Background/Objective: Esophageal cancer has a peculiar geographical distribution and shows marked differences in incidence within a particular geographical region. Presently, as there seems little prospect of early detection of this cancer, an understanding of the etiological factors may suggest opportunities for its primary prevention. In this paper, we have tried to determine the role of diet and other life-style related factors in the etiology of cancer of esophagus. Material and Methods: A total of 100 confirmed squamous cell carcinoma of esophagus patients were enrolled for the study (Group A). 100 healthy subjects were included as controls (Group B). A predesigned questionnaire dealing with the basic patient data, dietary and smoking habits etc. was distributed among the cases in both groups. The data was thoroughly analyzed to define an association with the development of cancer of esophagus. Results: Group A patients included 71 males and 29 females in the age range of 40-70 years. Majority 37% were farmers, 29% house wives. Of the 72% smokers, 66% smoked hookah. 29% had positive family history. More than 90% took salt-tea at breakfast. Meat consumption was low, 44% took it weekly and 42% on monthly basis. 69% took fish yearly. Group B included 75 males and 25 females of which 35.7% were hookah smokers. Conclusion: Poor socio-economic status resulting in fewer intakes of fresh fruits, vegetables and fish in addition to heavy hookah smoking are suspected to be the major risk factors for the development of esophageal cancer.

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Purpose: We evaluated the performance of the new 4-tiered melanoma-specific graded prognostic assessment (GPA) score and the previously published general GPA score in patients with brain metastases from malignant melanoma managed with different approaches including best supportive care. Materials and Methods: Retrospective analysis of 51 patients. Compared with the original analysis of the melanoma-specific GPA score, these patients were more representative of the general population of patients with brain metastases from this disease. Results: The present data confirmed that both scores identify patients with favorable prognosis who might be candidates for focal treatments. However, survival in the 2 unfavorable prognostic subgroups defined by the melanoma-specific GPA was not significantly different. Median survival in the melanoma-specific GPA classes was 3.1, 3.7, 7.5, and 12.7 months. Karnofsky performance status (KPS) and serum lactatdehydrogenase (LDH) level significantly predicted survival. Conclusion: In order to select the right patient to the right treatment and avoid overtreatment and suboptimal resource utilization in patients with very limited survival, improved prognostic tools are needed. The melanoma-specific GPA does not include extracranial disease extent or surrogate markers such as LDH. We suggest that a combination of KPS <70 and elevated LDH might better predict short survival than any of the GPA scores. This hypothesis should be confirmed in larger studies.

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Background: Although the vast majority of meningiomas are not malignant, their location within the cranial vault often leads to the development of symptoms. Traditional therapy has included observation, surgical resection, radiation therapy or a multimodality approach. The objective of this study is to review the outcomes in patients with meningioma treated at our institution using stereotactic radiosurgery. Materials and Methods: A total of 73 patients (median age of 59, 15 male and 58 female) with meningioma (median volume of 5.54 cc) underwent Cyber Knife ^TM stereotactic radiosurgery at our institution. Sixty patients had WHO grade 1 meningioma, eleven patients had WHO grade 2 meningioma, and two patients had WHO grade 3 meningioma. Treatment consisted of a median dose of 17.5 Gy (range, 6 - 27 Gy) delivered over a median of three fractions (range: 1 - 5). The patients were followed by clinical examination as well as serial imaging with magnetic resonance imaging (MRI). Results: The median follow-up was 16.1 months (range, 1.5 - 98.0). Follow-up MRI was available in all 73 patients. Local failure was documented in 11 cases. Actuarial local control at one year was 95, 71, and 0% for WHO grade 1, WHO grade 2, and WHO grade 3, respectively. There was no acute grade 3 or greater toxicity and only one episode of late grade 3 toxicity. A subjective improvement in the existing, tumor-related symptoms was noted in 60% of the patients. Conclusion: Stereotactic radiosurgery is a safe and effective treatment for meningioma. Tumor-related symptoms often improve after treatment.

