Despite a decreasing incidence, stomach cancer is the second leading cause of cancer mortality worldwide. Surgical resection offers the only chance for cure in this aggressive cancer. The surgical management of gastric cancer has witnessed numerous debates in the past decades. These include the extent of lymphadenectomy, extent of surgery, role of laparoscopic gastrectomy, and the impact of high volume of centers, on the outcome of surgery. This review attempts to address these controversies with an evidence-based perspective. A literature search in MEDLINE (www.pubmed.org) has been performed with the relevant key words and corresponding MeSH terms. The search has been limited to English publications on human subjects. A manual search of the bibliographies has also been carried out, to identify the relevant publications for possible inclusion.

Early enteral nutrition (EN) after major digestive surgery has been receiving increasing attention. Supporting evidence has not been clear. This evidence-based review traces the development of early EN and analyses whether it is indeed an advance. We performed a PubMed search in October 2009 with the key words enteral nutrition, early feeding, and gastrointestinal surgery. Our emphasis was on earliest studies documenting the benefits or adverse effects of EN, comparative studies, documenting the benefits or adverse effects of EN, comparative studies, and randomized controlled trials. Thirty-one results were returned from which 17 were included for evaluation (1979-2009). Fifteen papers concluded that early EN was beneficial. In general, patients put on early EN and immunonutrition postoperatively seemed to have decreased hospital stay, decreased complication rates, decreased treatment and hospital costs, and even decreased morbidity and mortality; however, judicious use has been suggested. One study did not recommend early enteral feeding in well-nourished patients at low risk of nutrition-related complications and another suggested that immunonutrition is not beneficial and should not be used routinely. Early EN has been safely given after major digestive surgery since 1979. It benefits patients undergoing major gastrointestinal (GI) surgeries, with reduction in perioperative infection, better maintainance of nitrogen balance, and shorter hospital stay. Early EN may be superior to total parenteral nutrition (TPN). However, TPN is perhaps better tolerated in the immediate postoperative period. Early enteral immunonutrition should be used only in malnourished and in transfused patients. Early EN after major digestive surgery is an old advance that is now in fashion.

Objective : A three dimensional (3D) image-based dosimetric study to quantitatively compare geometric vs. dose-point optimization in combination with graphical optimization for interstitial brachytherapy of soft tissue sarcoma (STS). Materials and Methods : Fifteen consecutive STS patients, treated with intra-operative, interstitial Brachytherapy, were enrolled in this dosimetric study. Treatment plans were generated using dose points situated at the "central plane between the catheters", "between the catheters throughout the implanted volume", at "distances perpendicular to the implant axis" and "on the surface of the target volume" Geometrically optimized plans had dose points defined between the catheters, while dose-point optimized plans had dose points defined at a plane perpendicular to the implant axis and on the target surface. Each plan was graphically optimized and compared using dose volume indices. Results : Target coverage was suboptimal with coverage index (CI = 0.67) when dose points were defined at the central plane while it was superior when the dose points were defined at the target surface (CI=0.93). The coverage of graphically optimized plans (GrO) was similar to non-GrO with dose points defined on surface or perpendicular to the implant axis. A similar pattern was noticed with conformity index (0.61 vs. 0.82). GrO were more conformal and less homogeneous compared to non-GrO. Sum index was superior for dose points defined on the surface of the target and relatively inferior for plans with dose points at other locations (1.35 vs. 1.27). Conclusions : Optimization with dose points defined away from the implant plane and on target results in superior target coverage with optimal values of other indices. GrO offer better target coverage for implants with non-uniform geometry and target volume.

Background : Oral cancer is the leading malignancy in India. Nitric oxide and antioxidant enzymes play an important role in etiology of oral cancer. Therefore, the present study evaluates nitric oxide and antioxidant enzyme levels in healthy individual without tobacco habits (NHT, N=30) and healthy individuals with tobacco habits (WHT, n=90), patients with oral precancers (OPC, n=15) and oral cancer patients (n=126). Materials and Methods : Blood samples were collected from the subjects. NO ₂ +NO ₃ (nitrite+nitrate), superoxide dismutase (SOD) and catalase levels were estimated using highly specific spectrophotometeric methods. Statistical analysis was done by SPSS statistical software version 10. Results : Mean plasma NO ₂ +NO ₃ levels were elevated in patients with OPC and oral cancer patients as compared to the controls. Mean activities of erythrocyte SOD and catalase were higher in WHT than NHT. Erythrocyte SOD and catalase levels were higher in WHT and patients with OPC as compared to NHT. The erythrocyte SOD and catalase activities were lower in oral cancer patients than patients with OPC. The erythrocyte SOD activity was higher in advanced oral cancer than the early disease. Erythrocyte catalase activity was lower in poorly differentiated tumors than well and moderately differentiated tumors. Pearson's correlation analysis revealed that alterations in plasma NO ₂ +NO ₃ levels were negatively associated with changes in erythrocyte SOD activities. Conclusion : The data revealed that the alterations in antioxidant activities were associated with production of nitric oxide in oral cancer, which may have significant role in oral carcinogenesis.

