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Subject: Gliosarcoma: An audit from a single institution in India of 24 post-irradiated cases over 15 years Kumar P, Singh S, Kumar P, Krishnani N, Datta NR - J Can Res Ther
Date: Mon, 5 Jan 2009 09:26:19 +0100
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}


function writeSubmenu(obj,item)
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	if(!this.evnt) return false
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function navleftMouseOut(src)
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function navtabMouseOver(src)
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function navtabMouseOut(src)
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function navMouseOver(src,item)
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function navMouseOut(src,lyr)
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function onlpgld(item)
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function navMouseBotOut(src)
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function navMouseBotOver(src)
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function menu(src,item)
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=09
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function resetTDs(item)
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	var ob;
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function writehDetail(obj,nm,cate,sing,dble,chkout,webadd)
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while (par.charAt(0)=3D=3D" "){
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------=_NextPart_001_0035_01C96F17.AAAF35B0
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	charset="Windows-1252"
Content-Transfer-Encoding: quoted-printable
Content-Location: http://www.cancerjournal.net/article.asp?issn=0973-1482;year=2008;volume=4;issue=4;spage=164;epage=168;aulast=Kumar

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" =
"http://www.w3c.org/TR/1999/REC-html401-19991224/loose.dtd">
<HTML><HEAD><TITLE>Gliosarcoma: An audit from a single institution in =
India of 24 post-irradiated cases over 15 years Kumar P, Singh S, Kumar =
P, Krishnani N, Datta NR - J Can Res Ther</TITLE>
<META content=3D"text/html; charset=3Dwindows-1252" =
http-equiv=3DContent-Type>
<META name=3Dkeywords=20
content=3D"Journal of Cancer Research and Therapeutics, full-text, =
online, electronic, e-journal, free access, open access, online =
submission">
<META name=3Ddescription=20
content=3D"Official publication of Association of Radiation Oncology of =
India (AROI)"><!--DC META DATA START-->
<META name=3DDC.Title=20
content=3D"Gliosarcoma: An audit from a single institution in India of =
24 post-irradiated cases over 15 years"><LINK=20
rel=3DSCHEMA.dc =
href=3D"http://purl.org/metadata/dublin_core_elements#title">
<META name=3DDC.Creator content=3DKumar><LINK rel=3DSCHEMA.dc=20
href=3D"http://purl.org/metadata/dublin_core_elements#creator">
<META name=3DDC.Subject=20
content=3D"Glioblastoma multiforme, gliosarcoma, radiotherapy, =
survival&#13;&#10;">
<META name=3DDC.Description=20
content=3D"<b>Background:</b> Gliosarcomas (GS) are biphasic brain =
tumors composed of glioblastoma multiforme (GBM) and sarcomatous =
component. Therapeutic approaches include maximum surgical decompression =
with postoperative radiotherapy. Outcomes in gliosarcoma are poor =
despite multimodality management. <br><b>Aims: </b> To analyze the =
outcome in patients of GS treated in our institute over a period of 15 =
years and compare it with GBM treated during the same period. =
<br><b>Settings and Design:</b> Clinical records of the post-irradiated =
GS patients and GBM patients seen between 1990 and 2004 were retrieved. =
<br><b>Materials and Methods:</b> Demographic and treatment variables =
were evaluated for their influence on overall survival (OS). The =
survival outcomes of GBM and GS treated during the same period were also =
compared. <br><b>Statistical Analysis:</b> Univariate analysis was =
carried out using the Kaplan-Meier method and tested using log-rank test =
for significance. <br><b>Results:</b>  During these 15 years, 24 =
evaluable GS patients were treated as compared to 251 evaluable patients =
of GBM. There was a slight male preponderance in GS (14 males vs.10 =
females) with a median age of 50 years. All patients underwent surgery =
followed by post-operative radiotherapy (median dose of 60 Gy). None of =
the patient or treatment related factors were found to be significantly =
influencing their OS. Median OS in GS was 7.3 months compared to 7.5 =
months in GBM patients (P =3D 0.790). <br><b>Conclusions:</b> The OS =
appears to be similar for GS and GBM. None of the demographic variables =
appeared to prognosticate the survivals of GS."><LINK=20
rel=3DSCHEMA.dc =
href=3D"http://purl.org/metadata/dublin_core_elements#description">
<META name=3DDC.Publisher content=3D"Medknow Publications"><LINK =
rel=3DSCHEMA.dc=20
href=3D"http://purl.org/metadata/dublin_core_elements#publisher">
<META name=3DDC.Contributor.PersonalName=20
content=3D"Kumar P, Singh S, Kumar P, Krishnani N, Datta NR"><LINK =
rel=3DSCHEMA.dc=20
href=3D"http://purl.org/metadata/dublin_core_elements#contributor">
<META scheme=3DISO8601 name=3DDC.Date content=3D2008-10-1><LINK =
rel=3DSCHEMA.dc=20
href=3D"http://purl.org/metadata/dublin_core_elements#date">
<META name=3DDC.Type content=3DText.Serial.Journal><LINK rel=3DSCHEMA.dc =

href=3D"http://purl.org/metadata/dublin_core_elements#type">
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rel=3DSCHEMA.dc=20
href=3D"http://purl.org/metadata/dublin_core_elements#format"><LINK =
rel=3DSCHEMA.imt=20
href=3D"http://sunsite.auc.dk/RFC/rfc/rfc2046.html">
<META name=3DDC.Identifier=20
content=3Dhttp://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar><LINK=20
rel=3DSCHEMA.dc =
href=3D"http://purl.org/metadata/dublin_core_elements#identifier">
<META scheme=3DISSN name=3DDC.Identifier content=3D0973-1482><LINK =
rel=3DSCHEMA.dc=20
href=3D"http://purl.org/metadata/dublin_core_elements#identifier">
<META scheme=3DISO639-1 name=3DDC.Language content=3Den><LINK =
rel=3DSCHEMA.dc=20
href=3D"http://purl.org/metadata/dublin_core_elements#language">
<META scheme=3DISO8601 name=3DDC.Date.X-MetadataLastModified =
content=3D2008-10-1><LINK=20
rel=3DSCHEMA.dc =
href=3D"http://purl.org/metadata/dublin_core_elements#date"><!--DC META =
DATA END--><!-- Google Scholar tags start -->
<META name=3Dcitation_journal_title=20
content=3D"Journal of Cancer Research and Therapeutics">
<META name=3Dcitation_publisher content=3D"Medknow Publications">
<META name=3Dcitation_authors=20
content=3D"Kumar P; Singh S; Kumar P; Krishnani N; Datta NR">
<META name=3Dcitation_title=20
content=3D"Gliosarcoma: An audit from a single institution in India of =
24 post-irradiated cases over 15 years">
<META name=3Dcitation_date content=3D10/1/2008>
<META name=3Dcitation_volume content=3D4>
<META name=3Dcitation_issue content=3D4>