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Diagnosis of orbital retinoblastoma traditionally carries a dismal prognosis. Although its incidence is less in the developed countries, it continues to contribute to an epidemic of extraocular disease at diagnosis in the developing world. Orbital retinoblastoma encompasses a wide range of distinct clinical entities with varying tumor load. There are no standard treatment protocols as of now but the current preferred management is multimodal with a combination of initial high-dose chemotherapy, surgery, external beam radiotherapy and prolonged chemotherapy for 12 cycles. Though orbital retinoblastoma is a catastrophic event, rapid advances on many fronts, especially the genetic, makes the future appear brighter than what it is now. This review looks at all the new frontiers that are in store in the near as well as the distant future. Looking at the ever expanding horizons makes one believe of a definite hope that one day we will conquer this disease as we have conquered many others in the past.

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Purpose: To explore the dosimetric advantages of the new MammoSite multilumen (ML) balloon for breast brachytherapy treatment compared to conventional single lumen (SL) device plan. Materials and Methods: Patients deemed appropriate for accelerated partial breast irradiation (APBI) were implanted with the MammoSite ML balloon. Two plans were generated in each patient for the same target coverage (PTV_EVAL) and dose to normal structures were plotted. The first plan used only the central single lumen with single-dwell position (SL), and the second plan (ML) was generated using the other lumens of the device. Dose distributions of the SL and ML plans were compared. Results: For the same PTV_EVAL, the ML balloon improved dose coverage at the tip and base of the applicator compared to SL plan. The skin and rib doses were reduced using the ML plan versus SL plan for the same PTV_EVAL in-patient 2, where the skin-balloon distance was 7 mm and the rib-balloon distance was <1 cm. For patient 1, the skin and rib distances were greater than 1 cm and the ML plan did not further minimize the dose to normal structures. Conclusion: In our initial experience, dosimetric goals can be better achieved using the ML MammoSite balloon when normal structures (skin and ribs) are close to PTV_EVAL with a distance of <7 mm and rib distance of <1 cm. The multiple lumen of ML balloon can optimize dose and reduce excessive dose to rib and skin and therefore minimize the long-term toxicities of rib discomfort, skin fibrosis and fat necrosis.

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Extragenital malignant mixed Mullerian tumor (MMMT) is a rare tumor in females, and it is even more rarely encountered among the multiple genital malignancies. There are some reports of extragenital MMMTs associated with synchronous or metachronous gynecologic tumors of Mullerian duct origin. We recently encountered an MMMT of broad ligament which is associated with papillary serous cystadenocarcinoma of the ovary and endometrioid adenocarcinoma arising in atypical polypoid adenomyoma endometrium in a 76-year-old woman. This case is presented for its rarity and unique presentation. To our knowledge, ours is the first reported case of this unique combination of multiple synchronous genital malignancies.

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Background: Administering drugs outside the terms of their official labeling is called off-label use. In the West, oncologists often use drugs off-label, which offers several advantages especially while treating patients with multiple comorbidities or advanced cancer. The practice of off-label prescribing of anticancer agents in India is not well documented. Materials and Methods: A survey on prescribing practices of 10 important drugs used in cancer was conducted in March 2010. Ten centers representing all parts of India were identified. One oncologist from each center was contacted by phone or email and explained about the survey. The list of drugs was sent to them by email if they agreed to participate and they were requested to fill all the indications for which these drugs were used in their center. Labeling for each drug was obtained from the Food and Drug Administration (FDA) website. Off-label practice was categorized as those recommended by the National Comprehensive Cancer Network (NCCN) and those without. Results: Nine out of 10 centers agreed to participate in the survey. Four centers responded to the questionnaire. Six out of 10 drugs were used for off-label indications, cisplatin being the most commonly used. All drugs were either used as per FDA labeling or according to the recommendations of NCCN, except for gemcitabine which was used in one center for some indications based on phase II data. Conclusion: Very limited off-label prescribing was found in oncology practice in India. Since off-label use offers several advantages, judicious use of this practice should be encouraged among the oncologists.

