In many cases scalp tenderness go away on their own. But sometimes it also require basic cleaning and care to ensure that the area heals successfully.

Get some good reading on the scalp tenderness and also on scalp you will be able to judge the real cause and come up with a good solution without even going to a doc.

I would just suggest you to keep the scalp clean and stop worrying about the issue for 3-4 days more. The issue will be solved ;)

Several days later, he called me in to the office, asked me to be seated and presented me with something I just did not want to hear. “Peter” he said, “I’m afraid I have some rather bad news for you, you have a 3 inch malignant tumor in the bowel”.
He went on to say that the growth was large and aggressive. It began to pierce through the bowel wall and was taken up by the lymph glands.

The Doctor Gave me 18 Months to Live!

When I asked, what could be done? He said there was a lot that medical science today could do. The first thing to do was to book me in for surgery as soon as possible to remove the initial growth. This would be followed by chemotherapy, and radiotherapy to “mop up the possible spread of the cancer”.

As the conversation continued, I asked him how successful this was all going to be, and if that would actually fix the problem? With rather a blank face, he went on to say that he was afraid the cancer was too advanced and although medicine could give me some time, it could not save my life.

I asked “Well, how long do you think I may have before the cancer overtakes me?” He said that he really wouldn’t like to say, but he believed approximately 18 months, maybe 2 years was possible.
My Feelings at this point in time were in describable.

I was enjoying my life and all of a sudden it comes to a final stop. How could this possibly happen? What had I done? Was there an answer? There was a deep, deep sensation of finality. Everything I was familiar with and cherished had come to an end.So the options were to accept my doctor’s prognosis, go ahead with the procedures and claw out some months, or to do nothing, enjoy myself and to pass on. Not much of a choice at all. Of course my first preference was to go along with the medical side and hope that something would turn around and save my life. I might be one of the lucky ones.

I was booked for surgery in the next few weeks…but a friend of mine told me that they might be another option. By this time, so many sympathetic friends had told me of supplements, herbs, foods and the like. But this all seems so experimental, and although I was nice about it, none of them seemed to understand that I was dying. Perhaps it was out of desperation that I listened to this particular friend, who seemed so sure.

With assurance, told me that bowel cancer is completely reversible. How convinced was I? Perhaps about 20%, but that was better than nothing!

It was explained that although a reversal was not instant. It was achievable. I had nothing to lose. So I began the program and after a few adjustments and getting used to things, everything seemed to work.
It was apparent that in order to beat this cancer, I had to be consistent. Every day had to be a new day and the program was to remain strict. It was explained that the cancer was expected to gradually shrink and that this was a process that had to be taken steadily. If the process happens immediately, the cancer would die far too quickly, and that would be highly detrimental to me.

Approximately 10 months later…

After many abdominal sensations, and a few trials, that is exactly what happened. The cancer came through as a scab like growth, and finally I knew I was free of it. That was many years ago now. I have shared my experience with many others, and referred them back to those that helped me. I have also become very curious about their methods and this book is a direct report on the philosophy, strategies, methods and outcomes of what I have personally witnessed and am a direct benefactor.

Plan: Radiotherapy (dose 55- 63 Gy) Thats maximum I think we can deliver in this location with photons.

Is there any role for hyperfractionated RT.

What should be the CTV margin/ volume from residual GTV?

With the migration to the wikidot website we got a great discussion platform but somehow the social aspects got de-emphasized. Thats an issue which some members felt was important but overall we could not implement it as a website is not a closed ecosystem like a mailing list. In addition with the widespread popularity of Isocentre we now have people coming in from all over the world joining us. While our community has grown it has also made it difficult to conduct "personal" discussions…., read more at http://isocenter.org/content/why-our-emphasis-social-aspects-isocentre

now the issue which may remain is EBRT to Brachy ratio in the scenerio of EBRT doses ranging from 40-50Gy. the difference of 10 Gy delivered by brachytherapy can make lot of difference in local cervical growth control and also treatment time (5 days to none). this becomes especially important if you have pelvic LN >/=3cm and if you are not using SIB IMRT for addressing the nodes.