Background : This study was conducted to analyze the frequency, expression patterns, and the impact of individual proteins BCL2, BCL6, and p53 on overall survival (OS) in adult, diffuse large B-cell lymphoma (DLBCL) patients. BCL2 gene was further investigated for potential alterations at the DNA level and correlated with OS. Materials and Methods : A total of 117 adult well-characterized DLBCL cases were included. The panel of antibodies comprised CD45, CD20, CD79a, CD3, BCL2, BCL6, and p53. PCR was also employed to correlate the events at the DNA level in BCL2. Results : The mean and median ages were 47.74 and 49 with a M:F ratio of 2.07:1. The incidence of BCL2, BCL6, and p53 expression was observed in 64.10%, 37.60%, and 52.13% of cases, respectively. Amplifiable quality DNA was available from 90 cases. BCL2/IGH translocation was found in 35/90 patients (38.88%) with 24 cases showing BCL2 (MBR)/IGH and 11 cases BCL2 (mcr)/IGH translocation. No association between BCL2 overexpression and BCL2 /IGH translocation was seen. Clinical data were available for 52 patients treated by CHOP therapy. It was found that patients with p53 overexpression had decreased overall survival (P = 0.0004) whereas BCL2, BCL6 expression, and BCL2/IGH translocation had no impact on overall survival. Conclusion : Our data suggest that simple p53 protein expression by IHC at the time of diagnosis may help to identify high-risk patients, who may benefit with more aggressive and newer treatments in addition to standard CHOP.

Aim : To study dosimetry of patients during the external radiotherapy of head and neck cancers from different hospitals of the northeastern region (NER) of India. Materials and Methods : 35 confirmed cases of head and neck cancers reporting to three different hospitals in the NER of India who underwent radiation treatment were the materials for the study. Dosimetry was carried out at 8(eight) anatomical points to these patients, namely, target (entrance and exit points), forehead, chest, abdomen, gonad, arm, and leg respectively by thermoluminescence (TL) as well as optically stimulated luminescence (OSL) dosimeters. Unlike conventional appliances, we used common iodized salt as TL/OSL phosphor. Results : Patient dosimetry was found to vary with an average of 1.17 ± 0.39 Sv at forehead, 1.24 ± 0.39 Sv at chest, 0.52 ± 0.13 Sv at gonad to a minimum of 0.26 ± 0.07 Sv at leg areas when exposed to a cumulative dose of 65 Sv at the target. Conclusion : Maximum dose received from a stray radiation is about 1.5 Sv at forehead/chest and dosimetry of patient among the three centers is not significantly different at the 5% level of probability.

Aim : To study the role of neoadjuvant imatinib mesylate in downsizing tumors in patients with locally advanced nonmetastatic gastrointestinal stromal tumors (GISTs), thus improving the possibility of complete resection. Materials and Methods : We used neoadjuvant imatinib in six patients with locally advanced GISTs, at a dose of 400 mg daily, given orally in all patients for a median period of 3.5 months (range 1-20 months). All patients had a computerized tomography scan (CT scan) once before starting the treatment and a repeat CT scan 1 month after starting imatinib. Some patients had another CT scan done at 3 months. The tumor volume was calculated using the formula V=4/3 ðr ³ . Results : Following imatinib therapy, the median reduction in the tumor volume was 40% (range 20-50%). Four of the six patients underwent successful complete resection of the tumor following neoadjuvant imatinib for a median period of 2 months, and are disease free after a median follow-up of 10.5 months (range 3-20 months). Two patients in whom the tumors were deemed to be operable after downsizing refused surgery and are continuing imatinib. Imatinib did not produce serious toxicity in any patient. Conclusion : Neoadjuvant imatinib can be used successfully in patients with locally advanced nonmetastatic GISTs to improve the rates of complete resection and reduce the chance of tumor spill. The optimal duration of neoadjuvant treatment needs to be tailored based on response assessment at frequent intervals to identify the ideal window period for surgery.