<META name=3Dcitation_firstpage content=3D164>
<META name=3Dcitation_abstract_html_url=20
content=3Dhttp://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar;type=3D0=
>
<META name=3Dcitation_fulltext_html_url=20
content=3Dhttp://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar>
<META name=3Dcitation_pdf_url=20
content=3Dhttp://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar;type=3D2=
>
<META name=3Dcitation_pmid content=3D19052388><!-- Google Scholar tags =
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                <TD width=3D"100%" colSpan=3D3><FONT =
class=3DtocAT><B>ORIGINAL=20
                  ARTICLE</B></FONT></TD></TR>
              <TR>
                <TD height=3D5 width=3D"33%"></TD>
                <TD height=3D5 width=3D"33%"></TD>
                <TD height=3D5 width=3D"34%"></TD></TR>
              <TR>
                <TD class=3Dother width=3D"100%" colSpan=3D3><B>Year =
</B>:=20
                  2008&nbsp; |&nbsp; <B>Volume</B> : 4&nbsp; |&nbsp;=20
                  <B>Issue</B> : 4&nbsp; |&nbsp; <B>Page</B> : =
164-168</TD></TR>
              <TR>
                <TD class=3Dother width=3D"100%"=20
            colSpan=3D3>&nbsp;</TD></TR></TBODY></TABLE>
            <P><FONT class=3DsTitle>Gliosarcoma: An audit from a single=20
            institution in India of 24 post-irradiated cases over 15=20
            years</FONT><BR><BR><FONT class=3DarticleAuthor>Piyush=20
            Kumar<SUP>1</SUP>, Shalini Singh<SUP>1</SUP>, Pavan=20
            Kumar<SUP>1</SUP>, Narendra Krishnani<SUP>2</SUP>, Niloy R=20
            Datta<SUP>1</SUP></FONT><BR><FONT=20
            class=3DAuthorAff><SUP>1</SUP>&nbsp;Department of =
Radiotherapy,=20
            Regional Cancer Centre, Sanjay Gandhi Postgraduate Institute =
of=20
            Medical Sciences, Lucknow- 226 014, U.P,=20
            India<BR><SUP>2</SUP>&nbsp;Department of Pathology, Regional =
Cancer=20
            Centre, Sanjay Gandhi Postgraduate Institute of Medical =
Sciences,=20
            Lucknow- 226 014, U.P, India<BR></FONT><BR></P>
            <P><FONT class=3DCorrsAdd><B>Correspondence =
Address</B>:<BR>Shalini=20
            Singh<BR>Department of Radiotherapy, Regional Cancer Centre, =
Sanjay=20
            Gandhi Post-Graduate Institute of Medical Sciences, =
Lucknow-226 014=20
            <BR>India<BR><A=20
            =
href=3D"http://www.cancerjournal.net/login.asp?rd=3Darticle.asp?issn=3D09=
73-1482;year=3D2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3D=
Kumar"><IMG=20
            border=3D0 alt=3D"Login to access the Email id"=20
            src=3D"http://www.medknow.com/images/email.gif"></A>
            <P><B>Source of Support:</B> None, <B>Conflict of =
Interest:</B>=20
            None</P></FONT>
            <P></P>
            <TABLE border=3D0 cellSpacing=3D0 cellPadding=3D0 =
width=3D"100%">
              <TBODY>
              <TR>
                <TD class=3DinsideLine height=3D1=20
            width=3D"100%"></TD></TR></TBODY></TABLE>&nbsp;<BR>
            <TABLE class=3DleftNav border=3D0 cellSpacing=3D0 =
cellPadding=3D0=20
            width=3D"100%">
              <TBODY>
              <TR>
                <TD class=3DpageSub height=3D15 =
width=3D"85%">&nbsp;&gt;<A=20
                  name=3Dabstract></A>&nbsp;Abstract</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD height=3D15 width=3D"15%"></TD></TR></TBODY></TABLE>
            <P class=3Dabst><B>Background:</B> Gliosarcomas (GS) are =
biphasic=20
            brain tumors composed of glioblastoma multiforme (GBM) and=20
            sarcomatous component. Therapeutic approaches include =
maximum=20
            surgical decompression with postoperative radiotherapy. =
Outcomes in=20
            gliosarcoma are poor despite multimodality management. =
<BR><B>Aims:=20
            </B>To analyze the outcome in patients of GS treated in our=20
            institute over a period of 15 years and compare it with GBM =
treated=20
            during the same period. <BR><B>Settings and Design:</B> =
Clinical=20
            records of the post-irradiated GS patients and GBM patients =
seen=20
            between 1990 and 2004 were retrieved. <BR><B>Materials and=20
            Methods:</B> Demographic and treatment variables were =
evaluated for=20
            their influence on overall survival (OS). The survival =
outcomes of=20
            GBM and GS treated during the same period were also =
compared.=20
            <BR><B>Statistical Analysis:</B> Univariate analysis was =
carried out=20
            using the Kaplan-Meier method and tested using log-rank test =
for=20
            significance. <BR><B>Results:</B> During these 15 years, 24=20
            evaluable GS patients were treated as compared to 251 =
evaluable=20
            patients of GBM. There was a slight male preponderance in GS =
(14=20
            males vs.10 females) with a median age of 50 years. All =
patients=20
            underwent surgery followed by post-operative radiotherapy =
(median=20
            dose of 60 Gy). None of the patient or treatment related =
factors=20
            were found to be significantly influencing their OS. Median =
OS in GS=20
            was 7.3 months compared to 7.5 months in GBM patients (P =3D =
0.790).=20
            <BR><B>Conclusions:</B> The OS appears to be similar for GS =
and GBM.=20
            None of the demographic variables appeared to prognosticate =
the=20
            survivals of GS.</P><BR>
            <P class=3Dkyds><B>Keywords:</B>&nbsp;Glioblastoma =
multiforme,=20
            gliosarcoma, radiotherapy, survival </P><BR>
            <TABLE class=3Dsitethis border=3D0 width=3D"100%">
              <TBODY>
              <TR>
                <TD class=3Dother><B>How to cite this =
article:</B><BR>Kumar P,=20
                  Singh S, Kumar P, Krishnani N, Datta NR. Gliosarcoma: =
An audit=20
                  from a single institution in India of 24 =
post-irradiated cases=20
                  over 15 years. J Can Res Ther=20
            2008;4:164-8</TD></TR></TBODY></TABLE><BR>
            <TABLE class=3Dsitethis border=3D0 width=3D"100%">
              <TBODY>
              <TR>
                <TD class=3Dother><B>How to cite this URL:</B><BR>Kumar =
P, Singh=20
                  S, Kumar P, Krishnani N, Datta NR. Gliosarcoma: An =
audit from=20
                  a single institution in India of 24 post-irradiated =
cases over=20
                  15 years. J Can Res Ther [serial online] 2008 =
[cited&nbsp;2009=20
                  Jan 5];4:164-8. Available from:&nbsp;<A=20
                  =
href=3D"http://www.cancerjournal.net/text.asp?2008/4/4/164/44286">http://=
www.cancerjournal.net/text.asp?2008/4/4/164/44286</A></TD></TR></TBODY></=
TABLE><BR><BR><BR>
            <TABLE class=3DleftNav border=3D0 cellSpacing=3D0 =
cellPadding=3D0=20
            width=3D"100%">
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  =
