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Indian Journal of Medical and Paediatric Oncology
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January-March 2017
Volume 38 | Issue 1
Page Nos. 1-95

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EDITORIAL  

The science and art of reviewing p. 1
Raghunadharao Digumarti
DOI:10.4103/ijmpo.ijmpo_50_17  
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EDITORIAL COMMENTARY Top

Eribulin approval in advanced liposarcoma – successful drug or a weaker methodology? p. 2
Sameer Rastogi, Vineet Gupta
DOI:10.4103/0971-5851.203492  
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ORIGINAL ARTICLES Top

Financial burden faced by families due to out-of-pocket expenses during the treatment of their cancer children: An Indian perspective p. 4
Latha M Sneha, Jeyanth Sai, S Ashwini, Sunitha Ramaswamy, Mahalakshmi Rajan, Julius X Scott
DOI:10.4103/0971-5851.203493  
Context: Life-saving cancer therapy is costly and may result in financial burden for these families. Financial costs for treating childhood cancer care are traditionally assessed based on the amount spent for diagnostic tests, hospitalization, and chemotherapy. The financial costs for travel, accommodation, out-of-pocket expenses for food, phone bills, and loss of income due to reduction or termination of parental employment are hidden nonmedical expenses that are rarely accounted for. Studies on the financial implications of pediatric cancer treatment are based on the Western model of healthcare with good government/state insurance coverage and hence literature on lifestyle implications for families in developing nations with limited resources is still scarce. Aims: The aim of this study is to find out the details of out-of-pocket expenses incurred by the families during their treatment of cancer children and its implications on their quality of life. Settings and Design: This study was conducted in a tertiary care center for pediatric malignancies for over 1-year period. Subjects and Methods: About seventy families whose children were diagnosed with acute leukemia and undergoing treatment at our center were asked to fill a questionnaire detailing their out-of-pocket expenses. Results: Nonmedical expenses accounts for about 46% of their monthly household income of parents from rural areas and 22% of their household income from urban areas. On an average, a family from rural area spends four times the normal amount spent on home for their daily food expenditure. Thirty-eight percent of families have borrowed money from money lenders with an average interest rate of about 12.5% which pushes them to a state of debt for the next few years. Conclusions: Out-of-pocket expenses contribute a significant proportion to the financial burden of the families with childhood malignancies and these invisible expenses should be recognized and provide adequate support to lessen the burden of this economic impact.
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Profile of primary pediatric brain and spinal cord tumors from North India p. 10
Nadia Shirazi, Meenu Gupta, Nowneet Kumar Bhat, Braham Prakash Kalra, Ranjit Kumar, Manju Saini
DOI:10.4103/0971-5851.203514  
Background and Objective: The study was carried out to find the profile of pediatric brain and spinal cord tumors during 2006–2015 in a tertiary referral center of North India. Materials and Methods: It was a retrospective medical record-based observational study. All children <18 years of age with confirmed histopathological diagnosis of cancer were included in the study. Results: Central nervous system (CNS) tumors constituted 5.6% of all pediatric solid malignancies in our hospital. A total of 54 brain tumors and 13 spinal cord tumors were studied. Medulloblastoma was the most common brain tumor (20.3%) followed by pilocytic astrocytoma (16.6%) and glioblastoma multiforme (9.2%). The most common spinal cord tumor was Ewing's sarcoma/primitive neuroectodermal tumor (30.7%) followed by ependymoma (23%). Mean age was 10.5 years and 12.1 years for brain and spinal cord tumors, respectively. There was male predominance in brain tumors while the sex ratio was almost equal in spinal cord tumors. Histomorphologically, necrosis and angiogenesis were associated with higher grades of tumor. Approximately 35% children were alive after a mean follow-up of 36 ± 6 months. Conclusion: Compared with most international studies, we found a higher percentage of medulloblastoma in the brain, thus stressing the role of regional and ethnic influences in the pathogenesis of CNS tumors.