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Background: Estrogen receptor (ER) and progesterone receptor (PR) status has been used since the mid-1970s in the management of breast cancer as an indicator of endocrine responsiveness and as a prognostic factor for early recurrence. Aim: To study the steroid receptor profile and its clinico-pathological correlation in post-menopausal breast cancer patients. Setting and Design: A retrospective and prospective analysis of 80 and 68 patients, respectively, was undertaken to study the prevalence of ER and PR in post-menopausal breast cancer patients. The result of collective observations was analyzed statistically. Material and Methods: In this study, retrospective data on hormonal receptor status of 80 post-menopausal breast cancer patients and prospective data of 68 patients were collected and analyzed. Statistical Analysis Used: Student "t" test, Chi-square test. Results: Receptor positivity was high in higher age group but unlike earlier studies the receptor positivity was lower in incidence. The study showed an incidence of 37.83% receptor positive tumors in post-menopausal women. ER was positive in 27.03% patients of whom 16.2% were also PR positive, while the remaining patients were ER/PR negative. ER was negative in 72.47% patients of whom PR was positive in 10.8% and negative in the remaining. Out of 148 cases, 128 (86.48%) had palpable axillary lymph nodes. Out of 148 patients, 36 (24.34%) had supraclavicular lymph node involvement (Chi-square = 1.70, P = 0.193). Out of 148 cases, 144 (92.29%) were infiltration ductal carcinomas. Grade I tumors were more common in receptor positive tumors while grade II and III tumors were more common in receptor negative tumors. Receptor negative tumors were more aggressive in terms of peau de' orange, ulceration, fungation and chest wall invasion. Metastases and axillary lymph node involvement was observed more in receptor negative tumors; however, supraclavicular lymph node involvement was equal in both the groups. Infiltrating ductal carcinoma was the most common type of carcinoma in both the groups. Conclusion: The receptor positivity of steroid receptors was more in higher age groups, but the incidence of receptor positivity was lower than that reported in earlier studies. No statistically significant association was found between receptor status and clinical presentation of breast cancer, histopathological status of tumor and metastases.

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Kaposi's sarcoma is a tumor caused by human herpes virus 8 also known as Kaposi sarcoma-associated herpes virus. Originally described by Kaposi in 1872, this tumor is recognized as an AIDS-defining illness. Classic Kaposi's sarcoma (CKS) is a relatively indolent disease affecting elderly men from the Mediterranean region or of eastern European descent, besides Jews in whom it is the most common. It has been also reported in the Arab population living in Israel. Kaposi's sarcoma has been reported in Arabs after kidney transplantation; however, there are no reports of CKS occurring in non-Israeli Arabs. This is first such article reporting two Arab patients who presented with CKS thus widening the ethnic and geographic area of involvement with this condition.

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Background: Hepatocellular carcinoma is the most common primary tumor of the liver. Disease dissemination occurs through hematogenous routes and frequently involves the lungs, bone, adrenal glands, and pancreas. The patterns of the extrahepatic manifestations are diverse. Soft tissue metastasis is extremely rare and mandates systematic pathological analysis, which may include the use of specific immunohistochemical staining. We report metastasis from a hepatocellular carcinoma, as a discrete subcutaneous mass to the right humerus muscle. Materials and Methods: We detail the approach to diagnosis and management of an unusual case of a patient with hepatocellular carcinoma, in whom we found a metastatic lesion as a subcutaneous mass to the right humerus muscle nine years after right hepatectomy. Conclusion: This condition poses differential diagnostic problems in the settings of clinical and pathological investigations. Metastasis of hepatocellular carcinoma should be included in the differential diagnosis of rapidly growing lesions.

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Only a minority of the patients who develop recurrence after definitive treatment for cervical cancer are detected after 5 years (late recurrence); the numbers are lesser still after 10 years (very late recurrence). Among the infrequent cases that do develop "late" and "very late" recurrence, the commonest site is the pelvis. We report an unusually rare recurrence of treated cervical cancer confined to the para-aortic nodal group after a protracted disease-free interval of 13 years. On the basis of the long disease-free interval, location of the mass at the periphery of the radiation field, and aggressive imaging appearance, a diagnosis of radiation-induced sarcoma was considered. However, the final diagnosis of isolated para-aortic nodal recurrence of cervical cancer was rendered based on the histopathological and immunohistochemistry findings, supported by the absence of disease elsewhere on whole-body imaging.