name=3DIntroduction></A>&nbsp;&gt;&nbsp;Introduction</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD width=3D"15%" align=3Dright><A=20
                  =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#top"><IM=
G=20
                  border=3D0 alt=3DTop=20
                  =
src=3D"http://www.cancerjournal.net/images/arrow_top.gif"></A></TD></TR><=
/TBODY></TABLE><BR><BR>Gliosarcomas=20
            (GS) are biphasic brain tumors composed of glioblastoma =
multiforme=20
            (GBM) and sarcomatous component, and were first described in =
1895 by=20
            Heinrich Stroebe.<SUP> <A class=3Dref name=3Dft1=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref1">[1=
]</A></SUP>=20
            The mesenchymal component typically resembles fibrosarcoma, =
but=20
            differentiation patterns resembling osteosarcoma, =
chondrosarcoma,=20
            angiosarcoma and rhabdomyosarcoma have also been =
described.<SUP> <A=20
            class=3Dref name=3Dft2=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref2">[2=
]</A></SUP>=20
            It is a rare cerebral tumor that has been classified as a =
separate=20
            clinico-pathological entity, even though it remains closely =
related=20
            to GBM.<SUP> <A class=3Dref name=3Dft3=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref3">[3=
]</A>,<A=20
            class=3Dref name=3Dft4=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref4">[4=
]</A></SUP>=20
            Gliosarcomas account for 8% of all GBM.<SUP> <A class=3Dref =
name=3Dft5=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref5">[5=
]</A></SUP>=20
            Therapeutic approaches include maximum surgical =
decompression with=20
            post-operative radiotherapy (RT) although prognosis =
continues to be=20
            poor despite these interventions. <BR><BR>This audit has =
been=20
            carried out to analyze the clinical features and survival =
outcomes=20
            in GS patients seen over a period of 15 years and to compare =
their=20
            demographic features and outcomes with GBM patients treated =
during=20
            the same period<B> .</B> <BR><BR><BR>
            <TABLE class=3DleftNav border=3D0 cellSpacing=3D0 =
cellPadding=3D0=20
            width=3D"100%">
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  name=3D"Materials and =
Methods"></A>&nbsp;&gt;&nbsp;Materials and=20
                  Methods</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD width=3D"15%" align=3Dright><A=20
                  =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#top"><IM=
G=20
                  border=3D0 alt=3DTop=20
                  =
src=3D"http://www.cancerjournal.net/images/arrow_top.gif"></A></TD></TR><=
/TBODY></TABLE><BR><BR>Between=20
            January 1990 and December 2004, 1,236 patients of brain =
tumors were=20
            registered in the Department of Radiotherapy at our =
Institute. Of=20
            these, there were 25 histopathological confirmed patients of =
GS and=20
            275 cases of GBM. Of the 25 patients of GS, one patient did =
not turn=20
            up for post-operative RT and was excluded from the analysis. =
Thus,=20
            the remaining 24 GS patients who received RT were considered =
for=20
            this audit. Of the 275 patients of GBM, 24 did not report =
for any=20
            adjuvant treatment after registration and hence were =
excluded from=20
            the analysis. The remaining 251 evaluable GBM who received =
RT were=20
            considered for a survival outcome comparison with GS =
patients of=20
            this audit. The status of all these patients on or before =
1<SUP>=20
            st</SUP> July 2007 was extracted from the individual =
treatment=20
            records. <I><BR><BR></I>Both patient and treatment related =
variables=20
            already documented in the clinical files of the patients =
were=20
            evaluated. The patient related parameters included age, sex, =

            duration of symptoms, tumor site and pre-radiotherapy =
Karnofsky=20
            performance status (KPS).<SUP> </SUP>Treatment related =
parameters=20
            examined included extent of surgical resection, interval =
between=20
            surgery and start of RT, and overall treatment time for RT. =
Total=20
            resection of the tumor was considered if 90% or more of the =
tumor=20
            was resected as recorded in neurosurgical operative=20
            records.<BR><BR>The target delineation was based on contrast =

            enhanced computed tomography (CECT) or magnetic resonance =
imaging=20
            (MRI) or both. CT scan was used in the initial years and in =
later=20
            years MRI was also used. Radiotherapy was usually delivered =
in two=20
            phases; phase I for clinical target volume, consisting of =
the volume=20
            encompassing the peri-tumoral edema as seen on CECT or the=20
            hyper-intense T2W image. For the phase II treatment, the =
contrast=20
            enhancing regions depicting the mass effect on CECT or T1W =
contrast=20
            images constituted the gross target volume.<BR><BR>All =
patients were=20
            subjected to RT simulation and dose distributions were =
evaluated on=20
            treatment planning systems (Radplan, ASHA- 3-D, M/s TSG=20
            Integrations, India and ISIS-3D, Technologie Diffusion, =
France).=20
            Patients were treated on telecobalt or 6 MV / 10 MV photon =
beams or=20
            their combinations. A majority of patients were scheduled to =
receive=20
            a dose of 40-45 Gy in phase I and 15-20 Gy in phase II, =
delivered at=20
            a dose per fraction of 180-200 cGy over a period of 6 to 7 =
weeks.=20
            Three patients were scheduled RT for a dose more than 60 Gy =
under a=20
            study protocol, two of whom received 70 Gy by altered =
fractionation=20
            and one received 66 Gy by standard fractionation schedule. =
One=20
            patient was treated with the hypofractionated protocol with =
a total=20
            dose of 35 Gy. <BR><BR><B>Statistical analysis=20
            </B><BR><BR>Demographic features between GS and GBM patients =
were=20
            compared using either chi-square test (for discrete =
variables) or=20
            t-test (for continuous variables). For OS, death from any =
cause was=20
            considered as an event. The end point was computed from the =
date of=20
            surgery. For patients not reporting for follow up, every =
possible=20
            effort was made to ascertain their status by postal or =
telephonic=20
            communication. The analysis was carried out as "worst case =
scenario"=20
            wherein the patients lost to follow up were considered as an =
event.=20
            Univariate analysis was carried out using the Kaplan-Meier =
method=20
            and tested using log-rank test for significance.<SUP> <A =