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Differential toxicities of tyrosine kinase inhibitors in the management of metastatic lung cancer p. 15
Karthik S Udupa, Rejiv Rajendranath, Tenali Sagar, Joseph Thomas
DOI:10.4103/0971-5851.203502  
Introduction: Erlotinib and gefitinib are the most commonly used epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) in the treatment of EGFR mutant nonsmall cell lung cancer (NSCLC). Both erlotinib and gefitinib have shown equal efficacy in terms of response rates and overall survival. Hence, their toxicity profile becomes the most important determining factor in choosing these agents when treating EGFR mutant NSCLC. In this study, we compared the toxicity profile of erlotinib and gefitinib among an Indian subset of lung cancer patients. Materials and Methods: In this prospective nonrandomized study, 85 patients of South Indian origin with NSCLC were tested for EGFR mutation status, and EGFR mutant patients were started on either erlotinib or gefitinib. They were periodically monitored for drug toxicities. Results: Out of the 85 patients tested, 34 patients were positive for EGFR mutation. Eleven of them were started on erlotinib and 23 were started on gefitinib. The most common side effect of TKIs was skin rash. Nine out of the 11 patients started on erlotinib and 7 of the 23 patients started on gefitinib had skin rash. Grade 3 and 4 skin rash was significantly more among patients treated with erlotinib which resulted in treatment delays. Other side effects of TKIs such as diarrhea and deranged liver functions were similar among the both subsets of patients. Conclusion: Skin toxicity is the major and serious side effect with erlotinib among Indian patients with EGFR mutant lung cancer. This resulted in significant treatment delay, which might adversely affect the overall survival of patients. Gefitinib was better tolerated and had a safer toxicity profile compared to erlotinib in Indian patients.
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Taxane combination chemotherapy in breast cancer: Experience from a tertiary cancer centre in India p. 18
Jyoti Bajpai, Deepa Susan, Vijay Patil, Reena Nair, Jaya Ghosh, RA Badwe, Sudeep Gupta
DOI:10.4103/0971-5851.203498  
Aims: Docetaxel, Doxorubicin, Cyclophosphamide (TAC) is an intensive chemotherapy regimen; however, being highly myelosuppressive, its usage is limited in developing countries and hence merits exploration for feasibility and efficacy. Materials and Methods: This was a retrospective audit of medical records of breast cancer patients receiving TAC chemotherapy) from 2004 to 2008. Demographic details, toxicity, and outcome analysis were carried out. Results: A total of 133 patients (126 in [neo] adjuvant and 7 in metastatic setting) received TAC chemotherapy. The median age was 45 (21–67) years; 31% had coexisting diabetes and 12% hypertension. The delivered dose intensity was 94%. Discontinuation rate was 21/133 (15.8%) and the most common reason was hematological toxicity. There were 43 (32%) cases of febrile neutropenia and 2 (1.5%) Grade III thrombocytopenia with 3 (2%) toxic deaths. Grade III gastrointestinal toxicity (diarrhea) occurred in 35 (26%) and cardiac toxicity (congestive cardiac failure) in 2 (1.5%) patients. On univariate analysis, none of the variables (baseline serum albumin, hemoglobin, disease stage, or age) was found significant for chemotoxicity. At a median follow-up of 27 months (0.13–71.30 months), the estimated median disease-free survival (DFS) was 52 months in locally advanced group; however, the early breast cancer cohort has not reached to median DFS. Conclusions: TAC is an effective regimen but has significant toxicity despite the use of primary prophylactic Granulocyte Colony-Stimulating-Factor (G-GSF), including a small possibility of death. It can be considered “practically feasible” regimen in the adjuvant setting in carefully selected, fit patients.
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Treatment challenges and survival analysis of human epidermal growth factor receptor 2-positive breast cancer in real world p. 22
Praveen Adusumilli, Meher Lakshmi Konatam, Sadashivudu Gundeti, Stalin Bala, Lakshmi Srinivas Maddali
DOI:10.4103/0971-5851.203511  
Context: Advent of trastuzumab has brought tremendous changes in the survival of human epidermal growth factor receptor 2 (Her2)-positive breast cancer patients. Despite the availability of the drug, it is still out of reach for many patients. There is very limited real world data regarding treatment challenges and survival analysis of these patients. Aims and Objectives: Primary objective is disease-free survival (DFS) and secondary objective is overall survival (OS) and toxicity profile. Statistics: Statistical analysis is done using GraphPad Prism 7.02. Materials and Methods: This is a retrospective study of all patients diagnosed with Her2-positive (Her2+) nonmetastatic invasive breast cancer from January 2007 to December 2013. Results: In the period of this study, 885 patients are diagnosed with carcinoma breast, of which 212 are Her2/neu positive (23.9%). Of the 212 patients, only 76 (35.8%) patients received trastuzumab along with chemotherapy. Patients receiving trastuzumab with chemotherapy have longer 5-year DFS compared to those receiving chemotherapy alone, 92% and 52.6%, respectively (P = 0.0001). Five-year OS is 90.5% and 41.7% in those patients who received chemotherapy with and without trastuzumab, respectively (P = 0.0001). Seven patients (9.45%) developed Grade II reversible diastolic dysfunction. Grade II/III peripheral neuropathy due to paclitaxel is the main adverse effect seen in 21 patients. Conclusion: In spite of improvement in DFS and OS with trastuzumab, the number of patient receiving targeted therapy is very low due to financial constraints which need to be addressed to bridge the gap in survival of Her2+ patients.
