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Indian Journal of Medical and Paediatric Oncology
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   Table of Contents - Current issue
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October-December 2019
Volume 40 | Issue 4
Page Nos. 461-600

Online since Monday, February 17, 2020

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EDITORIAL COMMENTARIES  

First-line immunotherapy in advanced non-small-cell lung cancer Highly accessed article p. 461
Vanita Noronha, Prashant Mehta, Prabhat Singh Malik, Amol Patel
DOI:10.4103/ijmpo.ijmpo_210_19  
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Personalized medicine in diffuse large B-cell lymphoma Highly accessed article p. 463
Prashant Mehta, Rahul Bhargava
DOI:10.4103/ijmpo.ijmpo_211_19  
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REVIEW ARTICLE Top

Anthracycline-induced cardiac toxicity: A clinical review Highly accessed article p. 465
Adil Abdelhameed Abbas, Aeshah Abdu Mubarak AlAzmi
DOI:10.4103/ijmpo.ijmpo_106_19  
Anthracyclines (ATCs) have a great efficacy against many types of cancer and is currently considered a cornerstone in the treatment of numerous pediatric and adult hematological and solid tumors. Great advances have been achieved after the entry of ATC group into the cancer treatment in the early 1960s, and the overall survival ratio has increased from 30% to near 70%. Due to their significant role and great value in cancer therapy, which is persistent to date, ATCs are listed in the World Health Organization model list of essential medicines. The clinical use of ATC such as doxorubicin and daunorubicin can be viewed as a sort of double-edged sword. On the one hand, ATCs play an undisputed key role in the treatment of many neoplastic diseases; on the other hand, the administration of ATC is associated with the risk of severe adverse effects. The most common side effect of the ATC group is cardiotoxicity (CTX), which may limit its use and increases mortality and morbidity rates. The clinical use of ATC is limited by unique maximum total cumulative dose (approximately 350 mg/m2) limiting CTX. ATC CTX is cumulative dose-dependent and is in most of the occasions irreversible. Lowering the cumulative dose has been proved to be useful in minimize the risk of heart failure (HF), but, yet, there is a growing concern that HF might occur following doses that were thought to be safe. The average incidence of HF is around 5% at a cumulative dose of 400 mg/m2 that becomes higher above 500 mg/m2, albeit with substantial individual variation. The newer generations ATC medications such as epirubicin, idarubicin, and mitoxantrone were thought to be safer; however, subsequent clinical studies showed more or less similar toxicity profiles. The use of cardioprotective agents (e.g., dexrazoxane and amifostine) has been associated with improved safety range; however, questions are looming on their effect on ATC antitumor effects. An overwhelming amount of clinical evidence suggests that ATCs are too good to be old. Yet, they would look much better if they caused less harm to the heart when administered as either single agents or in combination with otherwise promising new drugs. In this review article, we present a comprehensive account on the ATC and provide up to date data on their clinical use and toxicity profile. In addition, we provide a contemporary approach on the early detection, diagnosis, and treatment of ATC CTX.
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ORIGINAL ARTICLES- BONE & SOFT TISSUE Top

Histopathological spectrum of bone changes in skeletal metastasis p. 476
Asif Baliyan, Rajpal Singh Punia, Reetu Kundu, Harshi Dhingra, Purnima Aggarwal, Sudhir Kumar Garg
DOI:10.4103/ijmpo.ijmpo_142_18  
Background: Metastatic carcinoma is the most common secondary malignant tumor affecting the bone. Bone is the third most common site for metastasis after lung and liver. The present study was planned to analyze the histomorphological patterns of bone changes in metastatic tumors and their correlation with the radiological findings. Materials and Methods: The current prospective study was conducted over a span of 2 years, encompassing 150 patients with clinically and radiologically suspected metastatic bone disease. Bone biopsy samples were studied for the pattern of bone changes. Results: Of 150 total cases, 30 cases had metastatic bone tumors. The age of the patients ranged from 37 to 84 years (mean: 57.57 ± 11.9 years). Male-to-female ratio was 2:1. All patients with metastasis presented with a complaint of pain followed by tenderness (20, 66.7%). The lesions were commonly located in the vertebral column (14, 46.7%), followed by femur (6, 20%). The primary site was known in 21 (70%) cases. The tumor histotypes were adenocarcinoma (23, 76.7%), squamous cell carcinoma (5, 16.7%), pleomorphic sarcoma (1, 3.3%), and malignant melanoma (1, 3.3%). Histomorphological patterns of bone changes were osteolytic (16, 53.3%), mixed (8, 26.7%), and osteoblastic (6, 20.0%). Correlation between the radiological findings and histopathological patterns of metastases was found to be statistically significant. Conclusions: Histomorphological assessment of bone changes in metastasis is an important parameter. Besides the histological categorization of metastatic bone disease, it plays a pivotal role in identification of the primary tumor site.
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ORIGINAL ARTICLES - GASTROINTESTINAL Top

