AROI, West Bengal Annual Conference

Dated: 11th and 12th January, 2014

Venue : Hotel Hindusthan International, Kolkata

ORGANISING COMMITTEES

Chairman, Organising Committee Organising Secretary

Prof. (Dr) Siddhartha Basu Dr. Aloke Ghosh Dastidar

Organising Co-Chairman

Prof (Dr) Sajal Kumar Ghosh Prof (Dr.) Srikrishna Mondal

Joint Organising Secretaries

Dr Subrata Chatterjee Dr Anindya Chakroborty

Treasurer Assistant Treasurer

Dr Chandan Dasgupta Dr Shayam Sundar Adhikary

Scientific Sub-committee

Chairman Convener

Prof(Dr) Pradip Maiti Dr. Subrata Saha

Members

Dr. Chanchal Goswami Dr. Indranil Mallick

Dr. Amitava Roy (JR) Dr. Jyotirup Goswami

Dr. Chandrani Mallick Dr. Swapnendu Basu

Reception Sub- Committee

Chairman Convener

Prof (Dr) Shyamal Kumar Sarkar Dr.Shila Mitra

Members

Dr. Partha Dasgupta Dr. Diptimoy Das

Dr. Koustav Majmdar Dr. Anrundhuti Dey

Dr. Mukti Mukherjee

Registration Sub-committee

Chairman Convener

Dr. Subir Ganguly Dr. Asit Ranjan Deb

Members

Dr. L.N. Biswas Dr. Sanmoy Ganguly

Dr.Anupam Dutta Dr. Somnath Roy

Dr. Imran Khan Dr. Anirban Halder

Dr. Priyanka Biswas Dr Kaushambi Kar

Hospitality Sub-committee

Chairman Convener

Prof (Dr.) Amitava Roy Dr. Santanu Pal

Members (Hospitality Sub-committee)

Dr. Prasenjit Chatterjee Dr. Kakali Chowdhury

Dr. Saheli Bhattacharya Dr. Bishan Basu

Dr. Dhananjay Mondal Dr. Harris Mahammad Sepai

Souvenir Sub-committee

Chairman Convener

Dr. Phalguni Gupta Dr. Bikramjit Chakraborti

Members

Dr. Suman Mallik Dr. Niladri Behari Patra

Dr. Suparna Kanti Pal Dr. Shyam Sharma

Dr. Shiladitya Ray Chowdhury (Mondal) Dr. Sushovon Banjerjee

Dr. Avishek Basu

Hall Management & audio-visual Sub -committee

Chairman Convener

Dr. Gautam Bhattacharya Dr. Sanatan Banerjee.

Members

Dr. Priyanjit Kayal Dr. Rajat Banerjeee

Dr Tapas Kumar Das Dr. Krishnangsu Bhanja Chowdhury

Dr Anjan Bera Dr. Partha Sen

Dr. Ritam Joardar Dr. Niladri Roy

Dr Rajib Bhattacharya

Entertainment Sub-committee

Chairman Convener :

Dr. Swapan Sikdar Dr. Debabrata Mitra

Members

Dr. Ranen Kanti Aich Dr.Suparna Ghosh Roy

Dr. Pabitra Kumar Das Dr. Chandrima Banerjee

Dr. Rituparna Biswas Dr. Sushmita Sadhukhan

Dr. Saptarshi Banerjee

Transport Sub-committee

Chairman Convener

Dr Tapas Majhi Dr. Koushik Chatterjee

Members

Dr. Partha Dasgupta Dr. Amitava Chakorborty

Dr Tapan Saha Poddar Dr.Angsuman Ghosh

Dr. Avash Shankar Dr. Aruj Dhyani

AROI, West Bengal Annual Conference

Dated: 11th and 12th January, 2014

Venue : Hotel Hindusthan International, Kolkata

PROGRAM

(Subject to last minute change)

DAY 1 : 11TH JANUARY 2014, SATURDAY.

11a.m.: INAUGURATION PROGRAM.

12:00 to 1:45 p.m. : PAEDIATRIC ONCOLOGY

Chairperson: Prof. Subir Gangopadhyay

Speakers:

* Dr. Siddharth Laskar- Radiotherapy for paediatric cancers.

* Dr. Rimpa Achari 'Do not suffer little children…'

Panel discussion : RADIOTHERAPY FOR MEDULLOBLASTOMA.

Moderator : Dr. Suman Mallik

Panelists: Prof. P K Maiti, Dr. Tanveer Sahid, Dr. Partha Das Gupta, Dr.Anindya

Chakraborty, Dr. Suparna Ghosh Roy.

1:45 p.m. to 2:30 p.m. - LUNCH.

2:30 p.m. to 3:15 p.m.: G. I. ONCOLOGY

Chairperson: Prof. Abhijit Basu.

Speakers:

* Dr. Sarbani Laskar: Palliative Radiotherapy for esophageal cancer.

* Dr. Moujhuri Nandy: Do's and don't s of contouring for gastric cancer.

3:15 TO 4:30 P.M.: GYNAECOLOGICAL CANCERS

Chairpersons : Prof. Asit Ranjan Deb and Dr. Sanmoy Ganguly.

Speaker: Dr. Umesh Mahansetty - Endometrial cancers: current radiotherapy

standards.

Panel Discussion : MANAGEMENT DILEMMAS OF CERVIX CANCER

Moderator: Dr. Shila Mitra

Panelists : Dr. Chandan DasGupta, Dr. Jyotirup Goswami, Dr. Swapnendu Basu, Dr.

Shaikat Gupta (Surgeon).

(Contd.)

4:30 p.m.- 5: 15 p.m. : PANEL DISCUSSION ON HEAD AND NECK CANCERS.

Moderator : Prof. L N Biswas.

Panelists:

1. Dr. Suchanda Goswami

2. Dr. Subrata Chatterjee

3. Dr. Sanjoy Chatterjee

4. Dr. Tanmoy Mukhopadhyay.

5. Dr. Goutam Mukhopadhyay (Surgeon)

6. Dr Rajib Sharon (Surgeon)

5:15 to 5:45 p.m.: TEA

5:45 6:15 p.m.: BREAST CANCER

Chairpersons: Prof. Anjali Majumdar and Dr. Goutam Bhattacharya

Speaker: Dr. Rajiv Sarin- APBI: Techniques and Long Term results in Indian Women.

* Short paper on breast cancer. Dr. Prabir Bijoy Kar.

6:15 PM to 7:00 p.m.: PROSTATE CANCER.

Chairperson : Prof. Sajal Kumar Ghosh and Dr. Santanu Pal

Speakers:

* Dr. Anish Bandopadhyay (Do's and don'ts of prostate contouring).

* Dr. Vievek Anand: Dose escalation in prostate cancer what is the best way?