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Background: Neurocognitive effects following whole-brain and partial-brain irradiation can cause considerable morbidity. Sparing of neural stem cells (NSCs) is proposed as an avenue for reducing the long-term radiation-induced defects in learning, memory, and intelligence. We performed an analytical study to spare the NSC from partial-brain irradiation by intensity-modulated radiotherapy (IMRT). Objective: The aim of this study is to achieve maximal sparing of NSC during irradiation of brain tumors using biologically equivalent dose (BED) for all plans. The consequent clinical benefit will possibly be in terms of acute effects on stem cells and delayed neurologic sequelae to brain. A tool to modulate various physical and biological dose metrics has been used to study the optimization of radiation therapy for brain tumors with constraints imposed on total radiation to NSC. Materials and Methods: A total of 10 successive patients of grade III and IV gliomas of brain, who underwent total or near total excision of brain tumors, were included in the study. Patients underwent computed tomography and magnetic resonance imaging fusion for contouring. Computational codes used to analyze the efficacy of the plan are quality of coverage, homogeneity index, and conformity index. Wide range of radiosensitivity parameters were evaluated by using equivalent uniform dose and tumor control probability (TCP) to predict tumor control with and without sparing of NSC. Results: The physical and biological dose metrics were modulated by fitting standard deviation of 0.3% for all plans. The maximum NSC sparing was achieved in IMRT plans with constraints applied to local TCP. Similarly, for BED of plans with and without constraints, the estimated mean reduction in acute complications of NSC achieved was 12.23% (range, 4.27-28.33%). The estimated mean reduction in BED for late complications of late-reacting brain tissue is 14.69% (range, 7.39-33.56%).

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Background: The conventional treatment planning system (TPS) gives analytical calculations with approximately ±15?20% dose uncertainty, which may lead to over exposure of critical organs or under dose of target as well as the presence of inhomogeneities, and the position of source affects the exact dose calculation like in breast and intraluminal brachytherapy. Aim: To obtain dose distribution parameters of GammaMed Plus high dose rate (HDR) ¹⁹² Ir source using Monte Carlo (MC) EGSnrc and GEANT4 codes as well as to find the effect on dose distribution due to source position, and due to presence of air and cortical bone by using MC GEANT4 code, and to find the similarity of both studies with any past study of any HDR brachytherapy source for either as input to TPS or verification of TPS calculations. Settings and Design: It is done using different software of the computer, e.g., excel, MS word, etc. Materials and Methods: The source, source position for different studies, water phantom, water characteristics, points of measurements, air and cortical bone inhomogeneities, and position of inhomogeneities were simulated. Statistical Analysis Used: For uncertainties calculation, mean and probability are used. Results: The calculated dose rate constant, radial dose function, and 2D anisotropy function of the source show similarity with published data. Calculated dose distribution differences due to presence of air and cortical bone, and position of source in water phantom also show similarity with published data. Conclusion: These results can either be implemented in TPS or can be used for verification of TPS calculations.

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Localized cavernous hemangioma of the uterus is an extremely rare lesion that often presents with heavy uterine bleeding and/or pelvic pain. Though more cases exist for pregnant women, some isolated case reports involve non-pregnant women. The diagnosis is difficult and requires a high index of clinical and radiological suspicion. Here we describe a clinically and radiologically unsuspected case of a localized cavernous hemangioma in a 27-year-old woman, with a prior history of an uneventful Cesarean section. Surgical excision of the lesion at the cornu of the uterus was performed. Histopathology revealed a cavernous hemangioma involving the endomyometrium and invading the foci of adenomyosis. A cavernous hemangioma localized to a portion of the uterus may be clinically silent during pregnancy and throughout delivery thus making it difficult to detect. Though rare, it may be an important differential in any female patient who presents with non-responsive uterine bleeding and/or unremitting pelvic pain.

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A middle-aged lady presented with headache, vomiting of sudden-onset with intermittent evening rise of temperature. She also had slurring of speech with no loss of consciousness or altered sensorium. The patient was under evaluation for hypercalcemia. A whole body bone scan was done to look for causes of hypercalcemia and the scan showed extraosseous ^99m Tc MDP (Technetium Methylene Di Phosphonate) uptake. One of the causes of extraosseous MDP uptake is cutaneous T-cell lymphoma (CTCL). On close interrogation the patient gave a history of hypopigmented dermal patches for more than 2 years duration. The coexisting dermal patches raised suspicion of CTCL. Skin biopsy confirmed CTCL. The patient was referred to oncology and was planned for six cycles of chemotherapy.

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Only a limited group of patients with non-small-cell lung cancer (NSCLC) is eligible for treatment with a curative intent. Adrenalectomy for a solitary adrenal metastasis of NSCLC may be curative when combined with resection of the primary tumor. It is unclear whether resection of an isolated adrenal metastasis is justified in patients with a second metastasis. We report a case of successful adrenalectomy with adjuvant chemotherapy in a patient who was previously treated with a right lower lobe resection and subsequent Gamma Knife treatment of an intracranial metastasis. At 20-month follow-up, patient was in a good clinical condition without signs of recurrent disease. In selected cases, adrenalectomy with adjuvant chemotherapy for an adrenal metastasis of NSCLC may be performed successfully, with good short-term results, even after earlier treatment of a cerebral metastasis.