Required treatment expenditures for Hepatitis C virus infection and advantage in the reduction of hepatocellular carcinoma incidence: Analysis of possible options in an endemic area p. 481
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/ijmpo.ijmpo_101_18  
Background: Hepatitis C virus (HCV) infection is a known underlying factor contributing to hepatocellular carcinogenesis. The use of direct-acting antiviral (DAA) medication is a form of clinical management for controlling HCV infection and reducing the hepatocellular carcinoma incidence. This medication is introduced to several endemic areas. The big concern is on the treatment expenditures. Several alternative options are proposed and it is required to assess the effect of each alternative option. Objective: Here, the authors assessed and estimated the required treatment expenditures for HCV infection and advantage in the reduction of hepatocellular carcinoma incidence based on the analysis of possible options in an endemic area. Methods: A medical economics analysis was done. Results: According to the cost–utility analysis, the best alternative option that is hereby recommended is DAA medication coverage for all cases. Conclusion: DAA medication coverage for all cases is recommended.
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ORIGINAL ARTICLES- GYNECOLOGY Top

Clinicoepidemilogical correlation of BRCA 1 and 2 mutations in carcinoma ovary - an Indian perspective p. 484
Anvesh Rathore, S Vishwanath, Subhash Ranjan, Abhishek Pathak, AP Dubey, P Nikhil
DOI:10.4103/ijmpo.ijmpo_67_18  
Introduction: All over the world in 2008, approximately 225,000 women were diagnosed with ovarian cancer, and 140,000 died from this disease.[1] Ovarian cancer is the second-most common gynecologic malignancy in the developed countries. In the developing countries, it is the third-most common gynecologic malignancy after breast and cervical cancer with an incidence of 5.0/100,000 and a mortality rate of 3.1/100,000. Women with BRCA1 gene mutations typically develop ovarian cancer at an earlier age than other women, with an average age at diagnosis of 50-year-old while for patients with BRCA2 mutation carriers it is 60 years, similar to the general population. Aim and Objective: The aim of this study is to study the incidence, clinical profile, and outcomes of a patient with BRCA 1 and BRCA 2 mutation in carcinoma ovary and its comparison with patients without mutation. Results: Out of total 50 patients, 45 (90%) were BRCA negative and rest fi ve (10%) were BRCA positive. Of the five patients, only two (4% of total) had pathological mutations while the rest of three patients had benign mutations only. Overall median age of presentation was 61 years for BRCA-negative patients and 38 years for BRCA-positive patients. Most of the patients presented in Stage III (23 out of 50; 46%), while the second-most common presentation was in Stage IV (34%). In our study, we had an overall mortality of one patient who was BRCA negative, in Stage IV while no mortality was noted in BRCA positive subset of patients. Conclusion: This was a single center-based and spanned over 24 months involving limited number of patients with ovarian cancer with maximum follow-up for 9 months.
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ORIGINAL ARTICLES - HEAD AND NECK Top

Secretory leukocyte protease inhibitor in oral potentially malignant disorders and oral squamous cell carcinoma p. 491
Vidya Ajila, Subhas Babu, Veena Shetty, Shruthi Hegde, Shilpa Shenoy
DOI:10.4103/ijmpo.ijmpo_75_18  
Objectives: Secretory leukocyte protease inhibitor (SLPI) is a protein found in body fluids and implicated as a prognostic factor in many cancers. There is limited research regarding serum and salivary SLPI in oral potentially malignant disorders (OPMDs) and oral squamous cell carcinoma (OSCC). Materials and Methods: A total of 90 participants were included in the study; of which 30 formed the control group, 30 included participants with OPMD, and 30 included participants with OSCC. Serum and salivary levels of SLPI were estimated using enzyme-linked immunosorbent assay. Results: Serum levels of SLPI showed progressive increase in potentially malignant disorders and SCC patients when compared with controls, while salivary levels were increased in both OPMD and OSCC groups as compared to controls. However, the difference between groups was not statistically significant (P < 0.05). Conclusion: The above results suggest that increase in SLPI levels in the serum may have a role in indicating progression of OPMD to OSCC.
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ORIGINAL ARTICLES - HEMATOLOGY Top

