of optimal cytoreduction by 10 than giving 3 cycles of NACT which was statistically significant (p = 0.046) Thus, we conclude that administering 6 cycles of neoadjuvant chemotherapy before debulking surgery helps in achieving optimal cytoreduction in a higher number of patients with lesser surgical morbidity. What is already known on the subject? Currently, there are no established criteria that would help to determine the number of chemotherapy cycles before debulking surgery in patients with advanced ovarian malignancy. What do the results of this study add? Administering 6 cycles of neoadjuvant chemotherapy before debulking surgery helps in achieving optimal cytoreduction in a higher number of patients with lesser surgical morbidity in cases of advanced epithelial ovarian cancer. What are the implications of these findings for clinical practice and/or further research? We conclude that late interval debulking may be used as a treatment option in the advanced stage IIIc/stage IV. However, the findings need to be studied in a larger study group with a longer follow up period. [ABSTRACT FROM AUTHOR]

Introduction: Dosimetric study to compare high dose rate (HDR) vaginal vault ovoid brachytherapy plan versus intensity-modulated radiation therapy (IMRT) boost plan for doses delivered to target volume and organs at risk (OAR) in postoperative patients of cervical carcinoma following whole pelvic radiotherapy (WPRT). Materials and Methods: Fifteen postoperative patients of cervical carcinoma suitable for vaginal ovoid brachytherapy following WPRT of 46 Gy/23 fractions/4.5 weeks were included. All were treated with brachytherapy (two sessions of 8.5 Gy each). The equivalent dose for IMRT was calculated by computing biologically effective dose of brachytherapy by linear quadratic model. Dose of brachytherapy (two sessions of 8.5 Gy) was equivalent to IMRT dose of 26 Gy/13 fractions. Doses to target volume and OAR were compared between HDR and IMRT plans. Results: Target volume was well covered with both HDR and IMRT plans, but dose with brachytherapy was much higher (P < 0.05). Mean doses, doses to 0.1, 1, 2, and 5cc, 1/3rd, 1/2, and 2/3rd volume of bladder and rectum were significantly lower with HDR plans. Conclusion: In postoperative patients of cervical carcinoma, HDR brachytherapy following WPRT appears to be better than IMRT for tumor coverage and reducing dose to critical organs. [ABSTRACT FROM AUTHOR]

For definitive treatment of carcinoma cervix with conformal radiation techniques, accurate target delineation is vitally important, yet a consensus definition of clinical target volume (CTV) remains variable within the literature. The aim of the present article is to review the guidelines for CTV delineation published in the literature and to present the guidelines practiced at our institute. For this a literature pub med/medline search was performed from January 2000 to December 2012 and reviewed to identify published articles on guidelines for CTV primary and pelvic lymph node (LN) delineation for carcinoma cervix. Taking into consideration the traditional bony landmark based fields for treating cancer cervix, the knowledge of the patterns of disease spread and recurrence and the findings from imaging studies identifying typical anatomic distributions of areas at risk of harbouring subclinical disease, the differences in various guidelines have been analyzed and discussed. The CTV in cervical cancer consists of the CTV nodal and CTV primary. In all the published guidelines, CTV nodal consists of common iliac, external iliac, internal iliac, pre-sacral and obturator group of lymph nodes, and CTV primary consists of the gross tumor volume, uterine cervix, uterine corpus, parametrium, upper third of vagina and uterosacral ligaments. The various guidelines differ however, in the definition for these individual component structures. This is the first report to provide the complete set of guidelines for delineating both the CTV primary and CTV nodal in combination. [ABSTRACT FROM AUTHOR]

Despite its limited coverage, palliative care has been present in India for about 20 years. Obstacles in the growth of palliative care in India are too many and not only include factors like population density, poverty, geographical diversity, restrictive policies regarding opioid prescription, workforce development at base level, but also limited national palliative care policy and lack of institutional interest in palliative care. Nonetheless we have reasons to be proud in that we have overcome several hurdles and last two decades have seen palpable changes in the mindset of health care providers and policy makers with respect to need of palliative care in India. Systematic and continuous education for medical staff is mandatory, and a major break-through for achieving this purpose would be to increase the number of courses and faculties in palliative medicine at most universities. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented related to the treatment of therapy related acute promyelocytic leukemia (t-APL).