To keep the long story short we had a good time at Isocenter. Our website was being hosted by wikidot a famous provider of wiki sites. The wiki based structure ment that people could come in and edit the content on a page in the same way as wikipedia works. The tools provided were great and the permission system was important in maintaining a semblance of control over the website. Earlier this year there was a design overhaul along with efforts to streamline the membership process in an effort to maintain the site. The efforts have been a success in that we have maintained a steady influx of visitors over the last 4 - 5 months and a steady growth in our subscriber base. Our discussion forums are lively with lots of discussions on pressing issues. But with the popularity of the site several limitations became known….. Read more at http://www.isocenter.org/node/10287

62/M
5*4 cm Rt BM lesion involving lower alveolar mucosa. No palpacble LN
Biopsy: Verrucous Ca
CT not done yet
Unfit for surgery due to cardiac morbidity.
What are the treament options?
Should we offer him radical RT as there is no other treatment option?

EDITORIAL
Induction Redux: Once More With Taxanes
David J. Adelstein
Journal of Clinical Oncology, Vol 23, No 34 (December 1), 2005: pp. 8556-8558.

EDITORIAL
Redefining the Role of Induction Chemotherapy in Head and Neck Cancer
David J. Adelstein
Journal of Clinical Oncology, Vol 26, No 19 (July 1), 2008: pp. 3117-3119

Review Article
Induction Chemotherapy: To Use or Not to Use? That Is the Question
David M. Brizel, Everett E. Vokes
Seminars in Radiation Oncology
Volume 19, Issue 1, Pages 1-68 (January 2009) ,Pages 11-16

Hope atleast after reading this article , our fellow colleagues will deter in following the said policy.

But the treating team sent him for Chemotherapy again and now he has lung mets.

I brought this case for discussion as this type of cases are so very common, being sent after 4, 5 and even 6 NACTS.
Patients coming with large T4a or b tumours and not getting a chance for a radical intent treatment.

NACT is STILL NOT INDICATED in ORAL CANCERS. The only proof of NACT in Head and Neck having worked was in antiquated Veteran's Laryngeal Trial which "prevented" surgery (or delayed the salvage) conducted well over 20 years ago. I wonder how has this been extrapolated to other subsites (my imagination refuses to wander there).

For the sake of argument, Cetuximab IS NOT MAGICAL drug. Molecular pathways (it has been mentioned in the previous forum posts many times) is very deceptive. EGFR Blockade is NOT the solution in face of resistant clones which would have MANY alternative pathways to resist apoptosis.

These resistant clones HAVE ALREADY been PRE-SELECTED by NACT.

TAX 324 trial (and others exploring the use of NACT/Taxanes) have been HEAVILY criticized in various forums earlier for the lack of standardized definition of "cure rates".

In my opinion, it is justifiable to base treatment decisions on high quality evidence accrued from properly conducted phase III trials or pooled analysis. Justifying a neo-adjuvant approach on basis of poorly conducted phase II (or stunted statistical evaluated) trials is NOT justified in the best interests of the patient. Most of the patients are unlikely to complete their radical chemoradiation, or radiation without chemotherapy and the treatment is likely to involve many breaks. Which again would prolong treatment time worsening the outcome further.

The point here, again, is what's best for the patient in terms of salvage. That issue has already been addressed.

I would recommend strongly going through the chocrane review which clearly shows that NACT doesnot give better results over LRT alone. In particular there is no convincing evidence that it increases the operability (which i presume was the premise behind the use of this regimen).

Another interesting read for ROs who are apologetic for NACT is this very very well written editorial by Jeremic et al (http://jco.ascopubs.org/content/26/10/e1.full) for NSCLC. The phenomenon of accelerated repopulation after NACT is known for a long time.. its a different matter that sanofi aventis is "helping" the oncologists to reinvent the wheel over again!!

The real reason that this patient is now not going to have any response after RT is the accelerated repopulation thanks to the NACT. If there is any way of making the RT better it is by altered fractionation .. please do consider hyperfractionation for her..

1. Why was this patient offered NACT with Cisplatin + Taxane ?

The std international regime has been Cis + 5FU, and over the last 4-5 years, based on TAX 324 study, there is a survival benefit of TPF (Docetaxel + Cisplat + 5 FU) Vs PF (Cispl + 5FU).
The response rate were (67.8% versus 53.6%) p=0.006.

http://theoncologist.alphamedpress.org/cgi/content/full/12/8/967#SEC4

2. I agree with Prasads comments with regards to PS and high dose Pall RT Vs CTRT.

3. Cisplatin
When used as induction chemo, we exploit the ability of this drug damaging DNA crosslink,
while in CTRT, we exploit its radiosensitising property in addition.
Hence using Cisplatin in such scenario would still impart some value if intention is RADICAL
If we respect the patients pocket, she probably cannot afford Cetuximab as earlier suggested, but is
certainly a valid option.