7:15 to 8:00 p.m.: DEBATE

“THE HOUSE BELIEVES IT IS NOW TIME TO WRITE OBITUARY

FOR TELECOBALT IN INDIA”.

Moderator : Dr. Prasenjit Chattopadhyay.

Participants:

1. Dr. Indranil Mallik (For) 2. Dr. Abhisek Basu (Against)

3. Dr. Koushik Chatterjee (For) 4. Dr. Amitava Roy (Against)

8:00 p.m.: DINNER.

(Contd.)

DAY 2 : 12TH JANUARY 2014, SUNDAY.

9 a.m. 11:00 a.m. : BEST PAPER SESSION. (TOTAL 11 ABSTRACTS

SELECTED).

Chairpersons: Dr. Debabrata Mitra and Dr. Ranen Aich.

Speakers: Dr. Kazi S Manir, Dr Animesh Saha, Dr.Saheli Bandhopadhyay, Dr.

Somnath Roy, Dr Susmita Sadhukhan, Dr. Sumit Panditia, Dr. Santu Mondal, Dr.

Arundhati De, Dr. Devleena, Dr. Vikram Bansal, Dr. Mukti Mukherjee.

11:00 a.m. to 11:45 a.m.: CLINICAL AND TRANSLATIONAL RESEARCH

Chairperson : Prof. Sekhar Nath Mallik & Dr. Tapas Maji

Speakers:

* Dr. Tanmoy Mahapatra (UCLA, USA): “How will we know what isn't so” -

presentation on research methodology.

* Dr. Saikat Das (CMC, Vellore) : Recent advances in translational research in

radiation biology.

12: 00 noon to 1: 00 p.m. : LUNG CANCER

Chairpersons: Prof. Syamal Sarkar and. Dr. Chhaya Roy

Speakers:

* Dr. J P Agarwal :SBRT for lung cancers

* Dr. D N Sharma:Role of brachytherapy in lung cancer

* Dr. Chanchal Goswami: Controversial areas in biological therapy for lung cancers.

1:00 to 1:30 p.m. : Young Oncologists Forum.

Representation: Dr. Krishnangsu Bhanja Chowdhury, Dr. Jibak Bhattacharya.

Moderator : Dr. Arunangsu Kar and Dr. Dipak Shankar Roy

1:45 p.m. to 2:30 p.m. : LUNCH.

2:30 p.m.: BEST PAPER AWARD DISTRIBUTION.

2: 45 p.m.: VOTE OF THANKS AND MEETING ADJOURNS.

*****

OPTIMUM UTILIZATION OF MEGAVOLTAGE TELETHERAPY MACHINE IN

DEVELOPING COUNTRIES: AN EXPERIENCE AT N. R. S MEDICAL COLLEGE,

KOLKATA

Prof. Asit Ranjan Dev, Department of Radiotherapy, Medical College and

Dr. Ranen Kanti Aich, Dr. Phalguni Gupta

Department of Radiotherapy, NRS Medical College, Kolkata

Proper utilization of mega voltage Teletherapy machine is a matter of fierce debate over

the last three decades. On one hand there are developed countries like United States of

America where mega voltage machine means “Linear Accelerator” and their radiation

oncologists often face a decision as to when to buy a new LinAc or when to replace the

existing one. At what point do the demands of the equipment become so high that it justifies a

second machine? Every institution has to take the permission from the “State Health Care

Commission” before purchasing a new machine. In a competitive medical marketplace, such

as the United States a tremendous amount is at stake in the manipulation of methodology to

justify new equipment procurement. The type of methodology used to determine the need for

LinAc are manipulated on a machiavellian manner to advantage some hospitals in obtaining a

LinAc and prevent others from obtaining them. This methodology is often used to financially

advantage some hospitals and drive competitors from the market 1.

On the other hand in developing countries like India the picture is just the reverse. Here

though LinAc is making its' progress, mega voltage machine mostly means Telecobalt units

and the number is far from adequate to meet the demand of the newly diagnosed cancer

patients. World Health Organization has recommended one teletherapy machine for every 2-3

million populations in developing countries2. Let us consider a relatively advanced state like

West-Bengal. By last census it has a population of about 85 millions and considering one

teletherapy machine for 2 million population it must have at least 43 teletherapy machines.

But as of 2012, it has only seven LinAc and 12 telecobalt machines (including both public and

private facilities). Installation of a new machine does not depend upon the problem of

obtaining a “certificate of need” but on the financial constrains. Another question is how long a

machine should be used per day? Eight hours a working day,five days per week is a

universally accepted policy but as the radioactive Cobalt decays 24 hours a day, seven days

per week, why should a telecobalt machine not be used round the clock to accommodate a

larger number of patients per day.

Radiotherapy department of N R S Medical College had one Telecaesium unit since

1975, and in 2001 a latest model Telecobalt unit (Theratron 780E) was installed replacing the

obsolete Telecaesium machine. Certain qualitative changes also accompanied the new

machine, e.g 3D TPS, wall mounted laser alignment system, Head & neck fixation devices,

half beam blocker etc. With these qualitative changes, quantitative changes cannot be far

behind. Number of new patients registered increased from 870 in 2000 to 1433 in 2002.

Naturally the delay in initiation of radiotherapy (from the date of advice) increased to about 50

days despite increase in number of exposures from 6890 to 16843 in the same period. In

December 2002, certain decisions were taken in the departmental committee meeting to

decrease the delay, which were later ratified by the college authorityand Government of West

Bengal.

The decisions were: -

(1) To increase the machine running period from the usual 9am 4pm to 7.30am - 9.30pm.

i.e. 14 hours a day instead of 8 hours.

(2) All Radiotherapists were allotted shifting duty to cover up the machine running period.

(3) Overlapping duty of the Radiotherapy technicians to cover up the lunch hour break.

(4) Treatments needing single exposure (e.g. for bone metastases from unresectable

primaries) or weekly one exposure (e.g. for inoperable non-small cell lung cancer as per

MRC schedule3) or treatments like hemi body irradiation etc. to be done only on Saturdays.

(5) Quality assurance to be done by the Physicist- cum- RSO everyday.

(6) All complicated radiotherapy planning to be done on Saturdays and to be executed

from Mondays.

(7) Close liaison to be maintained with the local representative of the vendor, so that the

machine can be thoroughly checked once in a month to prevent / minimize the machine down

time.

(8) Patients receiving similar treatments (e.g. parallel opposing antero posterior or

lateralbeams) should be grouped together to minimize the machine setting time.

The proposals were enforced from 1st April 2003 and the results themselves justified our

attempt.

The total number of cancer patients registered in

the department of Radiotherapy of N R S Medical

College. Kolkata was 1433 in 2002.The number

gradually increased to 2329 in 2004, a 63 % increase

over a period of 2 years.