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Polymorphous low-grade adenocarcinoma (PLGA) has been recently recognized as a distinct entity with a known predilection for minor salivary glands. We present an unusual case of recurrent PLGA arising within the right parotid gland in a 25-year-old lady. The striking histological picture is diverse architecture combined with benign cytological features. Even in the light of multiple recurrences, our tumor displayed a relatively indolent course which is commonly associated with this adenocarcinoma sub-type. Thus, unusual occurrence demonstrates that this tumor should also be considered in differentials of tumors of the major salivary glands. Long-term follow-up is essential to ensure local control.

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Background: The importance of hormone receptor status in diagnosis, prognosis and response to hormone therapy of breast cancer has already been proven. Aim: Morphologic mimicry and similarity between salivary gland tumors and breast tumors led us to undertake an immunohistochemical evaluation on the expression of progesterone receptors (PRs) in pleomorphic adenoma (PA) and adenoid cystic carcinoma (ACC) of salivary glands. Study and Design: We researched the role of PRs in tumorigenesis and hormone therapy of PA and ACC with immunohistochemistry and their expression in normal salivary glands was studied. Association of progesterone expression with grade 2 and 3 ACC was researched. Methods: In a descriptive, analytical, cross-sectional study, 29 paraffin blocks (14 samples of PA and 15 samples of ACC) were prepared for immunohistochemical staining with progesterone antibody. t-Test and Mann-Whitney test were used for the statistical analysis of the results. Results: PR staining was negative in 15 ACC and 13 PA cases. Slight to moderate staining was seen around the tumor in 12 normal cases. Little or no PR staining was observed among endothelial cells, fibroblasts and inflammatory cells. No progesterone expression in grade 2 and 3 ACC in the salivary glands was observed. Conclusion: Although progesterone seems to be essential for normal function of the salivary glands, it does not have a role in tumorigenesis and hormone therapy in PA and ACC. No association was found between progesterone expression and differentiation grade in ACC.

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Aim: To determine interfractional three-dimensional set-up errors using X-ray volumetric imaging (XVI). Materials and Methods: Between December 2007 and August 2009, 125 patients were taken up for image-guided radiotherapy using online XVI. After matching of reference and acquired volume view images, set-up errors in three translation directions were recorded and corrected online before treatment each day. Mean displacements, population systematic (Σ), and random (σ) errors were calculated and analyzed using SPSS (v16) software. Optimum clinical target volume (CTV) to planning target volume (PTV) margin was calculated using Van Herk's (2.5Σ + 0.7 σ) and Stroom's (2Σ + 0.7 σ) formula. Results: Patients were grouped in 4 cohorts, namely brain, head and neck, thorax, and abdomen-pelvis. The mean vector displacement recorded were 0.18 cm, 0.15 cm, 0.36 cm, and 0.35 cm for brain, head and neck, thorax, and abdomen-pelvis, respectively. Analysis of individual mean set-up errors revealed good agreement with the proposed 0.3 cm isotropic margins for brain and 0.5 cm isotropic margins for head-neck. Similarly, 0.5 cm circumferential and 1 cm craniocaudal proposed margins were in agreement with thorax and abdomen-pelvic cases. Conclusion: The calculated mean displacements were well within CTV-PTV margin estimates of Van Herk (90% population coverage to minimum 95% prescribed dose) and Stroom (99% target volume coverage by 95% prescribed dose). Employing these individualized margins in a particular cohort ensure comparable target coverage as described in literature, which is further improved if XVI-aided set-up error detection and correction is used before treatment.

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Pneumonectomy is done in patients with operable bronchogenic cancer and intractable end-stage lung diseases such as tuberculosis and bronchiectasis. It is often followed by postoperative complications with an incidence of 20-60%. Factors influencing the incidence and type of complication after lung resection include age, physical status, and procedure. Many of these complications are life threatening and require appropriate immediate management. Therefore, the knowledge of diverse radiologic appearances of these complications and familiarity with the clinical settings in which specific complications are likely to occur are vital for prompt and effective treatment. This pictorial review intends to educate the radiologists and clinicians regarding early detection of these complications.

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