Background: To evaluate a 2-day course of palliative radiation in patients diagnosed to have inoperable or metastatic head and neck carcinoma. Aim: To evaluate the symptom relief and quality of life in these patients after this short course of radiation. Settings and Design: A pilot study was conducted in a tertiary care institute in India. Materials and Methods: Fifteen patients with stage IV B/C disease, KPS 50-70, were inducted after informed consent. External radiation was given in 2 days, two fractions per day, 6 h apart to a total dose of 14 Gy. Washington University quality of life questionnaire (QOL) was used for assessing QOL before and after radiation. Patients who had more than 50% regression of disease received a second course of similar radiation. All patients were followed up for a mean duration of 6 months. Statistical Analysis: The Wilcoxon signed rank test was used to evaluate the difference between the QOL scores before and after treatment. Results and Conclusions: Out of these 15 patients, majority (13) were males and the mean age of the patients was 62 years. After the first course, all patients had good symptom relief, improvement in the QOL, and 13 out of 15 had more than 50% objective response. The short duration of the treatment was favored by the outstation patients and their attendants. It may be concluded that this short course of radiation is an effective tool for palliative radiation and merits a larger randomized trial. [ABSTRACT FROM AUTHOR]

Purpose: To derive and validate an index to correlate the bladder dose with the catheter balloon dose using limited computed tomography (CT) slices. Materials and Methods: Applicator geometry reconstructed from orthogonal radiographs were back-projected on CT images of the same patients for anatomy-based dosimetric evaluation. The correlation indices derived using power function of the catheter balloon dose and the bladder volume dose were validated in 31 patients with cervical cancer. Results: There was significant correlation between International Commission on Radiation Units (ICRU)-38 balloon reference dose (Dr) and the dose received by 25% bladder volume (D25) (P < 0.0001). Significant correlation was also found between the reference dose of mid-balloon point (Drm) and the dose to D25 (P < 0.0001). Average percentage difference [100 x (observed index - expected index) / expected index] of observed value of I'25 (index for the dose to D25 bladder with respect to mid-balloon reference point) from that of expected value was 0.52%, when the index was modeled with reference dose alone. Similarly the average percentage difference for I'10cc (index for the dose to 10 cc volume of bladder with respect to mid balloon point) was 0.84%. When this index was modeled with absolute bladder volume and reference dose, standard deviation of the percentage difference between observed and expected index for Drm reduced by approximately 2% when compared to Dr. Conclusion: For clinical applications, correlation index modeled with reference dose and volume predicts dose to absolute volume of bladder. Correlation index modeled with reference dose gives a good estimate of dose to relative bladder volume. From our study, we found Drm to be a better indicator of bladder dose than Dr. [ABSTRACT FROM AUTHOR]

We report this first case of synchronous cervical rhabdomyosarcoma and Sertoli-Leydig cell tumor (SLCT) of ovary with congenital absence of unilateral ovary and fallopian tube in a 16-year-old female patient. A review of the English-language literature identified only six cases of double malignancies with cervical rhabdomyosarcoma and SLCT but none of the case was associated with congenital absence of ovary and fallopian tube. When such multiple conditions involving one system occur in an individual, the possibility of single etiology arises, but beside some hypothesis, no definite link could be established in any of the cases reported. [ABSTRACT FROM AUTHOR]

Primary malignant lesions of the vagina are uncommon, and vaginal sarcomas are even rarer. We describe a rare case of stage I, high-grade leiomyosarcoma of the vagina treated with combined modality treatment. A 39-year-old female presented with vaginal mass and underwent resection. Histopathological examination revealed atypical leiomyoma of the vagina with definite risk of recurrence. Eleven months later, she presented with a recurrent vaginal mass and underwent exploratory laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy plus resection of recurrent tumor and partial vaginectomy. The detailed histopathological examination was suggestive of leiomyosarcoma of the vagina. The patient received adjuvant radiotherapy and chemotherapy. The patient is alive and disease-free 29 months postsurgery. Experience with vaginal leiomyosarcomas is limited. The optimal treatment methods have not yet been established because of the rarity of the tumor. We add another case of leiomyosarcoma of the vagina to the limited existing literature. [ABSTRACT FROM AUTHOR]

Although metastases to bones from solid tumors are very common, involvement of small bones of the hands is extremely rare. We report the first case of acrometastasis in vaginal carcinoma. We present a 65-year-old multiparous woman with FIGO Stage II vaginal carcinoma. The patient received treatment with external beam radiotherapy followed by brachytherapy. She had complete response to above treatment. Eleven months later, she presented with swelling on dorsum of hand. Investigations revealed metastasis to 4th metacarpal bone with lung metastasis. Hence, we present a patient with metastasis of carcinoma vagina to the 4th metacarpal to draw the attention for the potential of such lesions to be developed in this region. It should be remembered that bone metastasis at unusual sites might be seen in vaginal carcinoma. We present this case because of its rarity and for documentation and discussion. [ABSTRACT FROM AUTHOR]