Number of new patients per year (Figure I)

In the same period the number of radiotherapy exposures increased from 16843 to

32247, a 91 % increase (Figure II).Total number of

exposures per year.

During the same period we have not lost a

single working day due to machine failure. Physical

quality assurance and dosimetry were done on first

Saturday of every month. The authorized engineer

on behalf of the vendor under annual maintenance

contract did preventive maintenance and repair,

once in every month.With the installation of the new Total number of exposures per year (Figure II).

Cobalt machine and associated qualitative changes, both the number of new cancer patients

registered as well as number of exposures per day increased considerably; the former by

65% and the latter 144% over a period of three years (January 2000 to December 2002). But

with the changes of daily working period as well as the working pattern the same two further

increased by 63% and 91% respectively over a period of about two years( April '03 to Dec

'04).This brought down the waiting period of Radiotherapy from a mean of 50 days in 2001 to

18 days in 2004. This trend is continuing till the time of reporting.

The month wise exposure distribution from April 2004 to March 2005 is shown in Figure

III. Similarly,the day wise exposure distribution for the month of December 2004 is shown in

Figure IV

Monthly distribution of exposures 2004-05

(Figure III)

Figure IV

Radiation oncology, together with surgical oncology and medical oncology, is one of the

three primary disciplines involved in cancer treatment. 60% of the cancer patients will need

radiotherapy, with either curative or palliative intent, in the course of their disease3. But

Dr.Vikram on behalf on International Atomic Energy Agency4 opined that it is required for the

treatment of as many as 80% of the cancer patients in the developing countries, due to the

locations and the advanced stages of the disease. IAEA also estimated that between 2005

and 2025, 260 million new cancer cases will be diagnosed of which approximately 150 million

will be in developing countries4. It is implied that patients should receive definitive treatment

as soon as the diagnosis to treat this huge cancer load at present and in coming days, we will

have to consider the optimum utilization of the mega voltage teletherapy machine. At the

same time like other developing countries we are facing severe financial constraints to

purchase and maintain sufficient number of machines and lack of adequate number of trained

radiotherapy technicians to run them. Part of it may be overcome by optimum use of the

machine. Due to lack of equipment and staff, patients have to wait for a period of about 6

weeks after recommendation of RT before initiation of radiation. This enforced delay of

Radiotherapy is psychologically damaging for patients, who are understandably anxious to

start and complete their treatment. At the same time some of the potentially curative patients

may progress to an advanced stage during this period, making palliation as the only treatment

option, left behind.

Over the last few years there has been an increased awareness of the importance of

fractionationand its relationship to the risk of producing side effects. There is, therefore a

steady increase in the number of fractions per treatment course, to make the treatment as

safe as possible. Between 1992 and 1997 the average number of fractions per course of RT

rose from 24 to 27 5. This has also reduced the throughput of patients. All these factors have

put considerable pressure on Radiotherapy services5.

Optimum utilization of the mega voltage teletherapy machines is a much-discussed

matter and the discussion is still going on. In USA and Canada, it is generally accepted that

28 patients can be treated per day in a LinAc 2. In their opinion treatment of a single patient

needs 15 minutes and therefore 4 patients can be treated per hour. Considering a 8-hours

working day with one hour lunch break,a total of 28 patients can be treated. Here again some

argued that treatment of a Mantle field or treatment of a child under anesthesia cannot take

same time as a direct field treatment. Therefore the figure 28 is quite high. In UK, the total

number of exposures is considered as the most sensitive indicator of LinAc workload as each

fraction of Radiotherapy may require one to seven exposures, depending on the complexity of

the treatment. They consider 20,000 exposures per year as a reasonable workload for a

modern LinAc machine5. Consideration of 5 working days per week and 50 weeks per year (2

weeks public holiday) and on an average 3 exposures per patients, that comes to about 28

patients to be treated per day.

In 1993, the report of an independent review of specialist services in London 6 stated

that between 4.3 and 4.8 LinAc are required per million head of population. This pointed out

the serious under provision of mega voltage teletherapy machines in developing countries as

well as rules out LinAc as a solution.

With our miserable number of mega voltage machines, we will have to consider

someinnovative measures to treat more patients per day per machine. IAEA has pointed out

that the number of deaths world wide from cancers due to non availability of or inadequate RT

is almost 50,000 per week 4 and RT is one of the most effective as well as the cheapest form

of cancer management. In our country one Telecobalt unit costs about 20 million rupees and

its usual life span is 20-30 years. A cobalt source costs about 3 million rupees and can be

changed over a period of 5-6 years (just one half life). If a Telecobalt machine is used for 25

years and the source is changedfor four times (after just one half life), then the cost of the

therapy will be around 32 million rupees. Establishment cost and salaries of the various

categories of staff have not been taken into account. If we can deliver 120 exposures per day,

then cost of single exposure will be about 43 rupees, less than the cost of a single week of

analgesic tablet. Though a single exposure may render a patient suffering from painful bone

metastasis, pain free for about 100 days. As the cobalt source emits radiation round the

clock, the more hours it can be used per day, the more cost effectiveit will be. We have

proved beyond doubt that simple measures may change the number of patientstreated per

day enormously. However there is no flexible rules or guidelines for optimum use of mega

voltage teletherapy machines and each institute should formulate its' own policy depending

upon the demand and resources it can provide.

References:

1. Halperin Edward C, Schmidt-Ullrich Rupert K, Perez Carlos A, Brady Luther W. The

Disciplineof Radiation oncology Pgs 74-77; in Halperin Edward C, Schmidt-Ullrich Rupert K,

Perez Carlos A, Brady Luther W. Editors. The Principles and Practice of Radiation oncology:

4th Edition

2. Optimization of Radiotherapy: World Health Organization technical report series 644;

Pg 3.6.5

3. Bleehem NM, Girling DJ, Fayers PM, Aber VR, Stephens RJ. Inoperable non-small cell

lung cancer (NSCLC): A Medical Research Council randomized trial of palliative radiotherapy

with two fractions or ten fractions. Report to the Medical Research Council by its lung cancer

working party. Br J. Cancer 1991; 63: 265-270.

4. Vikram B. The cancer burden in developing countries: The role of International

Atomic Energy Agency. B. Vikram@iaea.org

5. Board of the Faculty of Clinical Oncology.The Royal College of Radiologists (1998).

Equipment, Workload and Staffing for radiotherapy in the UK 1992-1997. Royal Collegeof

Radiologists, London.

6. Department of Health (1993) Independent Review of Specialist Services in London.

London: HMSO

. *****

ARTICLE

PROBLEMS OF CANCER PATIENT AND ITS MANAGEMENT

DR. BASAB RAJ GHOSH

What we learn from texts is treatment and what we do is management. How it

defers?