Effect of dose and schedule of L-asparaginase administration on early minimal residual disease in acute lymphoblastic leukemia p. 496
Satyanker Gupta, Amit Sehrawat, Ketan Dang, Lalit Sharma, Sarita R. Jaiswal, Suparno Chakarbarti
DOI:10.4103/ijmpo.ijmpo_106_18  
Background and Objectives: L-asparaginase has become the backbone of acute lymphoblastic leukemia induction. In Berlin–Frankfurt–Munster (BFM) 95/2000 protocols, L-asparaginase was given twice weekly for initial 4 weeks. While sufficient L-asparaginase levels are important, there is no apparent correlation between high L-asparaginase levels and minimal residual disease (MRD). In view of toxicities of L-asparaginase, we planned to study the effect of dose and schedule of Escherichia coli-derived L-asparaginase on early MRD by phasing the same total dose, once a week over 8 weeks. Methods: This prospective, observational study enrolled 45 children and young adults ≤40 years. Modified BFM 95 protocol was followed. Weekly 5000 IU/m2 L-asparaginase was given intravenously, and MRD was analyzed at the end of 4 weeks (MRD1) and at 8 weeks (MRD2), using multicolor flow cytometry. MRD positive was defined as residual blasts ≥0.01%. Results: Thirty-one patients were eligible for final analysis. Nine could receive scheduled eight doses of L-asparaginase and 22 patients received less than eight doses. We analyzed age, gender, diagnosis, prednisone response, cytogenetics, central nervous system status, BFM risk group, MRD2, and relapse. L-asparaginase dose association was not statistically significant with respect to MRD2 (P = 0.237). There were no cases of pancreatitis, hypersensitivity, bleeding, or thrombosis. Reasons for patients receiving less than the scheduled eight doses were low serum fibrinogen levels and liver dysfunction. This study revealed 8 MRD1-negative and 13 MRD2-negative patients. Conclusion: L-asparaginase dose intensity does not affect early MRD. Phasing L-asparaginase over 8 weeks could lead to the achievement of more MRD2-negative status and thereby improve long-term outcome. This strategy may also reduce the incidence of adverse drug events.
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ORIGINAL ARTICLES- PEDIATRICS Top

Treatment adherence and abandonment in acute myeloid leukemia in pediatric patients at a low-resource cancer center in India p. 501
Sudha Sinha, Gustav Brattström, Gayatri Palat, Vineela Rapelli, Mikael Segerlantz, Eva Brun, Thomas Wiebe
DOI:10.4103/ijmpo.ijmpo_84_18  
Aim: One of the causes for lower cure rates in acute childhood leukemia in low- and middle- income countries (LMIC) compared to high-income countries is abandonment from treatment. The International Society of Pediatric Oncology (SIOP) defines abandonment as failure to begin treatment or an absence of 4 weeks during treatment. The aim of this study was to evaluate the extent of abandonment among patients diagnosed with acute myeloid leukemia (AML) at the pediatric ward at a low-resource cancer center in India. Methods: Medical records of all patients, aged 0–15 years, diagnosed with AML between January 1, 2014, and March 31, 2015, at the hospital were reviewed. Age, sex, date of diagnosis, and survival during the short follow-up time after completed treatment and information regarding abandonment were collected. SIOP definition of abandonment was used. Eight patients were diagnosed with AML at the hospital whereof 65 met the inclusion criteria of this study. Results: Of the included 65 patients, 6 died before treatment could be initiated and 3 were referred to palliative care upfront. Thus, 56 patients were offered curatively intended treatment. Of these patients, six refused treatment at this stage and another five abandoned during therapy. Altogether, 11 children abandoned treatment. Conclusion: In this study, the abandonment rate from treatment of childhood AML was 20%, which is in concordance from other studies conducted in India and other LMIC, stating that abandonment is a problem and hindrance when treating with a curative intent.
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Radiotherapy in children without anesthesia: A feasibility approach using distraction p. 507
Aswin Anapathoor Nagarajan, Venkatraman Radhakrishnan, Selvaluxmy Ganesharajah
DOI:10.4103/ijmpo.ijmpo_120_18  
Context: Radiotherapy is an important component of treatment of children with cancer. However, delivery of radiotherapy to children is challenging because of the requirement of sedation or anesthesia for immobilization. The present study attempts to highlight our experience of successful delivery of radiotherapy to children with cancer without the use of sedation or anesthesia. Subjects and Methods: The study included pediatric patients <12 years who were treated with radiotherapy at our center between January 2015 and June 2017. Retrospective analysis of patient case records was performed to obtain the treatment details. Results: During the study, 50 children received radiotherapy, among them, 44 (88%) were treated without sedation or anesthesia. The most common diagnosis was acute lymphoblastic leukemia (25%) followed by Ewing's sarcoma (16%) and rhabdomyosarcoma (14%). About 56% of the children belonged to the age group of 1–5 years and 44% belonged to 6–12 years. The latter age group were cooperative and completed the treatment without anxiety. Although the children belonging to 1–5 years age group had anxiety in the commencement of treatment, they completed it without anesthesia, using distraction techniques. There were no treatment delays or physical trauma sustained due to nonusage of sedation or anesthesia. Conclusions: The study shows that with adequate counseling and use of distraction techniques it is possible to deliver radiotherapy to children without the requirement of anesthesia. This practice will be useful for settings were the availability of staff and equipment for anesthesia is limited.
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ORIGINAL ARTICLES- THORACIC Top

