Background: Tobacco products continue to be used in large quantities in India despite the mandatory inclusion of pictorial health warnings (PHWs) on all tobacco packaging. The circumstances as to how people could continue the use of tobacco to the point of developing head and neck cancer despite enhanced awareness about the ill effects of tobacco is the main focus of this study. Materials and Methods: This study concerned patients with least 5-years history of tobacco use, having been diagnosed with histopathologically proven malignancies of the hypopharynx, larynx, oropharynx and oral cavity presenting at the Government Medical College-Haldwani, Nainital, India. A total of 183 patients were eligible for inclusion during July 1 2013-June 30 2014. Of these, 59 patients used smoked tobacco exclusively, 22 patients used smokeless tobacco exclusively, and 102 patients used both forms of tobacco. Among users of smoked forms, 75.2% (n=121) were beedi users, and 24.8% (n=40) were cigarette users. Patients were asked direct questions as to whether they had noticed the presence of PHWs upon tobacco products. The reasons as to why PHWs were not effective in stopping the patients from tobacco use were investigated. Results: Of the 183 patients, 146 reported being aware about the presence of PHWs, and when they were asked reasons as to why they continued tobacco despite being aware of ill-effects, the commonest reason chosen (by 53.4%) was that patients had not regarded themselves as using tobacco heavy enough to cause cancer. Among the 36 patients who reported as being oblivious to the presence of PHWs on tobacco products, 63.9% reported that the products they used never displayed any PHWs, and 36.1% reported never having paid attention to the packaging. The awareness about PHWs was higher among cigarette smokers in comparison to beedi smokers (100% vs 76.1%, p=0.0002). Conclusions: Locally produced and marketed tobacco products such as beedis and oral tobacco often fail to display PHWs. The presence of PHWs without doubt enhances awareness about the carcinogenic risks of tobacco. However, enhanced awareness alone may not be enough, and as elucidated by this study, some persons continue to use tobacco to the point of developing malignancies. The need of the hour is the implementation of legal and economic sanctions discouraging the use of tobacco products.Keywords: Pictorial health warnings -health warning labels -smoking health warning -head and neck cancer

A survey was conducted to determine the cancer profile in Nainital and adjoining districts of Uttarakhand. Epidemiological information was collected from the records of patients with confirmed cancer cases. A total of 354 cases were studied for the year 2010. Lung cancer was found to be leading cancer type (17.23%) overall. Breast cancer was most prevalent in females (22.29%) followed by cervical (14.86%) and ovarian cancers (13.51%). Men were mainly suffering from tobacco- and alcohol-related cancers, e.g., lungs (26.21%), larynx (11.16%), oropharynx (9.7%), oral cavity (6.79%), and esophagus (6.79%). Cancers of unknown primary site (1.41%) were also detected.

Mucoepidermoid carcinomas (MECs) of lung are rare neoplasms originating in bronchial submucosal glands and comprising 0.1-0.2% of primary lung cancers. MECs, the most common malignancy in salivary glands, were earlier thought to occur only in salivary glands. Later studies showed that they can arise as a primary in bronchus, esophagus, lacrimal glands, pancreas, thymus and thyroid gland. Initially described as a benign adenoma, it is now considered to be a malignant epithelial tumor. There have been reports of metastases to regional lymph nodes, other parts of the lung and distant organs. Cavitary lesion in MEC of lung is rare. Here, we report a case of MEC of lung with metastases to skeletal muscles of thigh and arm. To the best of our knowledge, this is the only case of MEC of lung presenting with such unusual pattern of metastasis as presenting feature with almost no symptoms of primary lesion.

IntroductionThe incidence of multiple primary cancers is reported to be between 0.3% and 4.3%. The second primary lesion is identified either simultaneously with the primary lesion (synchronous) or after a period of time (metachronous). Few cases of metastasis of breast carcinoma to the esophagus and vice versa have been reported in the past.Case presentationWe report an extremely rare case of a 55-year-old Indian woman who had carcinomas in both the esophagus and the breast simultaneously. She was treated successfully using combined modalities of surgery, chemotherapy and radiation therapy.ConclusionCases of synchronous double malignancies can be treated by dealing with the malignancy in the two sites as independent carcinomas. We have to take into consideration the total dose of radiation to a critical organ as well as the effect of the total dose of toxic chemotherapeutic drugs on our patient.