class=3Dref=20
            name=3Dft6=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref6">[6=
]</A></SUP>=20
            Cut-off points for univariate analysis of continuous =
variables were=20
            based on median values of their distribution. <BR><BR><BR>
            <TABLE class=3DleftNav border=3D0 cellSpacing=3D0 =
cellPadding=3D0=20
            width=3D"100%">
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                name=3DResults></A>&nbsp;&gt;&nbsp;Results</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD width=3D"15%" align=3Dright><A=20
                  =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#top"><IM=
G=20
                  border=3D0 alt=3DTop=20
                  =
src=3D"http://www.cancerjournal.net/images/arrow_top.gif"></A></TD></TR><=
/TBODY></TABLE><BR><BR><B>Patient=20
            demography</B><BR><BR>The incidence of GS among all brain =
tumors=20
            registered in our department was 2.0%. Male to female ratio =
was 1.4=20
            with the median age of 50 years. Temporal lobes (37.5%) were =
more=20
            frequently involved than other cerebral regions. Median =
pretreatment=20
            KPS was 70 with the mean duration of symptoms being 8 months =
<A=20
            class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_b1.jpg')">[Table=20
            1]</A>.<BR><BR>The demographic features of the 251 GBM =
patients are=20
            summarized in <A class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_b1.jpg')">[Table=20
            1]</A>. Median age was 48 years with a male predominance =
(male:=20
            female: 3.7:1). Most of them had KPS in the range of 50 to =
80 and=20
            only 26 patients (10%) had a KPS of at least 90 or more. All =

            patients had surgical interventions, before being referred =
for=20
            adjuvant therapy. <BR><BR>Treatment related parameters for =
GS have=20
            been detailed in <A class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_b2.jpg')">[Table=20
            2]</A>. All patients had surgical interventions; a majority=20
            underwent subtotal resection, before being referred for=20
            post-operative RT. The surgical descriptions were entered as =
per the=20
            neurosurgical records. RT was usually started within 3 to 4 =
weeks=20
            (median - 24 days) of surgery and a median dose of 60 Gy was =

            delivered. <BR><BR>In GBM, post-operative RT commenced =
within 3 to 4=20
            weeks (median - 26 days) of surgery, and a dose of 60 Gy was =

            received by 151 patients (60.2%), while 59 (23.5%) patients =
received=20
            less than 60 Gy and 41 (16.3%) received doses more than 60 =
Gy to a=20
            maximum of 73 Gy. The minimum and median RT doses for =
patients who=20
            received less than 60 Gy were 12.6 Gy and 55 Gy =
respectively, while=20
            the median dose for those who received more than 60 Gy was =
60 Gy.=20
            Chemotherapy either in the form of a single agent CCNU =
(lomustine)=20
            or a combination protocol of PCV (procarbazine, lomustine =
and=20
            vincristine) for a maximum of six cycles was prescribed in =
108 (43%)=20
            patients, which was based upon the discretion of different=20
            clinicians.<BR><BR><B>Survival analysis</B><BR><BR>The =
maximum=20
            follow up for GS patients was 67.5 months (median: 5.4 =
months).=20
            Fifteen (62.5%) patients were actually lost to follow up out =
of=20
            which 11 (45.8%) had disease persisting at the time of last =
follow=20
            up. Eight (33.3%) patients were dead. Following completion =
of=20
            post-operative RT, a majority (83.4%) had either improvement =
or=20
            their KPS was stable with respect to their pre-RT =
status.<BR><BR>On=20
            univariate analysis, none of the patient or treatment =
related=20
            factors were found to be statistically significantly =
influencing the=20
            OS, although the subgroup of patients who had received the =
total RT=20
            dose of 60 Gy or more had a better outcome (median survival =
&lt; 60=20
            Gy <I>vs.</I> <U>&gt;</U> 60 Gy was 5.5 <I>vs.</I> 9 months, =
(<I> P=20
            </I>=3D 0.059) <A class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_b3.jpg')">[Table=20
            3]</A>.<BR><BR>There was a definite impact of this =
chemotherapy in=20
            terms of overall survival in our cohort of GBM patients. The =
overall=20
            survival in the group of patients receiving chemotherapy and =
not=20
            receiving chemotherapy was 9.8 and 5.4 months respectively, =
which=20
            was statistically significant (<I> P</I> =3D 0.005). =
<BR><BR>Median OS=20
            for the entire cohort of GS patients was 7.3 months. Overall =

            survival for GS at 1 year, 2 years and 5 years were 32.0%, =
4.6% and=20
            4.6% respectively. In GBM patients, the median OS was 7.5 =
months and=20
            the OS at 1, 2 and 5 years were 29%, 6.8% and 1.7% =
respectively.=20
            There was no significant difference in the OS between GS and =
GBM=20
            patients (log-rank, <I>P </I>=3D 0.790)<I> </I><A =
class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_u4.jpg')">[Figure=20
            1]</A>.<BR><BR><B>Toxicity</B><BR><BR>Treatment administered =
was=20
            well tolerated by patients and no significant neurotoxicity =
was=20
            evident. There was no added requirement of steroids. No =
significant=20
            acute or late radiation induced toxicities were noted for =
both GS=20
            and GBM patients.<BR><BR><BR>
            <TABLE class=3DleftNav border=3D0 cellSpacing=3D0 =
cellPadding=3D0=20
            width=3D"100%">
              <TBODY>
              <TR>
                <TD class=3DpageSub><A=20
                  name=3DDiscussion></A>&nbsp;&gt;&nbsp;Discussion</TD>
                <TD class=3Dinthis align=3Dright>&nbsp;</TD>
                <TD width=3D"15%" align=3Dright><A=20
                  =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#top"><IM=
G=20
                  border=3D0 alt=3DTop=20
                  =
src=3D"http://www.cancerjournal.net/images/arrow_top.gif"></A></TD></TR><=
/TBODY></TABLE><BR><BR>Gliosarcoma=20
            is a rare malignant brain tumor with mixed morphological =
features of=20
            both GBM and sarcoma. The incidence reported in various =
series=20
            ranged from 2% to 8% of all GBM,<SUP> <A class=3Dref =
name=3Dft3=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref3">[3=
]</A>,<A=20
            class=3Dref name=3Dft4=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref4">[4=
]</A></SUP>=20
            which is almost similar to 8.7% in our audit. Therapeutic=20
            irradiations given for GBM influence sarcomatous=20