Aim : The aim of the present study was to compare the efficacy and safety of weekly versus an every 2-week administration of cetuximab in association with irinotecan in patients with metastatic colorectal cancer (MCRC). Methods : We reviewed the clinical records of 50 patients with MCRC who began treatment with cetuximab from February 2004 to January 2007. Two different treatment schedules were used. In the first group (N = 32), cetuximab was given at an initial dose of 400 mg/m ² , followed by weekly infusions of 250 mg/m ² . In the second group (N = 18), cetuximab was administered every 2 weeks at a dose of 500 mg/m ² . The two groups were compared for tumor response, time to progression (TTP), overall survival (OS), and toxicity. Results : All patients had received irinotecan and 5-fluorouracil; a majority had previously received oxaliplatin. Disease control (partial response + stable disease) was achieved in 56.3% of patients receiving weekly cetuximab versus 77.8% in the other group (P = 0.21). The median follow-up for all patients was 34.2 months. TTP (Group 1: 28% vs. Group 2: 18%, P = 0.9356) and OS (Group 1: 75% vs. Group 2: 72%, P = 0.6748) rates at 7 months were similar in the two groups. Skin toxicity was the most relevant adverse event: 78.1% of the patients had acne-like rash in the first group and 61% in the second group. However, only one patient in each group had a grade 3 toxic reaction. Conclusion : There is no major difference of efficacy and safety between cetuximab given every 2 weeks and a weekly dosing regimen, in association with irinotecan.

Background : Increasing incidence and significant stage migration from distant metastases to a localized disease, due to screening application of PSA, is taking place in carcinoma prostate. Also, role of radiotherapy is increasing in carcinoma prostate due to rapid strides in technology. Aim : The present retrospective study, evaluates escalating the dose in the treatment of localized carcinoma prostate using integration of multiple advanced techniques. Settings and Design : The settings designed are: a) use of gold seed internal fiducial markers: b) clinical application of emerging Megavoltage Cone Beam Computed Tomography (MVCBCT) technology for Image Guided Radiotherapy (IGRT); c) Intensity Modulated Radiotherapy (IMRT); d) adopting biochemical method for follow-up. Methods and Material : Twelve consecutive, biopsy proven localized cancer of prostate patients, treated with dose escalation IMRT& IGRT protocol between August 2006 and January 2008, were analyzed. Gold seed markers in prostate were used for daily localization with MVCBCT or Electronic Portal Imaging (EPI). All patients underwent clinical and biochemical follow-up. Statistical Analysis& Results : Planned dose of 7740 cGy was delivered in 10 out of 12 patients (83%). While one patient had migration of maximum of 3 mm, two others had 1 mm migration of one seed during course of treatment. One patient (8%) developed Grade II proctitis at 12th month. During the mean follow-up duration of 12.2 months, 92% (11/12) had biochemical control within 3 months of treatment. Conclusions : IGRT technique using MVCBCT for implanted fiducial gold seed localization was feasible for IMRT dose escalation in carcinoma prostate with excellent results.

Purpose : To characterize metal oxide semiconductor field-effect transistors (MOSFETs) for a 6-MV photon beam with a first helical tomotherapy Hi-Art II unit in India. Materials and Methods : Standard sensitivity MOSFETs were first calibrated and then characterized for reproducibility, field size dependence, angular dependence, fade effects, and temperature dependence. The detector sensitivity was estimated for static as well as rotational modes for three jaw settings (1.0 cm × 40 cm, 2.5 cm × 40 cm, and 5 cm × 40 cm) at 1.5-cm depth with a source-to-axis distance (SAD) of 85 cm in virtual water slabs. The A1SL ion chamber and thermoluminescence dosimeters (TLDs) were used to compare the results. Results : No significant difference was found in the detector sensitivity for static and rotational procedures. The average detector sensitivity for static procedures was 1.10 mV/cGy (SD 0.02) while it was 1.12 mV/cGy (SD 0.02) for rotational procedures. The average detector sensitivity found was the same within the experimental uncertainty for static and rotational dose deliveries. The MOSFET reading was consistent and its reproducibility was excellent (+0.5%) while there was no significant dependence of field size. The angular dependence of less than 1.0% was observed. There was negligible fading effect of the MOSFET. The MOSFET response was found independent of temperature in the range 18°-30°. The ion chamber readings were assumed to be a reference for the estimation of the MOSFET calibration factor. The ion chamber and the TLD were in good agreement (+2%) with each other. Conclusion : This study deals only with the measurements and calibration performed on the surface of the phantom. MOSFET was calibrated and validated for phantom surface measurements for a 6-MV photon beam generated by a tomotherapy machine. The sensitivity of the detector was the same for both modes of treatment delivery with tomotherapy. The performance of the MOSFET was validated for and satisfactory for the helical tomotherapy Hi-Art II unit. However, MOSFET may be used for in vivo surface dosimetry only after it is calibrated under the conditions replicating as much as possible the manner in which the dosimeter will be used clinically.