Background: Head and neck cancer without distant metastases is amenable to various modalities of treatment. However, the stage at presentation is a very important determinant for treatment success. The present study was conducted to determine the stage-wise presentation of non-metastatic head and neck cancer patients from the hilly regions in Kumaon division of Uttarakhand, India. Materials and Methods: The hospital records for non-metastatic head and neck cancer patients from the only functional cancer centre of the region for the period of two-years (January 2012-December 2013) were included. Nasopharyngeal carcinoma was excluded due to its staging system being different. Non-squamous histopathologies were also excluded. Patients hailing from nearby regions of Uttar Pradesh and Nepal were excluded, as were patients from non-hilly regions of Kumaon. Results: Of the 271 patients of head and neck cancer, 27 with distant metastases at diagnosis were excluded from the analysis. Of the 244 eligible patient records, 90.1% (n=222) were male, and 9.9% (n=22) were female. The proportions of patients with carcinoma of the larynx, oropharynx, oral cavity, hypopharynx and maxillary antrum were 31.9% (n=78), 27.9% (n=68), 20.5% (n=50), 12.7% (n=31) and 1.2% (n=3). A further 5.7% (n=14) were diagnosed as having secondary involvement of neck nodes with unknown primaries. The proportion of patients presenting in stages I, II, III, IVA and IVB were 0.8% (n=2), 2.5% (n=6), 9.4% (n=23), 51.6% (n=126) and 35.7% (n=87) respectively. Conclusions: An abysmally low proportion (3.3%) of non-metastatic head and neck cancer patients presented in the early stages (I and II). A vast majority of the patients (88.1%) presented with stages IVA and IVB. Not only does this reflect a poor therapeutic outlook, but also exposes the dire need for programmes focusing on cancer awareness and early detection in the region.Keywords: Head and neck cancer -Kumaon -cancer in the Himalayas -Uttarakhand

Context:Among patients with locally advanced head and neck squamous cell cancers (LAHNSCC), the prognosis after nonresponse or progression despite induction chemotherapy (IC) is dismal, and further treatment is often palliative in intent. Given that nonresponse to chemotherapy could indicate subsequent radioresistance, we intended to assess the outcomes with two different fractionation schemes.Aims:To compare the outcomes of two fractionation schemes- ’standard’ (consisting 3GyX5 daily fractions for 2 consecutive weeks) versus ‘hybrid’ (6GyX3 fractions on alternate days during the 1st week, followed by 2GyX5 daily fractions in the 2nd week).Settings and Design:Prospective randomized controlled two-arm unblinded trial.Materials and Methods:Patients with locally advanced oropharyngeal, laryngeal, and hypopharyngeal cancers treated with a minimum of two cycles of taxane, platinum, and fluorouracil-based IC were eligible if residual disease volume amounted <30 cm3. Kaplan-Meier survival curves were compared by the log-rank test. Response rates were compared using the unpaired t-test. Quality of life (QOL) was measured via patient reported questionnaires.Results:Of the initially enrolled 51 patients, 45 patients (24 from standard arm, and 21 from the hybrid arm) were eligible for analysis. Despite being underpowered to attain statistical significance, there still seemed to be a trend towards improvement in progression-free (Hazard ratio (HR) for progression: 0.5966; 95% CI 0.3216-1.1066) and overall survival (HR for death: 0.6062; 95% CI 0.2676-1.3734) with the hybrid arm when compared to the standard arm. Benefits were also observed with regards to response rates and QOL. Rate of complications were similar in both arms.Conclusions:In comparison to the routinely used palliative fractionation scheme of 30 Gray (Gy) in 10 fractions (Fr), the use of hybrid fractionation which integrates hypofractionation in the 1st week, followed by conventional fractionation in the 2nd week, could possibly offer better response rates, QOL increments, and potential survival benefits among LAHNSCC patients even after failing to respond to IC.

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