Thyroid transcription factor-1 expression in adenocarcinoma lung and its association with histomorphological features p. 510
Saumya Shukla, Nuzhat Husain, Nidhi Anand, Surya Kant, Rajiv Garg, SK Verma, Santosh Kumar, Ved Prakash
DOI:10.4103/ijmpo.ijmpo_199_18  
Objectives: Thyroid transcription factor-1 (TTF-1) expression is frequently associated with adenocarcinoma lung. This study was undertaken with the objectives to assess the expression of TTF-1 in non-small cell lung carcinoma (NSCLC) with adenocarcinoma phenotype and to evaluate the TTF-1 expression with clinicopathological and histomorphological features. Materials and Methods: This was a tertiary care hospital-based case series that included 250 cases of NSCLC. TTF-1 immunostaining along with a basic panel of immunohistochemistry markers was performed. The histomorphological analysis was done to compare the morphological features of TTF-1-positive versus TTF-1-negative cases. Results: TTF-1 was positive in 144 cases (57.6%), while 106 cases were negative for TTF-1. The M: F ratio in the TTF-1-positive group was 1:2, and the mean age of the cases that expressed TTF-1 was 48.5 years. The most common pattern in the TTF-1-positive group was loose clusters or singly dispersed cells (77.78%), followed by the acinar (54.86%) and solid pattern (42.36%). In the TTF-1-negative group, 86.79% of cases had singly dispersed cells or loose cohesive clusters, followed by a solid pattern in 50.94% cases. Conclusion: TTF-1 is a useful and reliable marker for pulmonary adenocarcinoma. TTF-1 expression does not have any association with the patterns and degree of differentiation evident in the tumor.
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ORIGINAL ARTICLES- UROLOGY Top

Management and long-term outcomes of giant mediastinal germ cell tumors in children p. 515
Kashish Khanna, Sandeep Agarwala, Akshay Kumar Bishoi, Sameer Bakhshi, Veereshwar Bhatnagar
DOI:10.4103/ijmpo.ijmpo_80_18  
Purpose: The purpose of the study is to evaluate the outcome of children with giant mediastinal germ cell tumors (GCTs). Materials and Methods: A retrospective study of children diagnosed with GCTs treated at our hospital from 1998 to 2014 was performed. They were evaluated for their tumor size, malignancy, treatment, complications, and outcome. Results: Twelve giant mediastinal GCT patients were included in the study. Age ranged from 7 to 144 months (median 12 months) and all except one were males. The average tumor size was 10.4 cm (range 6 cm × 5 cm–16 cm × 13 cm) and in four patients, they were large enough to occupy nearly the entire hemithorax. Nine children had benign tumors, and these were resected upfront. The remaining three cases with malignant disease received neoadjuvant chemotherapy. No significant reduction in size was noticed in these patients, but alpha-fetoprotein levels decreased in all the three, and they were later resected. Eight (67%) were resected through posterolateral thoracotomy and 4 (33%) through median sternotomy approach. One patient had a dumbbell-shaped thoracoabdominal tumor extending through a Bochdalek hernia. He required additional laparotomy as well as diaphragmatic repair. There were no postoperative complications. The malignant GCTs received total four courses of PEB. All patients were alive and asymptomatic at a mean follow-up of 55.4 months (range 10–146 months). Conclusions: Mediastinal GCTs have bimodal age distribution and show male preponderance. Malignant mediastinal GCTs responded well to neoadjuvant chemotherapy through a reduction in size was not noticed. Complete excision often in coordination with cardiothoracic-vascular surgeons can lead to long-term symptom-free survival even in giant tumors.
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ORIGINAL ARTICLES - OTHERS Top