            transformation.<SUP> <A class=3Dref name=3Dft7=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref7">[7=
]</A>,<A=20
            class=3Dref name=3Dft8=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref8">[8=
]</A></SUP>=20
            However, in our series all the cases were primary GSs and =
none was=20
            secondary to GBM.<BR><BR>The usual age of presentation is in =
fifth=20
            to seventh decade.<SUP> <A class=3Dref name=3Dft9=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref9">[9=
]</A>,<A=20
            class=3Dref name=3Dft10=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref10">[=
10]</A>,<A=20
            class=3Dref name=3Dft11=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref11">[=
11]</A>=20
            </SUP>Data published by Meis <I>et al</I> .<SUP> <A =
class=3Dref=20
            name=3Dft3=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref3">[3=
]</A></SUP>=20
            and Galanis <I>et al.<SUP></I> <A class=3Dref name=3Dft12=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref12">[=
12]</A></SUP>=20
            showed that the median age of presentation in their series =
was 60=20
            years while in our study, the median age was 48 years =
(range: 20 to=20
            65 years). Gliosarcoma is usually not frequent in children, =
although=20
            it has been reported in the literature.<SUP> <A class=3Dref =
name=3Dft13=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref13">[=
13]</A>,<A=20
            class=3Dref name=3Dft14=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref14">[=
14]</A>=20
            </SUP>Gliosarcoma affects more males than female, which can =
be=20
            clearly seen in our series also (<A class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_b1.jpg')">[Table=20
            1]</A>; 58.3% vs. 41.7%). These are usually located in the =
cerebrum,=20
            involving the temporal, parietal, frontal, and occipital =
lobes in=20
            decreasing order of frequency.<SUP><A class=3Dref name=3Dft4 =

            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref4">[4=
]</A>,<A=20
            class=3Dref name=3Dft12=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref12">[=
12]</A></SUP>=20
            In our series, 37.5% had involvement of temporal lobes, =
compared to=20
            more than 50% reported by Morantz <I>et al</I> .<SUP> <A =
class=3Dref=20
            name=3Dft4=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref4">[4=
]</A></SUP>=20
            and Sarkar <I>et al</I> .<SUP> <A class=3Dref name=3Dft14=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref14">[=
14]</A></SUP>=20
            <BR><BR>We did not encounter cases with any systemic =
metastasis,=20
            although unusual cases with spread to lung, bone and lymph =
nodes=20
            have been reported in the literature.<SUP> <A class=3Dref =
name=3Dft9=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref9">[9=
]</A>,<A=20
            class=3Dref name=3Dft15=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref15">[=
15]</A>,<A=20
            class=3Dref name=3Dft16=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref16">[=
16]</A>,<A=20
            class=3Dref name=3Dft17=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref17">[=
17]</A>,<A=20
            class=3Dref name=3Dft18=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref18">[=
18]</A></SUP>=20
            <BR><BR>Histopathologically, GS is a bimorphic tumor =
composed of two=20
            distinct malignant cell populations. First, gliomatous =
component=20
            identified as astrocytes with endothelial proliferation and=20
            necrosis, and the other sarcomatous component, which is of=20
            mesenchymal nature and generally spindled <A class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_u5.jpg')">[Figure=20
            2]</A>. Reticulin stains <A class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_u6.jpg')">[Figure=20
            3]</A> and immunostains for glial fibrillary acidic protein =
are=20
            performed to distinguish the glial from the sarcomatous =
components=20
            of the tumor. <BR><BR>The demographic profiles of our =
patients of GS=20
            and GBM were nearly similar for age at presentation (<I> P =
</I>=3D=20
            0.906), pretreatment KPS (<I> P </I>=3D 0.791), duration of =
symptoms=20
            (<I> P </I>=3D 0.561) and site of tumor (<I> P </I>=3D =
0.727). However,=20
            a higher preponderance in GBM in males was observed compared =
to=20
            those in GS (GBM: male vs. females: 78.9% vs. 21.1%; GS: =
male vs.=20
            females: 57.7% vs. 42.3%, <I>P </I>=3D 0.025) <A class=3Dref =

            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_b1.jpg')">[Table=20
            1]</A>.<BR><BR>Most of our patients were given RT in the=20
            conventional fractionation (except 3 patients in altered=20
            fractionated schedules) with a median dose of 60 Gy. In =
other=20
            reported series, the RT dose ranged from 40-81 Gy with =
different=20
            fractionational schedules.<SUP> <A class=3Dref name=3Dft3=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref3">[3=
]</A>,<A=20
            class=3Dref name=3Dft4=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref4">[4=
]</A>,<A=20
            class=3Dref name=3Dft12=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref12">[=
12]</A>,<A=20
            class=3Dref name=3Dft14=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref14">[=
14]</A>,<A=20
            class=3Dref name=3Dft19=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref19">[=
19]</A></SUP>=20
            None of our patients had received chemotherapy since there =
is no=20
            strong evidence of its benefit. In a study of 24 patients by =
Morantz=20
            <I>et al</I> .,<SUP> <A class=3Dref name=3Dft4=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref4">[4=
]</A></SUP>=20
            where the average survival for all the patients was 21 =
weeks, a=20
            slight increase in survival was observed with the addition =
of=20
            chemotherapy (36 weeks) in 9 patients compared with RT alone =
(33=20
            weeks) in 15 patients. Chemotherapy was used as an adjunct =
to RT in=20
            various forms - mithramycin (5 patients), BCNU (2 patients), =

            adriamycin (1 patient) and intracarotid amethopterin (1 =
patient).=20
            Meis <I>et al</I> .<SUP> <A class=3Dref name=3Dft3=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref3">[3=
]</A></SUP>=20
            found that none of the treatment regimens, which included =
various=20
            combinations of radiation therapy and chemotherapy (BCNU,=20
            dacarbazine, semustine, misonidazole), improved survival of =
GS over=20
            GBM; median survival being 8.3 months vs. 9.6 months =