4. There are so many treatment options, ranging from palliative to radical, and from idealistic to realistic.

5. At the end of the day, this lady should be counselled, there is indeed a high probability that she would relapse.
My best estimate for her 5 yr OS would range 15-25% provided i have IMRT, Chemo and have Radical Intent.

Cetuximab (or any other biological therapy) is unlikely to be of any benefit; primarily because the original Bonner trial did not include "standard fractionation" and oral cavity cancers were not part of the subset. Unless, there is a proper Phase III trial, extension to treat Buccal Mucosa seems to out of place.

There is an unfortunate trend to label patients with advanced HNSCC as "palliative"; perhaps we are too liberal with the terminology. We have treated patients with oro-cutaneous fistulas and exposed bone surfaces and seen very gratifying results; some cases with spontaneous closure. Of course, surgical salvage with excellent reconstruction has helped the matter nonetheless.

Since it is ultimately the skill of all people involved in the multi-disciplinary team which matters , I think Institutional protocols are the way forward in achieving the ultimate objective of curing a cancer patient taking into account the "Pros and Cons" of each individual cancer hospital. The same will help as a stepping stone in the formulation of newer treatment protocols in the future because each and every patient with a particular cancer will receive uniform treatment.

May be all the institutional protocols put together will become the onus for much needed and often quoted lack of data in our setting.

This is a 42 year old patient. I am pretty certain he will be able to tolerate a radical course of Chemorad with proper nutritional support. it goes without saying that dental care prior to start of treatment is absolutely essential. I dont know how much this is applicable for your setting but I would have encouraged a second surgical opinion also -its not that he is not going to have residual disease after CRT or palliative CCT ..

Indeed this is a fairly common presentation in the OPD. I feel there is not much point in treating in-op BM is with radical radiotherapy alone. In this situation I would consider 2 options depending on the general health, disease status and affordibility of the patient.

1. If GC is not very good with very advanced disease and the patient is not very affordable, you could give palliative radiotherapy with 40 Gy in 16 fractions. This could possibly be followed by palliative chemo such as low dose Metho if responsive.

1. If patient is in good GC and is affordable, you could consider radical CT+RT+targeted therapy. The CT should not be the same drugs as NACT. Cetuximab or Biomab could be used in combination with CT + RT. The patient could be assesed 4 - 6 weeks post RT for operability. If the patient shows responce, but does not become operable, then we could continue Biomab / Cetuximab for a prolonged period.

Warm Regards,

Dr. Prasad Raj Dandekar
MD, DNB
Consultant Radiation Oncologist,
International Oncology Services Pvt Ltd,
Dr. L. H. Hiranandani Hospital,
Hill side Avenue, Hiranandani Gardens,
Powai, Mumbai, India - 400076.
Mobile: +91 9820040454
Phone: +91 22 25763300, Fax: +91 22 25763311
www.internationaloncology.com

Post RT MRI showed no residual disease. Pituitary and hypothalalmus doses were well kept very low. Second MRI last month was also WNL.Clinically he is doing well, with minimal residusal limp. he is under the care of an endocrinologist too.
Any more suggestions for his follow up?

Now the surgeon has in all probability, done a reasonable job… Done Right Hemicolectomy and addressed the primary well. and as bonus got us 3 nodes which are negative.

From an oncolgists perspective, this lady has 2 adverse features:
1. Presentation as obstruction
2. Inadequate LN dissection.

Most of the members have expressed an indication for adjuvant chemo, which is a reasonable treatment strategy.
The patient should be made aware, about the modest benefit chemotherapy may offer, approximately 3-5% absolute benefit in OS at 5 years.

But i must admit the risk of relapse indeed is gonna be low, since there was no deep muscle invasion, nor was there any LVI.

Patient choice and preference may be an important deciding factor as well (in addition to her comorbid conditions).

She of course needs a Staging Baseline CT of her chest to complete the workup, again the yield will be extrememly low in this scenario.

The management of polyps and stage I colon cancer is through surgical resection. Most cancer in polyps is not diagnosed until after the polypectomy is performed. Therefore, with respect to pedunculated lesions, care should be taken to perform the resection and the junction of the stalk and the mucosa. Invasive early stage I cancers found in a polyp managed by polypectomy do not require further resection if the margin at the stalk is free of cancer.190,191 Sessile lesions that are biopsied and shown to harbor an invasive cancer should be managed with a segmental colon resection. Large polypoid lesions may also require a segmental resection. Because the stage of the lesion will not be determined until after the resection, all colon cancer lesions managed with a segmental resection should be approached in the same manner. The type of resection will be dictated by the location of the lesion, as has been described. Following a complete resection of a stage I lesion, no further adjuvant therapy is required. Patients managed in this way can expect a more than 95% 5-year survival. Those that recur are most likely improperly classified stage II or III lesions.