The Conundrum of Dual Primary Malignancies: Four Years' Experience of a Single Tertiary Care Institute in India p. 521
Niharika Bisht, Sankalp Singh, Arti Sarin, Samir Gupta, Harinder Pal Singh, Amul Kapoor, Deepak Mulajker, Richa Joshi, Abhishek Purkayastha, Prabha Shankar Mishra, Divya Shelly
DOI:10.4103/ijmpo.ijmpo_69_18  
Background: Encountering more than one malignancy in a cancer patient is no longer uncommon; this increasing incidence is mostly attributable to the improvements in life expectancy, awareness, and diagnostic facilities. This article aims to highlight this institute's experience in diagnosis and treatment of patients of multiple primary malignancies and a comprehensive review of literature. Materials and Methods: This is a descriptive study of retrospectively collected data of a single institution over 4 years from 2013 to 2016. Known cases of cancer who were diagnosed with a second primary malignancy were included in the study. Various details such as age, sex, site of disease, temporal relation of two cancers (synchronous or metachronous), family history, tobacco use, treatment given, and survival at 1 year were recorded, organized in a tabular form, analyzed, and described. Results: A total of 29 cases of dual malignancies comprising 0.74% of a total of 3879 patients of cancer were encountered. Seventy-two percent of the cases were metachronous and 5 years was the mean time interval between tumors. There was a female preponderance, and the average age was 56 years. Breast was the most common site of malignancy. At 1 year from diagnosis of second primary, 69% of the patients were alive and 27% were disease-free. Conclusion: Second primary in a patient of cancer is becoming increasingly common and the suspicion of the same should always be borne in mind during follow-up. Prognosis as well as intent of treatment depends on respective stages of the two malignancies.
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Chemotherapy toxicity in elderly population ≥65 years: A tertiary care hospital experience from India p. 531
Aditi Mittal, Amit Agrawal, Sandeep Batra, Chandragouda Dodagoudar, Suhail Qureshi
DOI:10.4103/ijmpo.ijmpo_62_18  
Context: Trials in the elderly have established that older individuals may benefit from chemotherapy to the same extent as younger individuals. Although the elderly patient is a prototype for cancer, very few clinical trials focus on the therapeutic decisions most directly facing older adults. Aims: This study was undertaken to study the chemotherapy-induced severe toxicity among elderly. Settings and Design: This study was a prospective, observational cohort study. The study commenced in October 2014 after obtaining clearance from the hospital ethics and protocol committee. Subjects and Methods: A total of 100 patients were included in the study. All patients were of age ≥65 years, had malignancy, and were planned to start with chemotherapy. Development of Grade 3/4/5 nonhematologic (NH) or Grade 4/5 hematologic (H) toxicities was taken as the development of severe toxicity. Statistical Analysis Used: The quantitative variables were expressed as a mean ± standard deviation and compared using unpaired t-test. P < 0.05 was considered statistically significant. Results: Overall, 64 (64%) patients were able to complete their prescribed treatment. Forty-four patients (44%) of our study cohort experienced Grade 4 H or Grade 3/4 NH toxicity. The most common H Grade 4 toxicities were neutropenia (6%) and thrombocytopenia (5%). The most common NH toxicities were fatigue (18%), infection (10%), and cardiac abnormalities (4%). Conclusions: Less than 50% of elderly patients experience severe chemotherapy-related toxicity. First 30 days are most important for toxicity assessment as 45% of patients experienced toxicity in this time frame.
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Role of stromal myofibroblasts in the progression of oral lesions from dysplasia to invasive carcinoma p. 536
Aeman Khalid, Safia Siddiqui, Nafis Faizi, Jowairiah Hassan, Naila Nehal, Atiuddin Siddiqui
DOI:10.4103/ijmpo.ijmpo_121_18  
Background: Concurrent with the conversion of nondiseased epithelial tissue to precancerous epithelium and finally to carcinoma, the stroma also changes from normal-to-primed to tumor-associated reactive stroma. Cancerous cells secrete cytokines that promote differentiation of fibroblasts into cancer-associated fibroblasts/myofibroblasts. Myofibroblasts are tumor promoting and correlate with poor survival in many cancers. Vimentin expression is noted in epithelial cells of histologically more malignant oral squamous cell carcinoma (OSCC). Aim and Objectives: The aim of this study is to understand the role of tumor microenvironment by analyzing the expression of α-smooth muscle actin (α-SMA) in stromal myofibroblasts and to find a possible association between intensity and pattern of myofibroblast