respectively.=20
            In another study by Galanis <I>et al</I> .,<SUP> <A =
class=3Dref=20
            name=3Dft12=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref12">[=
12]</A></SUP>=20
            18 patients of GS were derived from a series of 748 grade 4=20
            astrocytoma cases that were part of four consecutive =
randomized=20
            phase III trials and were treated with external radiation =
and=20
            nitrosurea-based chemotherapy (carmustine, PCNU and=20
            dibromodulcitol). The median survival reported was 35.1 =
weeks and=20
            41.6 weeks for GS and GBM respectively, which was not =
statistically=20
            significant (<I> P </I>=3D 0.27). <SUP><BR><BR></SUP>The =
reported=20
            median survival in GS varied from 6.2 to 11.5 months.<SUP> =
<A=20
            class=3Dref name=3Dft11=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref11">[=
11]</A>,<A=20
            class=3Dref name=3Dft12=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref12">[=
12]</A>,<A=20
            class=3Dref name=3Dft19=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref19">[=
19]</A></SUP>=20
            In our group of patients, it was 7.3 months, which is =
relatively=20
            lower. Unlike GBM, in our audit of gliosarcoma patients, no=20
            prognostic factors affecting survival were seen. In a study =
of 11=20
            patients by Salvati <I>et al.</I> ,<SUP> <A class=3Dref =
name=3Dft20=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref20">[=
20]</A></SUP>=20
            age and KPS did not have any impact on the overall survival, =
as is=20
            also seen in our study, but the histopathological and =
radiological=20
            findings did have an effect. Patients with radiological =
features of=20
            meningioma and those with predominant sarcomatous features =
on=20
            histopathology, had significantly better survivals than =
those with=20
            GBM features or gliomatous component (62 weeks versus 53.5 =
weeks;=20
            <I>P </I>=3D 0.04). In some studies, young age and =
pre-treatment=20
            Karnofsky performance status <U>&gt;</U> 70 have been shown =
to be=20
            associated with higher survival probability.<SUP> <A =
class=3Dref=20
            name=3Dft11=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref11">[=
11]</A>,<A=20
            class=3Dref name=3Dft19=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref19">[=
19]</A></SUP>=20
            <BR><BR>The possible attributes for a lower survival in our =
patients=20
            could be poor KPS at the time of presentation (only 33.3% =
had KPS 80=20
            or more), larger tumor dimensions restricting total tumor =
excision=20
            (feasible only in 20.8%) and inability to complete at least =
60 Gy of=20
            postoperative RT (45.5% patients received less than 60 Gy). =
All=20
            these variables could have influenced treatment=20
            outcomes.<BR><BR>Comparing with the 251 evaluable patients =
of GBM,=20
            it was observed that median OS of GS did not differ =
significantly=20
            from GBM. The overall survivals, of 7.3 with GS and 7.5 =
months in=20
            GBM were similar (<I> P </I>=3D 0.790) <A class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_u4.jpg')">[Figure=20
            1]</A>. This has also been observed by Meis <I>et =
al.<SUP></I> <A=20
            class=3Dref name=3Dft3=20
            =
href=3D"http://www.cancerjournal.net/article.asp?issn=3D0973-1482;year=3D=
2008;volume=3D4;issue=3D4;spage=3D164;epage=3D168;aulast=3DKumar#ref3">[3=
]</A></SUP>=20
            with median survivals of 8.3 and 9.6 months in their GS and =
GBM=20
            patients respectively. Survival outcomes in GS and GBM thus =
appear=20
            to be identical.<BR><BR>The audit demonstrates that patients =
of GS=20
            and GBM appear to have similar clinical features and =
outcomes.=20
            Gliosarcoma may therefore be treated on the same lines as =
GBM, with=20
            maximal surgical decompression followed by post-operative =
RT. The=20
            possible role of chemotherapy in GS is still undefined and =
could be=20
            explored in future studies.<BR><BR>&nbsp;
            <TABLE class=3DleftNav border=3D0 cellSpacing=3D0 =
cellPadding=3D0=20
            width=3D"100%">
              <TBODY>
              <TR>
                <TD class=3DpageSub height=3D15><A=20
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nbsp;&nbsp;</TD></TR></TBODY></TABLE><BR><BR>
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                  =
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            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
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            1]</A>, <A class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_u5.jpg')">[Figure=20
            2]</A>, <A class=3Dref=20
            =
href=3D"javascript:omovimg('viewimaget.asp?img=3DJCanResTher_2008_4_4_164=
_44286_u6.jpg')">[Figure=20
            3]</A><BR>&nbsp;<BR>&nbsp;
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            1]</A>, <A class=3Dref=20
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<P class=3DpageSub align=3Dcenter><B>Figures and Tables</B></P>
<P align=3Dcenter><A target=3D_blank=20
href=3D"http://www.cancerjournal.net/viewimage.asp?img=3DJCanResTher_2008=
_4_4_164_44286_u4.jpg"><IMG=20
style=3D"BORDER-BOTTOM: #cccccc 1px solid; BORDER-LEFT: #cccccc 1px =
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2008_4_4_164_44286_u4.jpg"=20
width=3D150 height=3D102.75></A><BR><FONT class=3Dadlink>Figure 1: =
Kaplan-Meier=20
surviva...</FONT></P>
<P align=3Dcenter><A target=3D_blank=20
href=3D"http://www.cancerjournal.net/viewimage.asp?img=3DJCanResTher_2008=
_4_4_164_44286_u5.jpg"><IMG=20
style=3D"BORDER-BOTTOM: #cccccc 1px solid; BORDER-LEFT: #cccccc 1px =
solid; BORDER-TOP: #cccccc 1px solid; BORDER-RIGHT: #cccccc 1px solid"=20
alt=3D""=20
src=3D"http://www.cancerjournal.net/articles/2008/4/4/images/JCanResTher_=
2008_4_4_164_44286_u5.jpg"=20
width=3D150 height=3D102.41></A><BR><FONT class=3Dadlink>Figure 2: =
Spindling of tumor=20
c...</FONT></P>
<P align=3Dcenter><A target=3D_blank=20
href=3D"http://www.cancerjournal.net/viewimage.asp?img=3DJCanResTher_2008=
_4_4_164_44286_u6.jpg"><IMG=20
style=3D"BORDER-BOTTOM: #cccccc 1px solid; BORDER-LEFT: #cccccc 1px =
solid; BORDER-TOP: #cccccc 1px solid; BORDER-RIGHT: #cccccc 1px solid"=20
alt=3D""=20
src=3D"http://www.cancerjournal.net/articles/2008/4/4/images/JCanResTher_=
2008_4_4_164_44286_u6.jpg"=20
width=3D150 height=3D102.62></A><BR><FONT class=3Dadlink>Figure 3: =
Reticulin stain=20
demo...</FONT></P>
<P align=3Dcenter><A target=3D_blank=20
href=3D"http://www.cancerjournal.net/viewimage.asp?img=3DJCanResTher_2008=
_4_4_164_44286_b1.jpg"><IMG=20