For example we have prescribed an evidence based medicine but the patient is

economically poor.We have prescribed a medicine but patient is not willing to take

because he wants to fast on religious ground.Many patient cannot take radiation

because they cannot stay near machine.Many of them do not want surgery even after

counseling when it is indicated because of myth that biopsy or surgery spreads

cancer or they are afraid of surgery.

Expectation and realities

Expectation and realities are quite different in cancer services to cancer patients.

They expect that they will be cured; they will have disease free life and will have

excellent quality of life. They think that all these will be achieved at zero cost or

minimum cost. They want the full benefit of surgery of best hand, but they do not want

to pay best. They want to get treated in best institute with lowest cost. They want

cutting age technology and state of art medicine at no down payment when they think

about radiation therapy and PET (positron emission tomography) scans. Cancer

patients want predictive oncology and a basket of marker study to pin down their

diagnosis, treatment outcomes and to know their future without spending a penny.

They navigate internet and read a lot. Some are evidence based while others are

misleading blogs which confuses them as well as their physicians.

They want to get the benefit of target therapy which only kills cancer, sparing

normal tissue as they think that chemotherapy is old fashioned medicine. But target

therapy is expensive.

Science is progressing and new anti-cancer arms are added into the basket but

they are costly and beyond the reach of poor patients. People are not agreed to

participate in experiments but they want to enjoy the benefit of experiments. When

multinational companies invest on research and development of new dimensions in

science they want to enjoy the full return once the results come. Thus they make

process and product patency and the cost of medicine is high. Competitor brands try

to decode and crack the patency and bring the similar molecule at lower cost.

Sometimes qualities are compromised in lower costs which patients do not want.Thus

there is great divide between expectations and realities.

Training of doctors

Today patient wants hospitality more than treatment which they understand very

little. Doctors, nurses and health care givers are not trained in hospitality. Moreover,

they learn patient treatment skills, but they are doing patient management. Such

management courses are not done in their curriculum. Nor they are trained to do so to

meet the expectation of people. Crisis management, time management,

communication skills, personality development are very important for health care

givers in which many of them are not trained.

Medical education system has to be refashioned and reframed to handle high

expectation of people in upcoming era.

Positive attitude

There are doubts in people's mind regarding cancer treatment outcomes, What is

the use of treatment? In cancer treatment, patient will bleed their time, energy and

money, but will they gain anything?.

Timely treatment really makes difference, as cancer patients get benefits in terms

of overall survival, disease free survival and quality of life with treatment. So, there is

considerable difference, between treatments, versus no treatment. Patient spends

money for above mentioned benefits.For example, a severe mitral stenosis with

cardiac failure has a life span of 8 months and a pancreatic head of cancer patient will

have the same life span. But the heart patient is not so afraid, and refuses treatment,

as cancer patient.

This attitude has to be changed. We need a positive attitude from negative attitude.

Cancer patients can enjoy normal life, in comparison to CVA patients who cannot

move or heart failure patients who are bed bound, or chair bound or respiratory

distress patients, who suffer from air hunger. The treatment of cancer patients is not

life-long, in most of the times, unlike diabetes and hypertension patients, who are

lifelong dependent on medicines. Most of the early stage cancer can be cured, and

late stages diseases are controlled. The medical expenses for kidney transplant or

cardiac transplant or heart bypass or pace maker are more than cancer treatment.

The research shows, those who can cope with cancer, and are psychologically fit

and, enjoy life, live more, both in terms of life span and quality of life than those who

cannot.

Biggest question that the patients ask to physicians is the question of survival.

How long am I going to survive? In fact survival is the primary end point of many

research studies .Sometimes we say 5years survival, ie, percentage of patients

surviving after 5 years or median survival.

Today many patients do not know that majority of cancer patients do not die from

cancer and cancer is curable like Yuboraj sing's seminoma. But all patients are afraid

that they will dieof cancer. Percentage of survival is increasing over the years from

less than 40 percent in 1975 to more than 70 percent today considering all stages.

The next question is disease free survival that is living with or without disease. We

are treating with chemotherapy, radiotherapy, surgery, hormone therapy and more

importantly with target therapy to kill the tumor cells minimizing side effects. With the

increasing survival we are offering disease free survival to our patients.

How the patients will live rest of his life? Quality of life is the next entity that doctors

deal for cancer victims. Physical and mental sides are equally important. We offer a

life which is close to normal life. Treatments are given in phases. Usually patients do

not take lifelong treatment unlike hypertension or diabetes.

Training of care givers is very important. Motivating for positive thinking will cure

the disease. Doctors are God to patients and to patients' parties. However, simple

mistake in counseling can lead to suicide of patient.Patients expect good treatment,

quality care, evidence based medicine at affordable cost. At this point patients suffer

from lots of insecurities like financial, social, family etc. What will happen if I die?

What will happen to my children or my husband or wife or mother of father? Often

they ask about hereditary and genetic issues: prevention of cancer among kith and

kins.

Cancer is not only the problem to the patient, family, society, country, but also a

problem to family doctor. Patients have physical problems as we observe from signs

and symptoms .Such symptoms depends on primary organ of involvement to

metastasis and stage of disease.

But psychological issues are perhaps greatest problems to patients and family

members. Breaking the bad news seems to be the death certificate to patients. Every

biopsy report positive for malignancy is like a death certificate for patients and their

relatives. Emotional intelligence is near zero at this stage. Anger, depression, denial,

bargaining with god why I am, to acceptance is stages of psychological reactions.

While some reactions might be missing others may overlap with all permutations and

combinations. Any one may predominate. Collusion is hide and sick reaction to

relatives where relatives hide the diagnosis and prognosis to patients. Relative often

requests the doctors to do the same.” If you reveal the diagnosis to my father or

mother or my patient the patient will die"-now the doctors are in dilemma whether to

tell the truth or lie to patient. Definitely this is a problem to doctors. On one hand

according to western medicine every patient has right to know his diagnosis and

prognosis, on the other hand the relatives push the doctors to lie especially in our

country. Like psychiatric patients, every cancer patient is a stress to doctors.

Patients and their relatives are stressed and they transfer some part of it to doctors

who are their primary counselors. More we see patients more we are stressed.

Doctors need to distress themselves.

*****

ABSTRACT

KNOWLEDGE AND AWARENESS OF BREAST CANCER AMONG URBAN WOMEN:

AN INTERNET SURVEY - A PRELIMINARY REPORT.

Dr. Kazi S Manir M.D. Dept of Radiation Oncology,Medical College, Kolkata and Dr

Swapnendu Basu, M..D. Assistant Professor. Dept of Radiation Oncology, North Bengal

Medical College,Derjeeling.