expression and progression of oral lesions from mild, moderate, and severe dysplasia to verrucous and invasive carcinomas. Materials and Methods: The study was divided into two groups. Sixty cases of premalignant lesions and 60 cases of OSCC were taken as the study groups. Smooth muscle cells surrounding the blood vessels were taken as positive control (internal control). Immunohistochemistry (IHC) for α-SMA was performed for the identification of myofibroblasts. The cases were then assessed for intensity and pattern of myofibroblastic proliferation. IHC for vimentin-positive epithelial cells was also done. Results: Fisher's exact test and Chi-square test were used. There was an increased α-SMA expression in malignant cases. Few cases of dysplasia showed focal staining pattern, whereas network pattern predominated in invasive carcinomas. Vimentin expression was seen in histologically more malignant OSCC cases and higher number of myofibroblasts was observed in such cases. Conclusion: Myofibroblasts increase as the disease progresses. Network arrangement of myofibroblasts represents higher invasive characteristics and a weaker prognosis.
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Depression in cancer patients: Magnitude of problem and factors responsible p. 542
Kartick Rastogi, Amrita Rakesh, Subhash Chand Bairwa, Sandeep Bhaskar, Shivani Gupta, Shantanu Sharma, Sandeep Jain
DOI:10.4103/ijmpo.ijmpo_99_18  
Context: Cancer patients usually have various psychological complications, depression being the most common among them. Depression poses difficulties in continuing the prescribed treatment within the scheduled time frame, ultimately affecting the outcome. Aims: The aims of this study were to determine the magnitude of depression and various factors associated with it, to initiate the timely intervention. Subjects and Materials: Brief Edinburgh Depression Scale was used to measure depression in 203 cancer patients who received chemotherapy at Department of Radiotherapy, SMS Medical College, Jaipur; in August 2017, were above 18 years of age, and could read, understand, and write. Association of depression with various factors such as age, gender, education and occupation details, income, marital status, history of other comorbid disease, type and site of cancer, presence of metastases, number of chemotherapy cycles going on, and source of cost of therapy, was also computed. Results: Of 203 patients, depression was present in 130 (64%) patients. Statistically significant association of depression was found with both extremes of the age (P = 0.04), paid treatment (P = 0.03), and <4 chemotherapy cycles (P = 0.04). No significant association was seen between depression and gender, occupation, performance status, site of cancer, presence of coexisting disease, and metastases. Conclusions: The magnitude of depression was high (present in 64% of patients) which often gets unnoticed. Depression should routinely be screened among cancer patients receiving chemotherapy and patients found to have depression should be referred to a psychiatrist for timely management.
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Tobacco cessation: Are oral cancer patients ready for it p. 547
S Sujatha, Asha Iyengar, S Pruthvish, R Priyadharshini
DOI:10.4103/ijmpo.ijmpo_94_18  
Aims: The objective was to examine the predictors of readiness to quit tobacco among oral potentially malignant disorder (OPMD) and oral cancer (OC) patients in dental health care setting. Settings and Design: Two hundred and seven patients diagnosed with OC or OPMDs comprising 153 males and 54 females, with mean age being 52.2 years, with varying levels of addiction formed the study group. Subjects and Methods: Readiness to quit tobacco as measured by the ladder of change and the single-item readiness question was significantly correlated with measures of perceived risk. Statistical Analysis Used and Results: Pearson's correlations showed that readiness to quit tobacco was significantly correlated with the participant's perception of his or her health compared with other tobacco users of the same age (P < 0.005). Readiness to quit was positively correlated with the degree to which participants felt that their oral condition is related to their tobacco use (P < 0.001), how much their general health is affected by tobacco use (P < 0.01), and how much quitting tobacco could influence their health positively (P < 0.001). Post hoc analyses showed that readiness to quit was also significantly and negatively correlated with nicotine addiction (P < 0.001) and decisional balance scores (P < 0.01). Conclusions: There is an urgent need for tobacco risk assessment, intervention, and education with this population of patients, and hence, health professionals can play a significant role in motivating and assisting to quit.
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MEDICO-LEGAL Top