style=3D"BORDER-BOTTOM: #cccccc 1px solid; BORDER-LEFT: #cccccc 1px =
solid; BORDER-TOP: #cccccc 1px solid; BORDER-RIGHT: #cccccc 1px solid"=20
alt=3D""=20
src=3D"http://www.cancerjournal.net/articles/2008/4/4/images/JCanResTher_=
2008_4_4_164_44286_b1.jpg"=20
width=3D135.12 height=3D150></A><BR><FONT class=3Dadlink>Table 1: =
Demographic features=20
...</FONT></P>
<P align=3Dcenter><A target=3D_blank=20
href=3D"http://www.cancerjournal.net/viewimage.asp?img=3DJCanResTher_2008=
_4_4_164_44286_b2.jpg"><IMG=20
style=3D"BORDER-BOTTOM: #cccccc 1px solid; BORDER-LEFT: #cccccc 1px =
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alt=3D""=20
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width=3D150 height=3D62.98></A><BR><FONT class=3Dadlink>Table 2: =
Treatment=20
interventio...</FONT></P>
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href=3D"http://www.cancerjournal.net/viewimage.asp?img=3DJCanResTher_2008=
_4_4_164_44286_b3.jpg"><IMG=20
style=3D"BORDER-BOTTOM: #cccccc 1px solid; BORDER-LEFT: #cccccc 1px =
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width=3D121.46 height=3D150></A><BR><FONT class=3Dadlink>Table 3: =
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f...</FONT></P></BODY></HTML>

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 if (_uanchor && _udlh && _udlh!=3D"") s=3D_udlh+"&";=0A=
 s+=3D_udl.search;=0A=
 var x=3Dnew Date(_udt.getTime()+(_ucto*1000));=0A=
 var dc=3D_ubd.cookie;=0A=
 x=3D" expires=3D"+x.toGMTString()+";";=0A=
 if (_ulink && !_ubl) {=0A=
  z=3D_uUES(_uGC(s,"__utmz=3D","&"));=0A=
  if (z!=3D"-" && z.indexOf(";")=3D=3D-1) { =
_ubd.cookie=3D"__utmz=3D"+z+"; path=3D"+_utcp+";"+x+_udo; return ""; }=0A=
 }=0A=
 z=3Ddc.indexOf("__utmz=3D"+_udh+".");=0A=
 if (z>-1) { z=3D_uGC(dc,"__utmz=3D"+_udh+".",";"); }=0A=
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 t=3D_uGC(s,_ucid+"=3D","&");=0A=
 t2=3D_uGC(s,_ucsr+"=3D","&");=0A=
 t3=3D_uGC(s,"gclid=3D","&");=0A=
 if ((t!=3D"-" && t!=3D"") || (t2!=3D"-" && t2!=3D"") || (t3!=3D"-" && =
t3!=3D"")) {=0A=
  if (t!=3D"-" && t!=3D"") c+=3D"utmcid=3D"+_uEC(t);=0A=
  if (t2!=3D"-" && t2!=3D"") { if (c !=3D "") c+=3D"|"; =
c+=3D"utmcsr=3D"+_uEC(t2); }=0A=
  if (t3!=3D"-" && t3!=3D"") { if (c !=3D "") c+=3D"|"; =
c+=3D"utmgclid=3D"+_uEC(t3); }=0A=
  t=3D_uGC(s,_uccn+"=3D","&");=0A=
  if (t!=3D"-" && t!=3D"") c+=3D"|utmccn=3D"+_uEC(t);=0A=
  else c+=3D"|utmccn=3D(not+set)";=0A=
  t=3D_uGC(s,_ucmd+"=3D","&");=0A=
  if (t!=3D"-" && t!=3D"") c+=3D"|utmcmd=3D"+_uEC(t);=0A=
  else  c+=3D"|utmcmd=3D(not+set)";=0A=
  t=3D_uGC(s,_uctr+"=3D","&");=0A=
  if (t!=3D"-" && t!=3D"") c+=3D"|utmctr=3D"+_uEC(t);=0A=
  else { t=3D_uOrg(1); if (t!=3D"-" && t!=3D"") =
c+=3D"|utmctr=3D"+_uEC(t); }=0A=
  t=3D_uGC(s,_ucct+"=3D","&");=0A=
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  t=3D_uGC(s,_ucno+"=3D","&");=0A=
  if (t=3D=3D"1") o=3D1;=0A=
  if (z!=3D"-" && o=3D=3D1) return "";=0A=
 }=0A=
 if (c=3D=3D"-" || c=3D=3D"") { c=3D_uOrg(); if (z!=3D"-" && =
_ufno=3D=3D1)  return ""; }=0A=
 if (c=3D=3D"-" || c=3D=3D"") { if (_ufns=3D=3D1)  c=3D_uRef(); if =
(z!=3D"-" && _ufno=3D=3D1)  return ""; }=0A=
 if (c=3D=3D"-" || c=3D=3D"") {=0A=
  if (z=3D=3D"-" && _ufns=3D=3D1) { =
c=3D"utmccn=3D(direct)|utmcsr=3D(direct)|utmcmd=3D(none)"; }=0A=
  if (c=3D=3D"-" || c=3D=3D"") return "";=0A=
 }=0A=
 if (z!=3D"-") {=0A=
  i=3Dz.indexOf(".");=0A=
  if (i>-1) i=3Dz.indexOf(".",i+1);=0A=
  if (i>-1) i=3Dz.indexOf(".",i+1);=0A=
  if (i>-1) i=3Dz.indexOf(".",i+1);=0A=
  t=3Dz.substring(i+1,z.length);=0A=
  if (t.toLowerCase()=3D=3Dc.toLowerCase()) cs=3D1;=0A=
  t=3Dz.substring(0,i);=0A=
  if ((i=3Dt.lastIndexOf(".")) > -1) {=0A=
   t=3Dt.substring(i+1,t.length);=0A=
   cn=3D(t*1);=0A=
  }=0A=
 }=0A=
 if (cs=3D=3D0 || _ufns=3D=3D1) {=0A=
  t=3D_uGC(dc,"__utma=3D"+_udh+".",";");=0A=
  if ((i=3Dt.lastIndexOf(".")) > 9) {=0A=
   _uns=3Dt.substring(i+1,t.length);=0A=
   _uns=3D(_uns*1);=0A=
  }=0A=
  cn++;=0A=
  if (_uns=3D=3D0) _uns=3D1;=0A=
  _ubd.cookie=3D"__utmz=3D"+_udh+"."+_ust+"."+_uns+"."+cn+"."+c+"; =
path=3D"+_utcp+"; "+x+_udo;=0A=
 }=0A=
 if (cs=3D=3D0 || _ufns=3D=3D1) return "&utmcn=3D1";=0A=
 else return "&utmcr=3D1";=0A=
}=0A=
function _uRef() {=0A=
 if (_ur=3D=3D"0" || _ur=3D=3D"" || _ur=3D=3D"-") return "";=0A=
 var i=3D0,h,k,n;=0A=
 if ((i=3D_ur.indexOf("://"))<0 || _uGCse()) return "";=0A=
 h=3D_ur.substring(i+3,_ur.length);=0A=
 if (h.indexOf("/") > -1) {=0A=
  k=3Dh.substring(h.indexOf("/"),h.length);=0A=
  if (k.indexOf("?") > -1) k=3Dk.substring(0,k.indexOf("?"));=0A=
  h=3Dh.substring(0,h.indexOf("/"));=0A=
 }=0A=
 h=3Dh.toLowerCase();=0A=
 n=3Dh;=0A=
 if ((i=3Dn.indexOf(":")) > -1) n=3Dn.substring(0,i);=0A=
 for (var ii=3D0;ii<_uRno.length;ii++) {=0A=
  if ((i=3Dn.indexOf(_uRno[ii].toLowerCase())) > -1 && =
n.length=3D=3D(i+_uRno[ii].length)) { _ufno=3D1; break; }=0A=
 }=0A=
 if (h.indexOf("www.")=3D=3D0) h=3Dh.substring(4,h.length);=0A=
 return =
"utmccn=3D(referral)|utmcsr=3D"+_uEC(h)+"|"+"utmcct=3D"+_uEC(k)+"|utmcmd=3D=
referral";=0A=
}=0A=
function _uOrg(t) {=0A=
 if (_ur=3D=3D"0" || _ur=3D=3D"" || _ur=3D=3D"-") return "";=0A=
 var i=3D0,h,k;=0A=
 if ((i=3D_ur.indexOf("://"))<0 || _uGCse()) return "";=0A=
 h=3D_ur.substring(i+3,_ur.length);=0A=
 if (h.indexOf("/") > -1) {=0A=
  h=3Dh.substring(0,h.indexOf("/"));=0A=
 }=0A=
 for (var ii=3D0;ii<_uOsr.length;ii++) {=0A=
  if (h.toLowerCase().indexOf(_uOsr[ii].toLowerCase()) > -1) {=0A=
   if ((i=3D_ur.indexOf("?"+_uOkw[ii]+"=3D")) > -1 || =
(i=3D_ur.indexOf("&"+_uOkw[ii]+"=3D")) > -1) {=0A=
    k=3D_ur.substring(i+_uOkw[ii].length+2,_ur.length);=0A=
    if ((i=3Dk.indexOf("&")) > -1) k=3Dk.substring(0,i);=0A=
    for (var yy=3D0;yy<_uOno.length;yy++) {=0A=
     if (_uOno[yy].toLowerCase()=3D=3Dk.toLowerCase()) { _ufno=3D1; =
break; }=0A=
    }=0A=
    if (t) return _uEC(k);=0A=
    else return =
"utmccn=3D(organic)|utmcsr=3D"+_uEC(_uOsr[ii])+"|"+"utmctr=3D"+_uEC(k)+"|=
utmcmd=3Dorganic";=0A=
   }=0A=
  }=0A=
 }=0A=
 return "";=0A=
}=0A=
function _uGCse() {=0A=
 var h,p;=0A=
 h=3Dp=3D_ur.split("://")[1];=0A=
 if(h.indexOf("/")>-1) {=0A=
  h=3Dh.split("/")[0];=0A=
  p=3Dp.substring(p.indexOf("/")+1,p.length);=0A=
 }=0A=
 if(p.indexOf("?")>-1) {=0A=
  p=3Dp.split("?")[0];=0A=
 }=0A=
 if(h.toLowerCase().indexOf("google")>-1) {=0A=
  if(_ur.indexOf("?q=3D")>-1 || _ur.indexOf("&q=3D")>-1) {=0A=
   if (p.toLowerCase().indexOf("cse")>-1) {=0A=
    return true;=0A=
   }=0A=
  }=0A=
 }=0A=
}=0A=
function _uBInfo() {=0A=
 var sr=3D"-",sc=3D"-",ul=3D"-",fl=3D"-",cs=3D"-",je=3D1;=0A=
 var n=3Dnavigator;=0A=
 if (self.screen) {=0A=
  sr=3Dscreen.width+"x"+screen.height;=0A=
  sc=3Dscreen.colorDepth+"-bit";=0A=
 } else if (self.java) {=0A=
  var j=3Djava.awt.Toolkit.getDefaultToolkit();=0A=
  var s=3Dj.getScreenSize();=0A=
  sr=3Ds.width+"x"+s.height;=0A=
 }=0A=
 if (n.language) { ul=3Dn.language.toLowerCase(); }=0A=
 else if (n.browserLanguage) { ul=3Dn.browserLanguage.toLowerCase(); }=0A=
 je=3Dn.javaEnabled()?1:0;=0A=
 if (_uflash) fl=3D_uFlash();=0A=