Introduction: Breast cancer is the second most common malignancy among

women in India. The average incidence rate varies from 22-28 per 100,000 women

per year in urban settings to 6 per 100,000 women per year in rural areas. Aim of our

study was to find out level of knowledge, attitude and awareness among urban

women.

Materials and methods: we mailed questionnaire to urban Bengali women of 20-

40 years age group through social networking sites. Breast Cancer Awareness

Measures (Breast CAM) questionnaire was used focusing on 7 domains parameters :

a) knowledge of symptoms b)confidence skill and behavior in relation to breast

changes c)anticipating delay in contacting doctor d) barrier seeking medical help

e)knowledge relating to age related and lifetime risk f)knowledge regarding breast

screening g) knowledge regarding risk factors.

Results: Among 112 emails sent only 33 women responded (30.25%) till now.

Median age was 24.5years (range 21-40years).Only 25% (7) responded questions

regarding knowledge of symptoms, 21.2 %( 7) mentioned breast lump as a common

symptom. 42.4%(14) told that they rarely check their breasts for changes, though

33%(11) are confident to elicit breast changes.77%(26) women told they feel no

barrier /hesitation seeking help from doctor for breast changes.54.8%(18) women

told that breast cancer can occur any age.48.6%(16) women do not have idea on

lifetime risk.45.5%(15) heard about breast cancer screening. Majority women were

sure about family history (60.6%), BMI>25(60.2%) as risk factors, but not sure about

Hormone replacement therapy (60.2%), nuliparity (45.5%), late menopause (54.5%).

39.4% women thinks alcohol is not a risk factor.

Conclusion: In this small study we observed low level of knowledge and attitude

among urban women regarding risk factors and symptoms in breast cancer. These

issues are to be addressed awareness programs.

******

ABSTRACT

CAN WEIGHT LOSS AFFECT SETUP ACCURACY IN HEAD & NECK CANCERS

PATIENTS TREATED WITH HELICAL TOMOTHERAPY ?

Dr Animesh Saha ;Radiation oncology fellow, Pinaki Das,Dr Sanjoy Chatterjee, Dr

Rimpa Achari, Dr Indranil Mallick , Department of Radiation Oncology, TATA MEDICAL

CENTER, Kolkata.

Introduction: Weight loss during head & neck radiotherapy can cause Illness,

treatment interruption, can alter anatomical contours and dosimetry. This study aimed

to evaluate whether weight loss can affect setup accuracy in head & neck cancers

patients treated with helical tomotherapy

Material/Methods : We retrospectively analyzed the setup data of 2481 fractions

of 86 head & neck cancer patients who were treated with daily online image

guidance. Using summary data from all treatment fractions, we calculated the

systematic error (?) and random error (s) in each of the three axis i.e, lat(x),

long(y),vert(z).We have also calculated the translational vector of each fractions of

individual patients. We simulated 2 no-action-level (NAL) offline correction protocols

where setup errors of the first 3 (Protocol F3) or 5 fractions (protocol F5) were

averaged and implemented for the remaining fractions, and the residual errors in each

axis for these fractions were determined along with the residual ? and s. PTV margins

using the van Herk formula were generated for the F3 and F5 protocols. For each

scenario, we tabulated the number of fractions where the residual errors were more

than 5mm (our default PTV margin)or 3mm. By tabulating the preradiotherapy and

postradiotherapy weight loss, we have calculated weight loss percentages of all these

patients. We have tried to evaluate whether set up accuracy differs in patient who had

less than 5% weight loss ( group A) compared to those who had 5% or more weight

loss( group B).

Results: Average weight loss was 5.6%, median 5% and weight loss ranged from

0-16.2%. In group A f3 protocol resulted in systematic and random errors of ?x,y,zof

1.0, 0.9,1.1mm and s x,y,z of 1.8,1.4,2.0 mm with a required PTV margin in x,y,z axes

of 3.7, 3.3 and 4.1mm and in f5 protocol resulted in ?x,y,zof 0.7,0.8,1.3mm and s

remain constant with a required PTV margin in x,y,z axes of 3.0, 3.1 and 4.6mm. In

group B f3 protocol resulted in systematic and random errors of ?x,y,zof 1.8,

1.6.2.1mm and s x,y,z of 1.7,1.4,1.8mm with a required PTV margin in x,y,z axes of

4.0,3.4,5.8mm and f5 protocol resulted in ?x,y,zof 1.1,0.7,1.5mm and s remain

constant with a required PTV margin in x,y,z axes of 3.7,2.7,5.0mm. There was a

significantly higher chance of residual set up errors more than 3mm in x( p value-

0.040723) and z axis( p value- 0.001292) for f3 protocol. There was no statistically

significant difference of residual set up errors more than 3mm for f5 protocol.

Conclusions: In this retrospective study it is seen that more than 5% weight loss

during treatment can affect the set up accuracy in helical tomotherapy for head &

neck cancer patients, in f3 NAL offline correction protocol. So an offline protocol

implementing the average shifts of first few frations should be very cautiously

implemented in patients who have more than 5% weight loss during head & neck

radiotherapy.

Key-words: Helical tomotherapy, setup errors, weight loss.

*****

ABSTRACT

DOSIMETRIC EVALUATION OF TWO VS THREE CHANNEL APPLICATOR IN HDR BRACHYTHERAPY IN POST-OP CARCINOMA CERVIX.

Dr.Saheli Bandhopadhyay. MD PGT.R G Kar MCH.Kolkata

Background : Post-operative (P/O) Carcinoma Cervix (Ca Cx) with high risk features have higher rates of recurrence mainly in the vault & paracervical area. External beam radiotherapy (EBRT) either alone or with High Dose Rate Intracavitary Brachytherapy (HDR ICBT) reduces these recurrence rates. Traditionally ICBT in P/O cases were done with 2 ovoids but this had a chance of dip in the prescribed isodose cranially with underdosing of vault & more bowel toxicity. This study evaluated the dosimetry using 2 (only ovoids,2C) & 3 channel (tandem + ovoids, 3C) applicators in HDR ICBT of P/O Ca Cx.

Material and methods: From Sep 2011- Feb 2012, 32 patients of P/O Ca Cx between stage IA2 - IIB with high risk features were initially planned for EBRT (50 Gy/ 25fractions/ 5 wks) with or without chemotherapy followed by 3D image based HDR ICBT with 60Co with three channel Manchester applicator to a dose of 7 to 9 Gy/fraction X 2 such 1 week apart. Dosimetric evaluation with two channel for the same plans was also done. Dose calculations were done at 6 reference points- R1, R2 (central part of the vault), R3L, R3R (at paracervical tissue Left &Right), R4L, R4R (at parametrial tissue Left &Right). Dose prescription was to the vault & 2 cm of vaginal & paracervical tissue defined as IRCTV. Doses (EQD2 EBRT + ICBT) at 0.1cc, 1cc, 2cc of the Organs at Risk (OARs) - bladder, rectum, sigmoid colon, and D90,95,98,100 & V100,150,200 of IRCTV were recorded.