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Clinical profile of pediatric oncology patients treated by external beam radiotherapy: An institutional experience p. 28
Virender Suhag, BS Sunita, Pankaj Vats, Arti Sarin, AK Singh, Mayuri Jain
DOI:10.4103/0971-5851.203497  
Introduction: Pediatric tumors are a heterogeneous group of malignant conditions requiring multimodal treatment, and management of such cases is at time challenging. We present the clinical profile of pediatric cancer patients who received radiation, either alone or as adjuvant to surgery and chemotherapy; in prophylactic, radical or palliative clinical setting. Aim: This study was envisaged to review our experience of pediatric oncology cases, their clinical and morphological profile, dosage schedule of radiotherapy, and the therapy induced complications. Settings and Design: This was a retrospective, observational study carried out in an apex tertiary care cancer institute of government set-up in a developing country. Materials and Methods: The treatment charts and clinical summary of patients who had received radiation over the last 5 years period were retrieved and perused. Various clinical and pathological parameters were studied and inferences drawn. Results: A total of 50 patients got radiation over 5 year study-period, including 37 male and 13 female patients. The commonest age group of presentation was 8-12 years followed by 13-16 years. The mean age of presentation was 9.3 years. The most common diagnosis was hematological malignancies followed by CNS tumors with 21 and 13 patients respectively. Overall the most common indication of RT was in adjuvant setting after surgery as the definitive management, where 24 patients were irradiated; and the next common indication was prophylactic cranial irradiation in 14 patients of childhood leukemias. 10 patients tolerated treatment with Grade 1 site-specific or systemic toxicities while 7 patients developed Grade 2 and more systemic toxicities. 9 patients received craniospinal irradiation, common indications being medulloblastoma and Atypical teratoma rhabdoid tumor (ATRT). 3 patients received concurrent chemotherapy with weekly Inj Vincristine. 17 patients required sedation or short general anaesthesia for radiation planning and execution. Conclusion: External beam Radiotherapy constitutes an important component of management of pediatric cancers. One should be judicious in Radiotherapy planning, execution and monitoring acute and delayed toxicities.
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REVIEW ARTICLES Top

Pediatric osteosarcoma: An updated review p. 33
Shachi Jain Taran, Rakesh Taran, Nagraj B Malipatil
DOI:10.4103/0971-5851.203513  
Osteosarcoma (OS), the most common type of primary malignant bone tumor, is defined by the presence of malignant mesenchymal cells producing osteoid or immature bone. The peak incidence of the most frequent type of OS, i.e., high-grade central OS, occurs in the second decade of life during the adolescent growth spurt. Most patients suffer from the pain and swelling in the involved region and, usually, seek medical attention. Diagnosis is carried out by conventional radiographs, computed tomography, and magnetic resonance image (MRI). In addition, three-phase bone scans, thallium scintigraphy, dynamic MRI, and positron emission spectroscopy are new innovative promising tools. OS can be treated with surgery, radiotherapy, and chemotherapy. There is a clear need for newer effective agents for patients with OS, especially for patients who afflicted with metastatic and recurrence tumor. Monoclonal antibodies directed against OS may prove useful as treatment, either for drug delivery or for radiopharmaceuticals.