Medical negligence p. 552
Sujit Nilegaonkar, Padmaj Kulkarni
DOI:10.4103/ijmpo.ijmpo_261_19  
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TRAINEES CORNER Top

Challenges in scientific writing p. 554
Amrita Prayag
DOI:10.4103/ijmpo.ijmpo_275_19  
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DRUG REVIEW Top

Trastuzumab deruxtecan: A quantum leap in HER2-positive breast cancer p. 556
Manikandan Dhanushkodi
DOI:10.4103/ijmpo.ijmpo_264_19  
Docetaxel, trastuzumab, and pertuzumab, known as THP, is the preferred first-line treatment for HER2-positive advanced breast cancer, and the second-line drug of choice is trastuzumab emtansine. Most patients eventually develop resistance to systemic therapy. Trastuzumab deruxtecan, a novel HER2-targeted antibody drug conjugate, has shown to be promising in this subset. It is a HER2-targeted antibody drug conjugate structurally composed of humanized anti-HER2 monoclonal antibody, cleavable tetra-peptide-based liker, and a potent payload (topoisomerase 1 inhibitor: Exatecan). A phase 2 trial of heavily pretreated advanced HER2-positive breast cancer (median of six lines of prior therapy) showed an overall response of 61% and a median progression-free survival of 16 months. In December 2019, the Food and Drug Administration announced accelerated approval of trastuzumab deruxtecan for HER2-positive advanced breast cancer patients who were prior exposed to two or more lines of anti-HER2 therapy in a metastatic setting.
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GRAND ROUND Top

Primary adrenal leiomyosarcoma: An extremely rare mesenchymal tumor p. 559
D Lokanatha, Linu Abraham Jacob, M C Suresh Babu, KN Lokesh, Ram Krishna Sai, AH Rudresha, LK Rajeev, Smitha Saldanha, MN Suma, A Usha
DOI:10.4103/ijmpo.ijmpo_270_19  
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ONCOLOGY BEYOND SCIENCE Top

Tryst with fitness p. 563
T VSVGK Tilak
DOI:10.4103/ijmpo.ijmpo_265_19  
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IMAGES IN ONCOLOGY Top

Young man with hodgkin disease with skin rash p. 565
Suresh VS Attili, Janarthan Babu, V Nishit
DOI:10.4103/ijmpo.ijmpo_268_19  
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REPORT ON INTERNATIONAL PUBLICATION Top

Interim-response-adapted therapy in advanced Hodgkin's lymphoma: Current status p. 566
Prasanth Ganesan
DOI:10.4103/ijmpo.ijmpo_276_19  
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CASE REPORTS Top

Paraneoplastic palmar fasciitis and polyarthritis syndrome in a metastatic breast cancer patient: Rare case report p. 570
Amit Sehrawat, Trivikram Rao, Lalit Sharma, KM Parthasarathy
DOI:10.4103/ijmpo.ijmpo_1_18  
Palmar fasciitis and polyarthritis syndrome (PFAPS) is a rare paraneoplastic event that has been reported mainly in ovarian cancers. Clinical diagnosis of PFAPS is characterized by the diagnosis of neoplasm with accompanying flexion contractures, inflammatory fasciitis, fibrosis, and generalized arthritis of the hands. Since first published report, only rare few additional cases of PFPAS have been reported. In this case report, we describe a patient with metastatic breast cancer who subsequently developed PFPAS in association with advanced breast cancer. She had clinical rheumatological symptoms course parallel to her primary breast cancer disease status.
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Giant sacrococcygeal teratoma in neonate: A case report and review of literature p. 573
Rajkumar Motiram Meshram, R Nikila, Nilesh Nagdive
DOI:10.4103/ijmpo.ijmpo_16_18  
Sacrococcygeal teratoma is considered the most common tumor in the neonatal period with a female-to-male ratio of 3–4:1. They are believed to arise early in gestation from the totipotential cells of Hensen's node and the derived ectoderm, mesoderm, and endoderm. A 2.25 kg cesarean-delivered male, term neonate presented with large nonpulsatile, globular erythematous mass with lobulated surface and variable consistency. Magnetic resonance imaging of the lumbosacral spine showed multilocular cystic and solid lesion with foci of calcification and subtle communication with spinal canal. Histopathological examination showed mature endodermal, ectodermal, and mesenchymal elements such as cartilage, glial tissues, keratin cyst, and glandular elements with focus of primary neuroepithelial and pancreatic elements. Entire tumor was excised. The baby expired secondary to wound infection. Early diagnosis by improving antenatal care with timely surgical intervention and good nursing care improves the outcome.
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Importance of cytohistological correlation and diagnostic utility of endoscopic ultrasound in gastric glomus tumor: A case report p. 576
Rakesh Kumar Gupta, Ravindra Kumar Saran, Prithiviraj Nabi, Hirdaya H Nag, Siddharth Srivastava
DOI:10.4103/ijmpo.ijmpo_61_18  
We present a case of gastric glomus tumor (GGT) in a 60-year-old female patient presented with progressive dysphagia for both solid and liquid diagnosed with the help of endoscopic ultrasound (EUS)-guided fine-needle aspiration cytology with histological correlation and detailed immunohistochemistry evaluation. Till date, only seven cases were correctly diagnosed by EUS-guided aspiration cytology. We report this case to highlight the cytological features and importance of EUS in diagnosing GGT.
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Secondary osteosarcoma of pelvic bone: Long-term complication of bladder cancer radiotherapy p. 579
K Siva Prasad, Stalin Bala, Ambalathandi Ravichandran, Gundeti Sadashivudu
DOI:10.4103/ijmpo.ijmpo_77_18  
Second cancer in the irradiated area is one of the complication of radiotherapy of which bone and soft tissue sarcomas predominate. Radiation-induced osteosarcoma (RIOS)accounts for 3.4%–5.5% of all osteosarcoma cases. A 70-year old male presented with complaints of swelling and pain in left gluteal region without any antecedent trauma. On clinical examination 8 × 8 cm size swelling palpable in left gluteal region arising form left iliac bone. He had history of bladder carcinoma 20 years ago for which he received concurrent chemoradiation. CT scan showed a large, erosive and lytic lesion of left iliac bone and biopsy of the lesion was suggestive of osteosarcoma. In view of extensive lesion eroding left half of pelvic bone, surgery was not done, and chemotherapy was planned.
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NEWS AND FILLER Top