1. Inadequate LN dissection (at least 12 - 14 is recommended)
2. Superficial muscle invasion - by itself not a absolute indication.

Essentially the patient would be T2NxMx (as I dont have metastatic workup) for the patient. I presume we wont be able to get MSI and 18q deletion status as that can point to a poorer prognosis specially in the Stage II patients. If the patient is in good general conditions and agrees to the morbidity of chemotherapy and is able to afford it I would err on the side of caution and give her the chemotherapy.

Emergency CT scan(Abd & Pelvis) showed telescoping of hepatic flexure loop with mesocolon into transverse colon loop noted in the Rt hypochondrium - s/o colo-colonic intessusception. Rest Normal

Pt taken for emergency surgery. RT Hemiicolectomy & Ileo-Transverse anastomoses done.

HPR - Cauliflower like growth 5x5x1cm seen in the transverse colon. The polyp is composed of neoplastic glands showing infolding and crowding with minimal intervening stroma. The neoplastic glands are seen invading the stalk of the polyp and the superficial muscle layer. No Lymphatic or vascular emboli noted. Resection margins are free. 0/3 lymph nodes show tumor deposits.
IMP - Adenomatous polyp with malignant transformation

Is any adjuvant chemotherapy required in this case considering that the superficial muscle layer is involved or can we consider that "ADEQUATE SURGERY" is already done and kept on close observation.

Any management guidelines for "COLORECTAL MALIGNANT POLYP"

I agree with Nikhilesh and may be this patient should go ahead with weekly chemo and RT in view of the advanced disease. But not all tumours with ITF involvement are unresectable. It depends on the expertise of the surgeon as well as the infra structure and support systems available. May be this patient could review with some other surgeon to assess operability. If common opinion is that she is inoperable, then you could go ahead with CT - RT.

Regards

Prasad D

Short-term neoadjuvant androgen deprivation and radiotherapy for locally advanced prostate cancer: 10-year data from the TROG 96.01 randomised trial

Volume 12, Issue 5, May 2011, Pages 451-459

Conclusion: 6 months of neoadjuvant androgen deprivation combined radiotherapy is an effective treatment option for locally advanced prostate cancer, particularly in men without nodal metastases or pre-existing metabolic comorbidities that could be exacerbated by prolonged androgen deprivation.

This trial showed 6 months better than 3 months ADT

Notes: They allowed pts with PSA = 203.9 ng / ml into the trial…

Someone could look into the PR 07 trial , the highest PSA level enrolled in the study.

She is indeed unresectable and has quite an extensive spread of her cancer.
There is indeed no phase 1 or 2 data in this scenario, and i agree with the comments of all the ppl in this house, regarding chemoradiotherapy as a possible and viable treatment option.
Weekly or 3 weekly cisplatin …both are fine.
We prefer the weekly option, as you do not admit the patient, while the latter requires hospital admission.
RT dose: 64-66 Gy (non IMRT)
66-70 Gy (IMRT)

The volume to treat is indeed extensive.
I wonder if anyone could anticipate the results of this approach, and wonder if it exceeds 15-20% ( 5 yr OS)

The morbidity resulting from CTRT, probably justifies the approach and this outcome in view of her age.
But as Andrew always says, keep the facts in front of the patient, and let her decide whats best for her…..

Recently i m not sure whether you guys are aware there was the practice changing results of a trial called PR07 trial reported in last years ASCO.

http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=74&abstractID=49170

And giving radiotherapy in addition to hormone therapy improves survival for men with locally advanced prostate cancer.

http://www.ctu.mrc.ac.uk/news_and_press_releases/news_archive/pr07_interim_analysis_010710.aspx

http://www.actaitalica.it/issues/2003/5_03/05.%20Airoldi.pdf

Get his PSA re-checked from a different lab AFTER making sure that there has been no "digital manipulation" of his prostate before we jump to conclusions.

I think it would be a worthwhile trial.

If not, then the case is HIGH RISK and should be treated with the intent of cure with neoadjuvant hormones, primary radiotherapy and adjuvant hormones (probably lifetime).

If you think it is, then I'd like to be informed of the system as I haven't seen it published.

Even if you believe his metastatic rate is 100%, the local radiotherapy will mean that local failure is very very unlikely, so local treatment is not wasted. Hormones alone will see local failure in 5-7 years (what I call the "Trial of Death" approach!)