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The role of chronic mucosal trauma in oral cancer: A review of literature p. 44
Hitesh Rajendra Singhvi, Akshat Malik, Pankaj Chaturvedi
DOI:10.4103/0971-5851.203510  
Chronic mucosal trauma resulting from sharp teeth, dentures, faulty restoration, or implants has frequently been associated with the development of oral cancer. The definitive evidence for the same is lacking. We undertook a search using the terms – dental trauma, mucosal trauma, oral cancer, squamous cell carcinoma, risk factor, potentially malignant lesion, dental factor, mechanical irritation, dental irritation, and cancer in the following electronic databases: MEDLINE, PubMed, ScienceDirect, Cochrane Database of Systematic Reviews, and Wiley InterScience. The search yielded 788 articles. Of these articles, only 22 articles described chronic mucosal trauma as risk factors for oral cancers and were considered in this review. The review shows that chronic mucosal irritation resulting from ill-fitting dentures may be considered a risk factor for the development of oral cancer, such cancers occur commonly over the lateral border of the tongue. However, no association has been proven between the duration of denture use and cancer formation. In patients without any addiction, such cancers occur more frequently in females. These cancers may present with an early nodal disease but their prognosis and outcomes have not been studied separately till now.
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Indian Council of Medical Research consensus document for the management of non-hodgkin's lymphoma (high grade) p. 51
Dinesh Chandra Doval, Dinesh Bhurani, Reena Nair, Sumeet Gujral, Pankaj Malhotra, Ganpati Ramanan, Ravi Mohan, Ghanshyam Biswas, Satya Dattatreya, Shyam Agarwal, Dinesh Pendharkar, Pramod Kumar Julka, Suresh H Advani, Rupinder Singh Dhaliwal, Juhi Tayal, Rupal Sinha, Tanvir Kaur, Goura K Rath
DOI:10.4103/0971-5851.203500  
This consensus document is based on the guidelines related to the management of Non Hodgkin's Lymphoma (High grade) in the Indian population as proposed by the core expert committee. Accurate diagnosis in hematolymphoid neoplasm requires a combination of detailed history,clinical examination, and various investigations including routine laboratory tests, good quality histology section (of tumor and also bone marrow aspirate/biopsy), immunostaining, cytogenetic and molecular studies and radiology investigations. The staging system used for adult high grade lymphomas is based on the Ann Arbor system and includes various parameters like clinical, haematology, biochemistry, serology and radiology. Response should be evaluated with radiological evaluation after 3-4 cycles and at the end of treatment based on criteria including and excluding PET. Treatment of high grade lymphomas is based on histologic subtype, extent of disease, and age of the patient. Autologous stem cell transplantation after high dose chemotherapy is effective in the treatment of relapsed NHL. Newer RT techniques like 3 dimensional conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) can significantly reduce radiation doses to surrounding normal tissues in lymphoma patients. Patients should be followed up every 3 to 4 months for the first 2 years, followed by 6 monthly for the next 3 years and then annually.
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CASE REPORTS Top

Pheochromocytoma in a child without hypertension: A contribution to the “rule of 10s” p. 59
Prasanta Kumar Tripathy, Kaumudee Pattnaik, Manjushree Nayak, Hiranya Kishor Mohanty
DOI:10.4103/0971-5851.203503  
Pheochromocytoma (PCC) is a neuroendocrine tumor originating from chromaffin tissue in adrenal medulla. Its diagnosis and treatment are well defined in adults, but experience in children is limited. Children constitute only 10% of reported cases, the average age at presentation being 11 years. The most common presentation is sustained hypertension, which is absent in only 10% of children. We managed a 14-month-old female child with PCC, but she was not hypertensive. We report two unusual features, in this case, an extremely young age at presentation and a childhood case of nonhypertensive PCC contributing for “rule of 10s.”
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Hepatic pseudolesion due to “vein of Sappey” in superior vena cava syndrome p. 62
Shitalmala Devi, Thangjam Gautam Singh, Reema Ningthoukhongjam
DOI:10.4103/ijmpo.ijmpo_125_16  
One of the common causes of superior vena cava (SVC) syndrome is malignancy of the lung. The invasion of SVC leads to opening of the various venous channels for continuation of the blood flow from upper extremity and proximal trunk and finally draining into right atrium. Vein of Sappey is one of these channels and it causes focal striking enhancement in segment IV of the liver on arterial phase of contrast computed tomography (CT). This enhancement causes diagnostic difficulty and unnecessary biopsy due to misinterpretation of it as a secondary from lung cancer. Awareness and accurate diagnosis can avoid further examination in such patients. It can also provide an idea of a more proximal major thoracic vessel obstruction if first detected on CT of the abdomen (contrast).