 if (_ubd.characterSet) cs=3D_uES(_ubd.characterSet);=0A=
 else if (_ubd.charset) cs=3D_uES(_ubd.charset);=0A=
 return =
"&utmcs=3D"+cs+"&utmsr=3D"+sr+"&utmsc=3D"+sc+"&utmul=3D"+ul+"&utmje=3D"+j=
e+"&utmfl=3D"+fl;=0A=
}=0A=
function __utmSetTrans() {=0A=
 var e;=0A=
 if (_ubd.getElementById) e=3D_ubd.getElementById("utmtrans");=0A=
 else if (_ubd.utmform && _ubd.utmform.utmtrans) =
e=3D_ubd.utmform.utmtrans;=0A=
 if (!e) return;=0A=
 var l=3De.value.split("UTM:");=0A=
 var i,i2,c;=0A=
 if (_userv=3D=3D0 || _userv=3D=3D2) i=3Dnew Array();=0A=
 if (_userv=3D=3D1 || _userv=3D=3D2) { i2=3Dnew Array(); c=3D_uGCS(); }=0A=
=0A=
 for (var ii=3D0;ii<l.length;ii++) {=0A=
  l[ii]=3D_uTrim(l[ii]);=0A=
  if (l[ii].charAt(0)!=3D'T' && l[ii].charAt(0)!=3D'I') continue;=0A=
  var r=3DMath.round(Math.random()*2147483647);=0A=
  if (!_utsp || _utsp=3D=3D"") _utsp=3D"|";=0A=
  var f=3Dl[ii].split(_utsp),s=3D"";=0A=
  if (f[0].charAt(0)=3D=3D'T') {=0A=
   s=3D"&utmt=3Dtran"+"&utmn=3D"+r;=0A=
   f[1]=3D_uTrim(f[1]); if(f[1]&&f[1]!=3D"") =
s+=3D"&utmtid=3D"+_uES(f[1]);=0A=
   f[2]=3D_uTrim(f[2]); if(f[2]&&f[2]!=3D"") =
s+=3D"&utmtst=3D"+_uES(f[2]);=0A=
   f[3]=3D_uTrim(f[3]); if(f[3]&&f[3]!=3D"") =
s+=3D"&utmtto=3D"+_uES(f[3]);=0A=
   f[4]=3D_uTrim(f[4]); if(f[4]&&f[4]!=3D"") =
s+=3D"&utmttx=3D"+_uES(f[4]);=0A=
   f[5]=3D_uTrim(f[5]); if(f[5]&&f[5]!=3D"") =
s+=3D"&utmtsp=3D"+_uES(f[5]);=0A=
   f[6]=3D_uTrim(f[6]); if(f[6]&&f[6]!=3D"") =
s+=3D"&utmtci=3D"+_uES(f[6]);=0A=
   f[7]=3D_uTrim(f[7]); if(f[7]&&f[7]!=3D"") =
s+=3D"&utmtrg=3D"+_uES(f[7]);=0A=
   f[8]=3D_uTrim(f[8]); if(f[8]&&f[8]!=3D"") =
s+=3D"&utmtco=3D"+_uES(f[8]);=0A=
  } else {=0A=
   s=3D"&utmt=3Ditem"+"&utmn=3D"+r;=0A=
   f[1]=3D_uTrim(f[1]); if(f[1]&&f[1]!=3D"") =
s+=3D"&utmtid=3D"+_uES(f[1]);=0A=
   f[2]=3D_uTrim(f[2]); if(f[2]&&f[2]!=3D"") =
s+=3D"&utmipc=3D"+_uES(f[2]);=0A=
   f[3]=3D_uTrim(f[3]); if(f[3]&&f[3]!=3D"") =
s+=3D"&utmipn=3D"+_uES(f[3]);=0A=
   f[4]=3D_uTrim(f[4]); if(f[4]&&f[4]!=3D"") =
s+=3D"&utmiva=3D"+_uES(f[4]);=0A=
   f[5]=3D_uTrim(f[5]); if(f[5]&&f[5]!=3D"") =
s+=3D"&utmipr=3D"+_uES(f[5]);=0A=
   f[6]=3D_uTrim(f[6]); if(f[6]&&f[6]!=3D"") =
s+=3D"&utmiqt=3D"+_uES(f[6]);=0A=
  }=0A=
  if (_udl.hostname && _udl.hostname!=3D"") =
s+=3D"&utmhn=3D"+_uES(_udl.hostname);=0A=
  if (_usample && _usample !=3D 100) s+=3D"&utmsp=3D"+_uES(_usample);=0A=
=0A=
  if ((_userv=3D=3D0 || _userv=3D=3D2) && _uSP()) {=0A=
   i[ii]=3Dnew Image(1,1);=0A=
   i[ii].src=3D_ugifpath+"?"+"utmwv=3D"+_uwv+s;=0A=
   i[ii].onload=3Dfunction() { _uVoid(); }=0A=
  }=0A=
  if ((_userv=3D=3D1 || _userv=3D=3D2) && _uSP()) {=0A=
   i2[ii]=3Dnew Image(1,1);=0A=
   =
i2[ii].src=3D_ugifpath2+"?"+"utmwv=3D"+_uwv+s+"&utmac=3D"+_uacct+"&utmcc=3D=
"+c;=0A=
   i2[ii].onload=3Dfunction() { _uVoid(); }=0A=
  }=0A=
 }=0A=
 return;=0A=
}=0A=
function _uFlash() {=0A=
 var f=3D"-",n=3Dnavigator;=0A=
 if (n.plugins && n.plugins.length) {=0A=
  for (var ii=3D0;ii<n.plugins.length;ii++) {=0A=
   if (n.plugins[ii].name.indexOf('Shockwave Flash')!=3D-1) {=0A=
    f=3Dn.plugins[ii].description.split('Shockwave Flash ')[1];=0A=
    break;=0A=
   }=0A=
  }=0A=
 } else {=0A=
  var fl;=0A=
  try {=0A=
   fl =3D new ActiveXObject("ShockwaveFlash.ShockwaveFlash.7");=0A=
   f =3D fl.GetVariable("$version");=0A=
  } catch(e) {}=0A=
  if (f =3D=3D "-") {=0A=
   try {=0A=
    fl =3D new ActiveXObject("ShockwaveFlash.ShockwaveFlash.6");=0A=
    f =3D "WIN 6,0,21,0";=0A=
    fl.AllowScriptAccess =3D "always";=0A=
    f =3D fl.GetVariable("$version");=0A=
   } catch(e) {}=0A=
  }=0A=
  if (f =3D=3D "-") {=0A=
   try {=0A=
    fl =3D new ActiveXObject("ShockwaveFlash.ShockwaveFlash");=0A=
    f =3D fl.GetVariable("$version");=0A=
   } catch(e) {}=0A=
  }=0A=
  if (f !=3D "-") {=0A=
   f =3D f.split(" ")[1].split(",");=0A=
   f =3D f[0] + "." + f[1] + " r" + f[2];=0A=
  }=0A=
 }=0A=
 return f;=0A=
}=0A=
function __utmLinkerUrl(l,h) {=0A=
 var p,k,a=3D"-",b=3D"-",c=3D"-",x=3D"-",z=3D"-",v=3D"-";=0A=
 var dc=3D_ubd.cookie;=0A=
 var iq =3D l.indexOf("?");=0A=
 var ih =3D l.indexOf("#");=0A=
 var url=3Dl;=0A=
 if (dc) {=0A=
  a=3D_uES(_uGC(dc,"__utma=3D"+_udh+".",";"));=0A=
  b=3D_uES(_uGC(dc,"__utmb=3D"+_udh,";"));=0A=
  c=3D_uES(_uGC(dc,"__utmc=3D"+_udh,";"));=0A=
  x=3D_uES(_uGC(dc,"__utmx=3D"+_udh,";"));=0A=
  z=3D_uES(_uGC(dc,"__utmz=3D"+_udh+".",";"));=0A=
  v=3D_uES(_uGC(dc,"__utmv=3D"+_udh+".",";"));=0A=
  k=3D(_uHash(a+b+c+x+z+v)*1)+(_udh*1);=0A=
  =
p=3D"__utma=3D"+a+"&__utmb=3D"+b+"&__utmc=3D"+c+"&__utmx=3D"+x+"&__utmz=3D=
"+z+"&__utmv=3D"+v+"&__utmk=3D"+k;=0A=
 }=0A=
 if (p) {=0A=
  if (h && ih>-1) return;=0A=
  if (h) { url=3Dl+"#"+p; }=0A=
  else {=0A=
   if (iq=3D=3D-1 && ih=3D=3D-1) url=3Dl+"?"+p;=0A=
   else if (ih=3D=3D-1) url=3Dl+"&"+p;=0A=
   else if (iq=3D=3D-1) url=3Dl.substring(0,ih-1)+"?"+p+l.substring(ih);=0A=
   else url=3Dl.substring(0,ih-1)+"&"+p+l.substring(ih);=0A=
  }=0A=
 }=0A=
 return url;=0A=
}=0A=
function __utmLinker(l,h) {=0A=
 if (!_ulink || !l || l=3D=3D"") return;=0A=
 _udl.href=3D__utmLinkerUrl(l,h);=0A=
}=0A=
function __utmLinkPost(f,h) {=0A=
 if (!_ulink || !f || !f.action) return;=0A=
 f.action=3D__utmLinkerUrl(f.action, h);=0A=
 return;=0A=
}=0A=
function __utmSetVar(v) {=0A=
 if (!v || v=3D=3D"") return;=0A=
 if (!_udo || _udo =3D=3D "") {=0A=
  _udh=3D_uDomain();=0A=
  if (_udn && _udn!=3D"") { _udo=3D" domain=3D"+_udn+";"; }=0A=
 }=0A=
 if (!_uVG()) return;=0A=
 var r=3DMath.round(Math.random() * 2147483647);=0A=
 _ubd.cookie=3D"__utmv=3D"+_udh+"."+_uES(v)+"; path=3D"+_utcp+"; =
expires=3D"+_uNx()+";"+_udo;=0A=
 var s=3D"&utmt=3Dvar&utmn=3D"+r;=0A=
 if (_usample && _usample !=3D 100) s+=3D"&utmsp=3D"+_uES(_usample);=0A=
 if ((_userv=3D=3D0 || _userv=3D=3D2) && _uSP()) {=0A=
  var i=3Dnew Image(1,1);=0A=
  i.src=3D_ugifpath+"?"+"utmwv=3D"+_uwv+s;=0A=
  i.onload=3Dfunction() { _uVoid(); }=0A=
 }=0A=
 if ((_userv=3D=3D1 || _userv=3D=3D2) && _uSP()) {=0A=
  var i2=3Dnew Image(1,1);=0A=
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i2.src=3D_ugifpath2+"?"+"utmwv=3D"+_uwv+s+"&utmac=3D"+_uacct+"&utmcc=3D"+=
_uGCS();=0A=
  i2.onload=3Dfunction() { _uVoid(); }=0A=
 }=0A=
}=0A=
function _uGCS() {=0A=
 var t,c=3D"",dc=3D_ubd.cookie;=0A=
 if ((t=3D_uGC(dc,"__utma=3D"+_udh+".",";"))!=3D"-") =
c+=3D_uES("__utma=3D"+t+";+");=0A=
 if ((t=3D_uGC(dc,"__utmx=3D"+_udh,";"))!=3D"-") =
c+=3D_uES("__utmx=3D"+t+";+");=0A=
 if ((t=3D_uGC(dc,"__utmz=3D"+_udh+".",";"))!=3D"-") =
c+=3D_uES("__utmz=3D"+t+";+");=0A=
 if ((t=3D_uGC(dc,"__utmv=3D"+_udh+".",";"))!=3D"-") =
c+=3D_uES("__utmv=3D"+t+";");=0A=
 if (c.charAt(c.length-1)=3D=3D"+") c=3Dc.substring(0,c.length-1);=0A=
 return c;=0A=
}=0A=
function _uGC(l,n,s) {=0A=
 if (!l || l=3D=3D"" || !n || n=3D=3D"" || !s || s=3D=3D"") return "-";=0A=
 var i,i2,i3,c=3D"-";=0A=
 i=3Dl.indexOf(n);=0A=
 i3=3Dn.indexOf("=3D")+1;=0A=
 if (i > -1) {=0A=
  i2=3Dl.indexOf(s,i); if (i2 < 0) { i2=3Dl.length; }=0A=
  c=3Dl.substring((i+i3),i2);=0A=
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 return c;=0A=
}=0A=
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