Results: 30 patients were eligible for final analysis. The doses at Ref points R1, R2, R3L & R3R had significantly higher value with 3C vs 2C applicators (p<0.01 for all). The dose to the D90 IRCTV was also significantly increased with 3C.The OAR doses were comparable in both the plans and were within the dose constraints as per GYN- GEC-ESTRO Guidelines.

Conclusion: This study demonstrates that in P/O CaCx with high risk features, HDR ICBT with 3C applicator is feasible & gives better dosimetric coverage than 2C applicator without increasing the OAR dose.

Key words: HDR Brachytherapy, Post-op Carcinoma Cervix,Three channel applicator

*****

ABSTRACT

CONVENTIONAL VERSUS HYPOFRACTIONATED RADIOTHERAPY WITH OR WITHOUT CHEMOTHERAPY IN HEAD AND NECK CANCER

Dr. Somnath Roy; MD PGT, Prof. Anup Majumdar, Dr. Suman Ghorai, Dr. Chandrani Mallik Department of Radiotherapy, Institute of Post Graduate Medical Education &Research,Kolkata

Background: To investigate tumor response in head andneck cancer using hypofractionated radiotherapy compared with conventional fractionation with or without chemotherapy.

Methods: The data from sixty (n=60) patients with squamous cell cancer of oral cavity, oropharynx, hypopharynxandlarynx (AJCC, 2010 Stage II to IVB); who received hypofractionated (n=30) and conventional fractionation(n=30) of radiotherapy with or without concurrent chemotherapy between January 2010 to June2011 were retrospectively analyzed.In hypofractionatedarm (ARM B)each patient received 55Gy at 2.75Gy per fraction over 4 weeks, along with concurrent cisplatin (100mg m-2) on days 1 and22 for stage III, IVA, IVB.In conventional arm (ARM A), each patient received 70Gy at 2 Gy per fraction over 7 weeks,along with concurrent cisplatin (100mg m-2) on days 1, 22 and43for stage III, IVA, IVB.The end points were analysis of tumor response; acute andlate toxicities; overall survival (OS)and diseases free survival (DFS) in each arm.

Results: 24(80%) patients in arm A and 23(76%) patients in arm B achieved complete response. Significant differences in frequencies of acute grade =2 skin toxicity (P 0.021)[77%Vs.36%]; mucositis (P 0.003) [80%Vs.33%];dysphagia(P 0.039)[20%Vs.6%] were found, with higher in arm B. Significant differences in frequencies of late grades =2dysphagia (P 0.016) [14%Vs.4%]; laryngeal edema (P 0.028) [25%Vs.15%]; xerostomia (P 0.005) [64%Vs.15%] andconfluent mucositis (P 0.001) [79%Vs.15%] were found, with higher in arm B at 6 months from start of chemoradiation. The2 year OS rate was 70% [95%CI, 86.4-53.6%] in arm A vs. 73.3% [95%CI, 89.1-57.47%] in arm B;(P 0.774) and median duration of DFS was 11months in arm A and 13.5 monthsin arm B.

Conclusions: Hypofractionated radiotherapy can achieve similar tumor response like conventional chemoradiation, avoid long waiting times to maximize service productivity and should be the subject of prospective evaluation.

Key words: Head Neck cancer, Hypofractionation, Chemoradiotherapy

*****

ABSTRACT

ASSESSMENT OF SEXUAL MORBIDITY AND QUALITY OF LIFE IN CARCINOMA CERVIX PATIENTS TREATED WITH RADICAL RADIOTHERAPY

Dr Susmita Sadhukhan, MD PGT; Dr Aloke Ghosh Dastidar, Dr Antara Mahato,Dr Anirban Halder Department of Radiotherapy, Institute of Post Graduate Medical Education &Research, Kolkata

Background: Majority of Ca cervix patients treated with radiotherapy have long been recognized to develop stenosis and agglutination involving upper third or more of vagina.Radiation exposure damages the rapidly dividing cells of vaginal epithelium and underlying tissue layers,causes mucosal shrinking, scarring, and vaginal fibrosis. Objectives were to assess the sexual functioning & QOL & to characterize the relationship between sexual dysfunction and overall QOL over time.

Materials and methods: Single arm, prospective observational study.N=40 Biopsy proven patients in Dept of Radiotherapy, IPGME&R,KOLKATA.Data were collected before starting treatment, after end of EBRT, after that at 3 , 6 months, and 1 year of completion of t/t. QOL and sexual activity was measured by EORTC QLQ C-30 (version 3) questionnaire & by Female Sexual Function Index (FSFI) respectively. The change in Quality of Life and Sexual morbidity were assessed by comparing before and after treatment. Data was analyzed using SPSS (V-17).Comparison was done using pared t test. Association between two variables was tested by one way ANOVA.

Results: Mean global health score before starting treatment was 63.22, which came down to 54.18 immediately after EBRT. All the functioning scale scores were decreased just after EBRT except emotional score which gradually increased over the time. At 1 year, all the functioning scale score reached base level except social functioning. all the symptoms increseded just after EBRT except constipation which decreased from pretreatment mean score 23.25 to 16.62 after radiotherapy. The mean full score of sexual function was 22.97 before starting treatment which decreased to 8.44 at 6 months and 8.88 at1 year.There was 50% reduction of total sexual function at 1 year. There was reduction of 25.4%,63.75%,72.95% & 55. 67%in desire, arousal, orgasm and satisfaction respectively and 65.84% increase of Sexual pain.

Conclusion: Radical radiotherapy has a negative effect on QOL & sexual function.

*****

ABSTRACT

PRIMARY PULMONARY SYNOVIAL SARCOMA: A CASE SERIES

Dr. Sumit Panditia; DNB PGT, Vikram Bansal,Dr Devleena, Dr G Bhattacharjee,Dr T Chaudhuri, Dr M Ariff,

Saroj Gupta Cancer Centre Welfare & Reseach Institute, Thakurpukur, Kolkata

Introduction: Most lung tumors are malignant in origin and carcinoma by nature. Primary lung sarcoma is an extremely rare tumor, accounting for less than 0.5%(1,2) of all lung tumors. The diagnosis is established only after sarcoma like primary lung malignancies and metastatic sarcoma have been excluded. Here we report four cases of pulmonary synovial sarcoma.