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A rare case of hemangioendothelioma of urinary bladder p. 65
Sumanta Bhattacharya, Indranil Das
DOI:10.4103/ijmpo.ijmpo_123_16  
Hemangioendothelioma is a vascular tumor of endothelial nature of intermediate grade. It most commonly arises from soft tissue of upper and lower extremities. We report a rare case of epithelioid hemangioendothelioma of the urinary bladder. Histologically, it was a vascular tumor formed by smaller capillaries lined by plump epithelioid cells having eosinophilic cytoplasm. Diagnosis was confirmed by immunohistochemistry, as the tumor cells were positive for CD34 and smooth muscle actin.
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PRACTITIONER SECTION Top

A case report of Krukenbergs tumor with cutaneous seeding p. 67
Banavasi Shanmukha Girisha, Tonita Mariola Noronha, Akshata C Alva, Preethi B Nayak
DOI:10.4103/0971-5851.203504  
A 47-year-old female patient presented with painless skin colored and erythematous papules coalesced to form plaques over lower abdomen for 10 days. She had undergone exploratory laparotomy with hysterectomy and bilateral oophorectomy 1 month ago, and histopathology was reported as Krukenbergs tumor. She was getting evaluated for primary, when she was referred to dermatology. A clinical diagnosis of cutaneous infiltration of tumor was made, and biopsy was done from a representative lesion which showed features suggestive of metastatic poorly differentiated adenocarcinoma. In the majority of cases in the past, cutaneous metastasis is seen much later in the course of the disease. High degree of suspicion and histopathology was helpful in the diagnosis of underlying malignancy in our patient.
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A case report of pleuropulmonary blastoma presenting as tension pneumothorax p. 70
Archana Addanki, Krishna Chaitanya, Sandip Bartakke, Srividya Sethuratnam
DOI:10.4103/0971-5851.203515  
Pleuropulmonary blastoma (PPB) is a very rare, highly aggressive, and malignant tumor that originates from either lungs or pleura. It occurs mainly in children aged <5 or 6 years. It has poor prognosis with three different subtypes: cystic (type I), combined cystic and solid (type II), and solid (type III). PPB is treated with aggressive multimodal therapies including surgery and chemotherapy. We present a case of PPB in a 3-year-old girl who presented with tension pneumothorax.
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Significant clinical benefit of pemetrexed-based chemotherapy for advanced diffuse malignant peritoneal mesothelioma: A case presentation p. 73
Milena Peitl, Sven Seiwerth, Martina Bašić-Koretić, Fedor Šantek
DOI:10.4103/0971-5851.203495  
Diffuse malignant peritoneal mesothelioma (DMPM) is generally an understudied disease, largely because most molecular and clinical studies of mesothelioma have been conducted in patients with the more common malignant pleural mesothelioma. We present the case of a 45-year-old male that initially presented with abdominal discomfort and ascites. Diagnostic workup revealed advanced DMPM. Bimodal treatment was stared with cytoreductive surgery and hyperthermic intraperitoneal perfusion with chemotherapy procedure, followed by pemetrexed systemic monotherapy. After the disease progression, and because of a very good previous treatment response to pemetrexed, we decided to rechallenge systemic pemetrexed, along with the introduction of cisplatin. Although the intent behind systemic treatment was at first solely palliative, overall survival after the initial diagnosis was 50 months. Treatment based on rechallenging pemetrexed with or without cisplatin in patients with advanced DMPM can result in a quite satisfactory disease control and symptom management.
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Synchronous malignant phyllodes tumor with skin ulceration and invasive carcinoma as collision tumor p. 78
Rajeshwari K Muthusamy, Sangita S Mehta
DOI:10.4103/0971-5851.203499  
Phyllodes tumor is a rare fibroepithelial biphasic tumor of the breast composed of hypercellular mesenchymal stroma and double-layered epithelial component, arranged in clefts with leaf-like projections. Phyllodes tumor with coincidental presence of invasive carcinoma or in situ ductal carcinoma in the same or distinct breast is a rare occurrence, documented by some reports. Invasive carcinoma can be seen within or outside the phyllodes tumor. Skin ulceration by malignant phyllodes tumor with coexisting invasive carcinoma as collision tumor is extremely rare. Here, we report an extremely rare presentation of malignant phyllodes tumor as a giant fungating mass with distinct invasive carcinoma in the same breast in a 51-year-old female.