Spinal epidermoid cysts, whether congenital or iatrogenic, are relatively uncommon in the spinal cord. When they occur, the typical location is in the subdural, extramedullary space of the lumbo-sacral region. We describe an unusual presentation in a 3-year-old male child which mimicked astrocytoma clinicoradiologically. The child developed sudden onset of inability in walking and weakness of both lower limbs after a fall. There was a dramatic reversal of symptoms after surgery. Histopathology revealed an epidermoid cyst of the spine. On the first follow-up visit at 3 months, the child was asymptomatic.

A rare case of simultaneous occurrence of three entirely distinct intracranial tumors is described. A 55-year-old male with no evidence of phacomatoses or history of radiation therapy presented with complaints of increased drowsiness, headaches, and dysarthria. Investigations revealed an olfactory groove meningioma, a glioblastoma multiforme in the left medial temporal lobe, and a diffuse glioma in the brain stem. Occurrence of multiple varieties of tumors at the same time is extremely rare. Theories that explain their occurrences including the role of common carcinogens, autocrine growth factors, and tumor suppressor genes are discussed.

Multiple myeloma (MM) is a hematological malignancy characterized by the occurrence of plasma cell tumor within the bone marrow. Extramedullary plasmacytomas form a small percentage of plasma cell tumors, and although 80-90% of extramedullary lesions occur in the head and neck, pulmonary plasmacytomas are found to be a very uncommon clinical entity. Hereby, we describe a case of a patient with pulmonary plasmacytoma, who developed nodal and pulmonary MM with a pleural effusion, the radiological appearance of which mimicked bronchogenic carcinoma.

Lymphoepithelioma-like carcinoma (LELC) of the uterine cervix is a rare variant of squamous cell carcinoma (SSC). It differs from the usual SSC of the cervix in its morphology and clinical behavior and shows a better prognosis than the more common SSC of the cervix. We report a case of LELC of the cervix, diagnosed on the basis of histopathology in a 42-year-old female who presented with a history of postcoital bleeding.

Second malignancy is one of the late complications of long-term cancer survivors, treated with radiation or chemotherapy. Here is a case report on acute myelogenous leukemia, which developed after 63 months following the completion of treatment with surgery and platinum-based chemoradiation in a patient of carcinoma cervix IB. The above-mentioned second malignancy is one of the late sequelae of platinum-based chemoradiation. This case is reported here for documentation because of its rarity.

Polycythemia vera (PV) is a common cause of Budd-Chiari syndrome (BCS) and portal vein thrombosis (PVT). The postpartum period is a precipitating cofactor. An additional heparin-induced thrombocytopenia/thrombosis (HIT/T) leads to a life-threatening condition in which transjugular intrahepatic portosystemic shunting (TIPS) seems to be the only life-saving procedure. We describe the case of a subacute BCS and PVT in the late postpartum period. The diagnosis was established using CT scan, MRI, and Doppler ultrasonography of abdominal vessels and the laboratory findings were compatible with PV. After a successful creation of TIPS, a HIT/T worsened the hemorrhagic and thrombotic picture. TIPS procedure was successfully repeated and heparin was replaced with Fondaparinux and then vitamin K antagonist. The treatment with interferon alpha-2A, started after the normalization of liver functions, resulted in a complete remission within 6 months. The JAK2 V617F mutation clone remained undetectable after 2 years' follow-up.