Background & Objectives: Invasive cervical cancer patients are primarily treated with chemoradiation therapy. The overall and disease-free survival in these patients is variable and depends on the tumoral response apart from the tumour stage. This study was undertaken to assess whether in vivo changes in gene promoter methylation and transcript expression in invasive cervical cancer were induced by chemoradiation. Hence, paired pre- and post-treatment biopsy samples were evaluated for in vivo changes in promoter methylation and transcript expression of 10 genes (ESR1, BRCA1, RASSF1A, MYOD1, MLH1, hTERT, MGMT, DAPK1, BAX and BCL2L1) in response to chemoradiation therapy., Methods: In patients with locally advanced invasive cervical cancer, paired pre- and post-treatment biopsies after 10 Gy chemoradiation were obtained. DNA/RNA was extracted and gene promoter methylation status was evaluated by custom-synthesized methylation PCR arrays, and the corresponding gene transcript expression was determined by absolute quantification method using quantitative reverse transcription PCR., Results: Changes in the gene promoter methylation as well as gene expression following chemoradiation therapy were observed. BAX promoter methylation showed a significant increase (P< 0.01) following treatment. There was a significant increase in the gene transcript expression of BRCA1 (P< 0.01), DAPK1 and ESR1 (P< 0.05), whereas MYOD1 and MLH1 gene transcript expression was significantly decreased (P< 0.05) following treatment., Interpretation & Conclusions: The findings of our study show that chemoradiation therapy can induce epigenetic alterations as well as affect gene expression in tissues of invasive cervical cancer which may have implications in determining radiation response., Competing Interests: The first author (SS) is currently working in the Editorial Unit of the Indian Journal of Medical Research as a contractual staff. The remaining three authors have no conflicts of interest.

Platinum-based chemotherapeutic drugs trigger apoptosis, and deregulation of apoptotic pathways may contribute to chemoresistance. We investigated the role of major Fas and Bcl-2 family members as predictors of response to platinum-based chemotherapy in epithelial ovarian cancer (EOC). The expression of Fas, FasL, FAP-1, Bax, Bcl-2, and Bcl-X(L) was analyzed in 35 women with EOC at the transcript level by semiquantitative RT-PCR and at the protein level by immunohistochemistry. The apoptotic index was determined by TUNEL assay. The response to chemotherapy was documented and at the end of six cycles of chemotherapy. Based on their response, two groups were identified: primary chemosensitive (n = 20) and primary chemoresistant (n = 15). Further, after a follow-up of 12-46 months, two groups were identified: no evidence of disease (n = 10) and evidence of disease (n = 25). The primary chemoresistant tumors in comparison to the chemosensitive tumors had significantly lower levels of Fas transcript (p = 0.026), Bax transcript (p = 0.042) and Bcl-2 protein (p = 0.038) and higher levels of Bcl-X(L) (p = 0.040). The apoptotic index revealed a significant inverse correlation only with Bcl-X(L) protein levels (p = 0.003). Patients with evidence of disease at last follow-up in comparison to those with no evidence of disease showed lower Bax transcript (p = 0.012), Bcl-2 protein (p = 0.014) and lower apoptotic index (p = 0.005) and higher Bcl-X(L) protein levels (p = 0.023). In conclusion, Bcl-2 family members and apoptotic index are useful in prediction of response to chemotherapy in EOC. These initial observations need to be validated in large-scale studies.

Objectives: This prospective study was carried out to evaluate the results of chemo radiation (CRT) in the treatment of locally advanced carcinoma cervix and to compare with patients treated with radiotherapy (RT) alone., Methods: Between 1996 and 2001, 57 patients of carcinoma cervix (bulky > 4 cm clinically, stage IIB/III) were treated with CRT. External radiation 46 Gy/23 fractions was followed by brachytherapy 35 Gy to Point A. Cisplatin was given in a dose of 50mg /week concurrently with external radiation for 5 cycles. A non-randomized comparison of CRT was done with the same subset of patients treated with RT alone (895 pts) during the same period., Results: Overall survival (OS), disease free survival (DFS) and pelvic control with CRT at 5 years (45.6 %, 43.9 % and 57.9 %) were similar to RT alone arm (47.4 %, 45.5 % and 61.3 %). Compared to RT alone arm, (11.6 %) severe acute toxicities (grade 3 > or =, RTOG criteria) were significantly higher in CRT arm (31.6 %) (p < 0.001). More late rectal toxicities were encountered in CRT arm (22.8%) compared to RT alone (12.5 %) (p = 0.01), but the incidence of severe late rectal toxicities (> or = grade 3) were similar; 1.8 % in CRT versus 1.1 % in RT arm., Conclusions: With CRT, there were no significant differences in the outcomes and the incidence of severe late toxicities compared to RT alone arm. As the patients in Indian subcontinent usually present in late stages with poor general condition, CRT should be used judiciously with careful attention given to patient selection with escalation of doses of cisplatin to get the optimal benefit.