Case History: In our hospital during the last 18 months we found four cases of primary pulmonary synovial sarcoma of lung. CECT Thorax, CT guided tru-cut biopsy lung SOL, Immunohistochemistry and USG whole abdomen was done in all four cases to confirm the diagnosis. Out of four cases, one patient was found operable and underwent Right lower lobectomy. Tumor board of our hospital advised for adjuant chemotherapy followed by assessment for radiotherapy. The patient has received third cycle of chemotherapy with Inj Doxorubicin 37 mg\d(d1-d3) and Inj Ifosfamide 2g\d(d1-d3) and is doing well.The other three cases were inoperable and tumor board of our hospital advised for chemotherapy followed by radiotherapy. Out of these three cases, one patient has received six cycles of chemotherapy with Inj Doxorubicin 50 mg\d(d1-d3) and Inj Ifosfamide 3g\d(d1-d3). After the completion of chemotherapy of chemotherapy, the patient was assessed for radiotherapy and received 50 Gy/25# to right lung mass. The patient is doing well and PET-CT scan done on six monthly follow-up showed a non-FDG avid mass in right lung and patient is under close observation and follow-up. The other two cases in the inoperable group are undergoing chemotherapy at present and will be assessed for radiotherapy after completion of chemotherapy.

Conclusion: Pulmonary sarcomas overall are very uncommon and comprise only 0.5% of all primary lung malignancies(1,2). Malignant fibrous histiocytoma and synovial sarcoma are the most common variants of pulmonary sarcoma. Immunohistochemically, synovial sarcomas are nearly uniformally positive for cytokeratin, EMA, bcl-2 and vimentin, and negative for S-100, desmin, smooth muscle actin and vascular tumor markers(3). Histology and IHC have been supplemented recently by cytogenic analysis. The prognosis for patients with primary synovial sarcoma is poor, with an overall 5-year survival rate of 50%. Factors predicting a worse prognosis include tumor size(>5cm), male gender, older age(>20 years), extensive tumor necrosis, high grade, large number of mitotic figures(>10 per high powered fields), neurovascular invasion, and recently, the SYT-SSX1 variant(4). The main prognostic factor is ability to achieve a complete resection. There is no standard therapy; most patients are treated with surgery or with surgery and adjuant radiation therapy. The rarity of this tumor has not permitted controlled studies of adjuant chemotherapy. Synovial sarcomas are chemosensitive to ifosfamide and doxorubicin, with an overall response rate of approximately 24%(5). In a meta-analysis, adjuant chemotherapy for sarcomas improved the time to local recurrence and recurrence-free survival rate, with a trend towards a better overall survival rate.

*****

ABSTRACT

PROSPECTIVE ASSESSMENT OF QUALITY OF LIFE IN PATIENTS UNDERGOING CONFORMAL RADIOTHERAPY IN HEAD- NECK CARCINOMA

Dr. Santu Mondal MD, Registrar in the Department of Radiation Oncology, Dr. Suman Mallik; Dr. Jyotirup Goswami; Debojyoti Dhar DRT; Sharbari Mitra DRT; Tarak Roy DRT; Somnath Pal DRT,

West Bank Health and Wellness Institute, Howrah.

Introduction: Cancer and its subsequent treatment may cause physical, emotional and psychological

difficulties for individuals. Quality of life (QOL) indices are as important as the traditional end points of overall survival, disease-free survival and tumour response in cancer management. QOL is particularly relevant for patients with head & neck cancer, because social interaction & emotional expression depend on a great extent on the structural & functional integrity of head-neck region.

Materials & methods: From june,2012 to june,2013, 33 head-neck squamous cell carcinoma patients, who received radical chemoradiotherapy, were consented and prospectively assessed for quality of life score using Europian Organization for research and Treatment of Cancer (EORTC) core questionnaires version-3(QLQ-C30) and EORTC QLQ-H&N35, in any one of three languages (English, Hindi, Bengali). The score was assessed thrice for each patient; before start of radical treatment, just after completion of treatment and at the time of first follow-up.

Results: There were significant improvement in emotional function, social function at post-radiotherapy and deteriotion of insomnia, appetite and nausea/vomiting. Follow-up QOL suggestive of improvement of functional and symptom scale in various general scale and head-neck specific scale. There was subjective deteriotion of salivary function.

Conclusion: In accordance with our prospective study of quality of life of patients with head-neck cancer, there was improvement of various functional and symptom scale including global health. This suggests conformal radiotherapy in head-neck region not only cure and improve survival of patients, but also improves quality of life in various aspects.

*****

ABSTRACT

GEOGRAPHIC MISS & TOXICITIES IN X-RAY VERSUS CT SIMULATED EBRT FOR CA CERVIX: AN INTERIM ANALYSIS

Arundhati De, Abhishek Basu, Krishnangshu Bhanja Chowdhury, Kousik Ghosh, Swapan Kumar Sikdar, Subir Gangopadhyay

Department of Radiotherapy, R G Kar Medical College & Hospital,Kolkata

Background: Concomitant chemoradiation followed by High Dose Rate Intracavitary Brachytherapy (HDR ICBT) is the standard treatment for locally advanced Carcinoma Cervix (Ca Cx). Traditional bony landmarks based field definition may result in inadequate coverage of disease as defined by 3D imaging. This study compared the dosimetric coverage, response & toxicities between X-ray based (XRB) & CT based (CTB) simulation for EBRT of Ca Cx.

Materials & methods: Between Sept 2011 - Aug 2012, 60 patients of stage IB2-IIIB Ca Cx meeting pre-specified criteria were randomized into 2 groups for 4 field box EBRT using : Arm A (Control)- XRB with bony landmarks for field definition & Arm B (Study)- CTB with target contouring and 3D treatment planning. Both groups received 50.4 Gy/28 fractions/5.5 wks with wkly Inj. Cisplatin 40 mg/m2 followed by HDR ICBT 9 Gy X 2 such 1 week apart. Field dimensions, local control & toxicities were assessed.

Results: A total of 52 patients were recruited: 25 in Arm A & 27 in Arm B, of which 21 & 25 respectively were eligible for final analysis. The baseline parameters were comparable. The median follow up was 15.4 months for arm A & 15 months for arm B. The total treatment time & average gap were comparable in both arms, p =NS. Mean length of AP-PA & Lateral pelvic fields at isocentre were 19.21cm vs 20.76cm in arm A & arm B respectively (p=0.04), whereas mean width of AP-PA & Lateral fields were comparable (p=NS). Overall Response Rates at last follow up were comparable 95.2% Arm A (with 1 local failure) & 96% Arm B, (p = NS). Acute toxicities (Total & Grade 3) Gastrointestinal, Dermatological, Haematological & Genitourinary were comparable in both arms (p=NS).

Conclusion: CTB EBRT for Ca Cx gives larger target volume coverage potentially minimizing geographic miss than XRB EBRT with comparable dermatological, gastrointestinal & haematological toxicities. Whether the lesser dimension of the XRB fields affects local control will be known from a larger sample size with longer follow up.

Key words: Carcinoma Cervix, EBRT, Geographic miss.