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Primary T-cell lymphoblastic lymphoma of the ovary: A case report p. 81
Sweta Singh, Susama Patra, Narbadyswari Deep Bag, Monalisha Naik
DOI:10.4103/0971-5851.203501  
Primary ovarian lymphoma is extremely rare. We report a case of primary T-cell lymphoblastic lymphoma of the ovary in a 31-year-old multiparous woman, who presented with abdominal pain. Her menstrual cycles were regular. There was no generalized lymphadenopathy or fever. On per abdominal examination, there was a firm, tender, solid, mobile mass with well-defined borders, corresponding to 20 weeks gestation, whose lower pole was easily reached. Per vaginum examination revealed a large adnexal mass in the right and anterior fornix. Transabdominal ultrasonography showed bilateral solid ovarian tumor measuring 13.9 cm × 11.8 cm on the right side and 10.0 cm × 6.3 cm on the left side with significant vascularity. Tumor markers were within normal limit except for significantly elevated serum lactate dehydrogenase. Magnetic resonance imaging showed two large solid homogeneous masses, hypointense on T1W1 and hyperintense on T2W1 imaging, with a normal sized uterus and no ascites or lymphadenopathy. The patient developed one episode of left hemiparesis preoperatively, which improved spontaneously. Staging laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy along with infracolic omentectomy was done. Histopathology with immunohistochemistry revealed primary T-cell lymphoblastic lymphoma of the ovary, involving both ovaries left fallopian tube and left serosal surface of fundal region of uterus. She developed generalized convulsions on the 12th postoperative day, and final diagnosis was primary ovarian T-cell lymphoblastic lymphoma Ann Arbor Stage IV. She received three cycles of chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone regimen and was on palliative care. She succumbed to her illness 5½ months postoperatively.
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Primitive neuroectodermal tumor of lung in adult with hemorrhagic brain metastasis: An extremely rare case scenario p. 84
Abhishek Purkayastha, Neelam Sharma, Amul Kapur, Kavita Sahai
DOI:10.4103/0971-5851.203491  
Primitive neuroectodermal tumors (PNETs) are highly malignant neoplasms of embryonal origin manifesting in children and adolescents, rarely seen in adults. Carcinoma lung with hemorrhagic metastasis to the brain is very common, but primary lung PNET with hemorrhagic brain metastasis is extremely uncommon. We hereby report a 29-year-old female diagnosed as PNET lung was treated with vincristine, adriamycin, and cyclophosphamide alternating with ifosfamide plus etoposide followed by radiotherapy (RT). After 9 months, she developed hemorrhagic brain metastasis from PNET lung confirmed from tissue immunohistology postcraniotomy. Received palliative whole brain RT followed by oral pazopanib resulting in significant improvement in performance status. A thorough review of literature reveals that our case may be the second case of primary lung PNET with hemorrhagic brain metastasis and also the first to be exhibited oral pazopanib resulting in a significant therapeutic effect to be reported in world literature till date.
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Squamous cell carcinoma in situ of the cervix with superficial intraepithelial extension to the endometrium of lower uterine segment: A rare presentation p. 88
Rajeshwari K Muthusamy, Sangita S Mehta
DOI:10.4103/0971-5851.203509  
Carcinoma of the cervix is the most common malignancy in women in India. Squamous cell carcinoma accounts for more than 70% of the cervical malignancies. Carcinoma of the cervix generally invades the uterine wall by direct extension with or without parametrial involvement, however, rarely can spread superficially to the inner surface of the uterus replacing the endometrium. It is an uncommon phenomenon for an in situ lesion of the cervix to have contiguous superficial spread to the endometrium. We report a case of cervical in situ squamous cell carcinoma in a 45-year-old female with contiguous extension to the endometrium of the lower uterine segment.
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PERSPECTIVE Top

Short of breath p. 90
Sujith Kumar Mullapally
DOI:10.4103/0971-5851.203505  
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LETTERS TO EDITOR Top

Mixed malarial infection with pancytopenia in a child with acute lymphoblastic leukemia: An unusual presentation p. 92
Venkateswari Ramesh, Naga Malleswari Muddana Venkata, Janani Sankar
DOI:10.4103/0971-5851.203507  
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Cannonball pulmonary metastases in gallbladder cancer p. 93
Rakesh Agarwal, Rashmi Baid
DOI:10.4103/0971-5851.203506  
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Zika virus infection in cancerous patient p. 94
Viroj Wiwanitkit
DOI:10.4103/ijmpo.ijmpo_191_16  
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