The article deals with a rare case of chordoma with increased prolactin levels. It could often result in a diagnostic dilemma and problems in differentiating it from a pituitary adenoma.

Hepatic veno-occlusive disease (VOD) remains one of the commonest and most serious complications after myeloablative hematopoietic stem cell transplantation (HSCT). Clinical diagnosis of hepatic VOD is based on the finding of the triad of painful hepatomegaly, hyperbilirubinemia, and unexplained fluid retention occurring within 21 days of the transplant. However, the uncommon clinical entity of late-onset VOD can occur even beyond 20 days and should be considered in the differential diagnosis of any liver disease of more than 3 weeks' duration. While mild cases usually resolve spontaneously, severe VOD is associated with a grim prognosis. Defibrotide, a polydisperse mixture of single-stranded oligonucleotide with antithrombotic and fibrinolytic effects on microvascular endothelium, has emerged as an effective and safe therapy for patients with severe VOD. We describe a patient who presented 55 days post transplant with clinical features suggestive of VOD. Upon treatment with oral defibrotide, he showed complete resolution of the VOD.

Primary liposarcoma of the pectoral major muscle is extremely rare. We report a case of liposarcoma of the pectoral major muscle which was treated with surgical excision and postoperative radiotherapy. A 70-year-old man admitted with left-sided painless progressively growing breast mass. Radiological investigation revealed liposarcoma of the pectoralis major muscle. The patient was treated by surgical removal. Pathological diagnosis was pleomorphic liposarcoma. The patient had postoperative radiotherapy and free of disease for 9 months. Surgical excision and postoperative radiotherapy is the most favored treatment strategy. Careful follow-up is mandatory for detecting recurrences.

Atypical teratoid/rhabdoid tumor (AT/RT) is a highly aggressive and uncommon tumor of the central nervous system, primarily affecting young children. AT/RT of the paraspinal region with involvement of the spine and spinal cord is extremely rare, with only few case reports in the literature. We report an unusual case of giant lumbar paraspinal AT/RT with intraspinal extension in a previously healthy 18-month-old female child. To the best of our knowledge, this kind of presentation has not been reported previously in the English literature.

Extramammary breast metastases (from non-breast primaries) are rare, constituting only about 2% of all breast metastases, although autopsy studies show that it may occur in up to 6% of cases. Lymphoma, metastatic melanoma, and bronchial carcinoma are the malignancies that account for the majority of breast metastases. Breast metastases from a colorectal carcinoma have been described in only a small number of cases in the literature. We present a case of a 42-year-old woman with an incidental finding of a breast lump. She had a history of Dukes C rectal carcinoma for which she had undergone an anterior resection 11 months earlier. The breast deposit was the first clinical indication of relapse. The patient subsequently developed liver and brain metastases and deteriorated rapidly; she died 2 months after presenting with the breast mass.

Clear-cell meningioma (CCM) is an uncommon, aggressive variant of meningioma, usually affecting younger females and having predilection for infratentorial locations. We present a rare case of recurrent supratentorial CCM in a 58-year-old male. Ten years back, he had an intra-axial tumor in the left occipital lobe, which was managed by surgical excision and radiotherapy. Currently, the patient presented with sudden severe headache along with speech and vision disturbances. Neuroimaging revealed an extra-axial parietooccipital tumor, with intratumoural bleed. Histopathology of both tumors showed features of CCM, immunopositive for epithelial membrane antigen (EMA) and vimentin. This case illustrates multiple unusual features of a rare variant of meningioma in the form of affection of an adult age group, supratentorial location, recurrence, and intratumoral bleed. It also highlights the importance of incorporating immunohistochemistry in the diagnostic workup, to exclude CCM mimics, each having distinctive biological behavior, and prognostic outcome, and warranting different therapeutic protocols.

Primary squamous cell carcinoma (SSC) of cecum is a very rare malignant neoplasm. The first case was reported by Schmidtman in 1919. Here, a well-differentiated, keratinizing SSC of cecum in a 34-year-old male patient is being reported. The neoplasm originated from surface epithelium, and invaded the bowel wall up to subserosal fat space. No predisposing factor was detected. Clinical features were that of an adenocarcinoma of the colon. Postoperative chemotherapy was given for 6 months to eradicate any micrometastasis. The patient is free of disease 2 years after having had the tumor removed. The case is being presented because of its rare occurrence.