*****

ABSTRACT

EPIDEMIOLOGICAL PROFILE OF LUNG CANCER

Dr. Devleena; Consultant Radiotherapist, Sumit Pandita, Vikram Bansal,Dr Gautum Bhattacharjee,Dr T Chaudhuri

Saroj Gupta Cancer Centre Welfare & Reseach Institute, Thakurpukur, Kolkata

Introduction: Lung cancer is one of the most common causes of cancer related death in India.

Geographically, epidemiological pattern of lung cancer is different. In all registries, cumulative lung cancer risks were higher in males than females. In general, incidence of lung cancer throughout the world reflects the prevalence of smoking. Aim of this study is to analyze the epidemiological aspect of lung cancer in Eastern India.

Material and methods: 324 patients with histology/cytology proven carcinoma of lung were assessed, who presented to radiotherapy OPD for investigations and treatment at Saroj Gupta Cancer Centre and Research institute from January 2012 to December 2012. All patients were interviewed with properly designed questionnaire with an attempt to understand the epidemiological profile of the disease.

Results: Out of 324 patients of lung cancer, majority were in 5th -7th decade, constituted by 62% of patients. 83.6% of patients were male and 16.3% were female. Majority of patients belong to low socioeconomic status with labor class constituting 27.5% followed by farmers comprising 19.7%. 68.5% patients were from west Bengal while rest of the patients came from neighboring states and countries. History of smoking was present in 68% patients. Of these 42.6% patients were bidi smokers while the rest were smoking cigarettes. Both adenocarcinoma and squamous cell carcinoma equally makes the majority of histological presentation (36.1% and 35.8% respectively). Other histologies were PDNSCLC, small cell, mesothelioma and synovial sarcoma. Almost all the patient presented with advanced disease with 50.1% patients having stage 4 diseases and 40.7% with stage 3 disease.

Conclusion: On analysis it can be said that lung cancer in eastern India is mostly male dominant in lower socioeconomic class with median age of presentation of 60 yrs. Most of them are smokers and present with advanced disease.

Key words: Lung Cancer, Epidemiology, Eastern India

*****

ABSTRACT

CLINICAL EFFICACY OF EXTERNAL BEAM (WHOLE BRAIN) TEMOZOLAMIDE IN THE TREATMENT OF BRAIN METASTASES

Vikram Bansal ;DNB PGT, Dr Gautum Bhattacharjee,Dr T Chaudhuri Saroj Gupta Cancer Centre Welfare & Reseach Institute, Thakurpukur, Kolkata

Methods: 50 patients (32 males and 18 females) with brain metastases from solid tumors between the age group of 43-79 years and RPA class I and II, were treated as per hospital tumor board decision in a prospective non-randomized observational study with one group receiving oral temozolamide (75 mg/m2/day) concurrent with 30 Gy fractionated conventional external beam radiotherapy to whole brain while the other group received 30 Gy fractionated radiotherapy alone. The primary end point was neurological symptom evaluation (assessed using ECOG score) and radiological response (RECIST criteria).

Results: At the end of the treatment it was seen that the patients belonging to chemoradiotherapy group had shown better but statistically non significant neurological improvement in terms of passage to better class of neurological functional level compared to only radiotherapy group. In group A total 16 patients (64%) has improved compared to only 11 patients (44%) in group B (p=0.1). A 6 weekly follow showed that although not statistically significant but more number of patients who received concurrent chemoradiotherapy had either improved neurological functional status or stable disease till the end of 36 weeks follow up. At the end of 12 weeks the radiological response was assessed. 19 patients (76%) of group A as compare to 16 patients (64%) had objective response (Complete or partial response) (p=0.15). Temozolamide concurrent with radiotherapy was generally well tolerated: however, grade I and II nausea (16% v 8% and 8% v/s 4%) and vomiting (8% v/s 0%) was higher in temozolamide group. Hematological and non-hematological toxicities were non-significant.

The mean brain metastases related progression free survival for group A was 28 weeks (6.4 months) where as for group B it was 25.6 weeks (5.9 months) which was statistically not significant.

Conclusions: In this study concomitant chemo-radiation was compared to only radiation in treatment of brain metastases from solid tumors. The radiation plus Temozolomide arm was found to be superior in terms of improvement in neurological status and radiological response but it was not statistically significant. The toxicities were slightly higher in radiation plus Temozolomide arm in comparison to only radiotherapy but well tolerated by both the groups.

*****

ABSTRACT

A CASE REPORT OF EARLY STAGE SQUAMOUS CELL CARCINOMA OF TONSIL WITH DISSEMINATED DISTANT METASTASIS

Dr. Mukti Mukherjee ;MD PGT, Dr. Susovan Banerjee, Prof. (Dr). Pradip K. Maiti, Prof. (Dr.) Amitava Roy.

Department of Radiotherapy, N R S Medical College, Kolkata

Purpose: Chances of distant metastasis in Head and Neck cancer patient is considered low. The incidence of distant metastases in different sites of Head And Neck Squamous Cell Carcinoma is about 10 - 20%. The factors influencing the incidence of distant metastases are specific site of the primary tumor (most common being hypopharynx followed by nasopharynx), initial Tumor and Nodal stage of the disease, histopathological grade, control of primary site. With the exception of nasopharyngeal carcinoma most head and neck cancer with distant metastasis affect only one organ, most commonly the lungs followed by bone and liver.Here we are reporting a case of early stage carcinoma of tonsil with metastasis to the lung, liver, bone, CNS, skin and scalp within a short period of treatment completion.

Case history: 34 year old male, chronic smoker and alcoholic presented with history of dysphagia for 3 months. Clinical examination, biopsy and all other relevant investigations were done. He was diagnosed as a case of early stage squamous cell carcinoma of left tonsil (TNM staging: cT2N0M0).The patient was treated by external radiotherapy with concurrent chemotherapy followed by interstitial brachytherapy as boost to the local diseased site.Within 2 years after completion of his treatment he presented with severe low back pain and diagnosed to have metastasis at lumbar vertebrae. The primary site was disease free.Further examination and investigations revealed multiple metastatic deposits in skin and scalp, brain, liver and lungs.He received palliative radiotherapy to the lumbar spine and whole brain along with symptomatic and supportive care.

Discussion: There is no previously reported case of early stage Head and Neck Cancer with evidence of such widespread systemic metastasis as in this reported case. Even advanced stage Head and Neck Cancer patients have only one or two distant metastatic sites.Review of literature suggests distant metastasis in head and neck cancer is more common than it was previously thought. So it is important to report all the cases of Head and Neck cancer with distant metastasis properly. A retrospective analysis of different series of this group of patient may be undertaken and the actual scenario of incidence of distant metastasis according to site and stage of disease may be re-evaluated.

*****