Ammunition to immunotherapy: The “Nobel” journey p. 581
HS Darling
DOI:10.4103/ijmpo.ijmpo_90_19  
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PRACTITIONER SECTION Top

Choroid plexus carcinoma enmasked with soft signs and symptoms p. 584
Shruti Appaji, K NV Prasad
DOI:10.4103/ijmpo.ijmpo_83_18  
Choroid plexus carcinomas (CPCs) are rare brain tumors, with preponderance in infants. They are highly invasive tumors with a dismal prognosis. The 5-year survival rates for CPC vary between 10% and 50%. They commonly arise from the lateral ventricles. CPCs in infants present with the subtle features of raised intracranial tension (ICT). Surgical resection is the mainstay of management with adjuvant chemotherapy and radiotherapy. We report a case of 11-month-old child with CPC, presented with subtle nonspecific signs and symptoms of raised ICT, treated by surgical resection and chemotherapy.
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Mucoepidermoid carcinoma of the vulva: A distinct pathological and clinical entity p. 588
Satyendra Narayan Sinha, Brajesh Kumar Choudhary, Sanjay Kumar, Manisha Singh
DOI:10.4103/ijmpo.ijmpo_85_18  
Unlike their major salivary gland counterparts, primary mucoepidermoid carcinoma of the vulva is extremely rare tumor. Here, we describe an unusual case of MEC arising from vulva and a short review of literature. This report describes an interesting and unusual case of mucoepidermoid carcinoma of vulva. A 42-year female presented with approx. 3.5 x 3.0 cm size painless polypoidal growth on right labia majora. CT scan abdomen & pelvis showed 30 x 27 cm size well defined lobulated polypoidal lesion is noted in right side of labia majora. Wide local excision had done with margin. Histological evaluation revealed a typical MEC with negative margin. Our tumor board has decided to keep on close follow-up because of the aggressive behaviour of such type of tumour. Follow-up at 6 months has revealed no evidence of recurrence. This is, to our knowledge, the first report of MEC arising from vulva in India. We report a very rare case of primary mucoepidermoid carcinoma of the vulva and this is the first case reported in India. Treatment strategy for MEC vulva yet to decide and patients should be closely followed-up for life to rule out late recurrence.
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Mistaken identity for gastric carcinoma Highly accessed article p. 591
Ajaz Nabi Koul, Aadil Rafeeq Rather
DOI:10.4103/ijmpo.ijmpo_105_18  
Isolated gastric tuberculosis, without evidence of pulmonary or other gastrointestinal involvement, is extremely rare. Due to inaccurate clinical diagnoses, most patients end up requiring surgical intervention,only after which is gastric tuberculosis diagnosed. we present a case where this dilemma between tuberculosis and malignancy costed the patient half of his stomach.
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LETTERS TO EDITOR Top

Malignancy-associated microangiopathic hemolytic anemia and thrombocytopenia p. 594
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/ijmpo.ijmpo_111_18  
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Pattern of non-hodgkin lymphoma in a tertiary care center in Northeast India using morphology and immunohistochemistry p. 595
Jagannath Dev Sharma, Debanwita Mahanta, Anupam Sarma, Shiraj Ahmed, Lopamudra Kakoti, Amal Chandra Kataki
DOI:10.4103/ijmpo.ijmpo_129_18  
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Cutaneous infarcts and antineutrophil cytoplasmic antibody-positive vasculitis in angioimmunoblastic T-cell lymphoma: A rare presentation p. 598
Ashwin Mahesh, Sandeep Kumar, Abhish Mohan, Niket Verma
DOI:10.4103/ijmpo.ijmpo_133_18  
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