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   Table of Contents - Current issue
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October-December 2018
Volume 39 | Issue 4
Page Nos. 425-558

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FROM THE EDITORS DESK  

I bid goodbye! Highly accessed article p. 425
Raghunadharao Digumarti
DOI:10.4103/ijmpo.ijmpo_240_18  
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EDITORIAL COMMENTARY Top

The quest for histology driven neoadjuvant chemotherapy in soft-tissue sarcoma: End of road or just the beginning? Highly accessed article p. 427
Aditi Aggarwal, Atul Sharma, Sameer Rastogi
DOI:10.4103/ijmpo.ijmpo_248_17  
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ORIGINAL ARTICLES Top

Comparison of conventional and advanced echocardiographic techniques in early detection of cardiotoxicity in patients undergoing cancer chemotherapy p. 429
HN Pradeep, George Rupesh, Thazhath J Anil, Krishnan Geethu, TG Jayakumar, S Khadar Abdul
DOI:10.4103/ijmpo.ijmpo_114_17  
Context: The assessment of left ventricular ejection fraction (LVEF) is the most important component in prediction and detection of cardiotoxicity in patients undergoing cancer chemotherapy. LVEF may not be sensitive enough to pick the cardiotoxicity early since drop in LVEF occurs in the last and irreversible stage. A 10%–15% early reduction in global longitudinal strain (GLS) by speckle tracking echocardiography proposed to be the earliest indicator of myocardial dysfunction. Aims: The aim of this study was to compare the early detection of cardiotoxicity (at 0 and 3 months) using drop in LVEF with two-dimensional echocardiography (2DE), three-dimensional echocardiography (3DE), and GLS techniques. Settings and Design: This was a prospective cohort study of patients attending cardiooncology clinic in a tertiary care institute. Subjects and Methods: Newly diagnosed 75 cases of cancer of various etiologies, for whom cardiotoxic chemotherapy drugs has to be used, were included from January 2016 to June 2016. Statistical Analysis Used: Data were analyzed with Pearson's Chi-square test, mean, standard deviation, and 95% confidence interval. Results: A total of 17 (22.6%) subjects out of 75, had drop in LVEF by GLS (<−18.9%) as compared to 5 (6.6%) in 2DE and 7 (9.3%) in 3DE at 3 months with statistically significant P values (P = 0.0001). In the 17 subjects who had significant fall in GLS at 3 months, the mean GLS was −16.17 ± 1.55% with a significant reduction of 13.48% from baseline. Conclusion: Reduction in GLS preceded decrease in ejection fraction. Early detection allows modification of chemotherapeutic regimens and medical intervention preventing the irreversible cardiac damage.
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Assessment of potential drug–drug interactions in an oncology unit of a tertiary care teaching hospital p. 436
Ramya Kuzhikattu Vayalil, K Jayarama Shetty, Uday Venkat Mateti
DOI:10.4103/ijmpo.ijmpo_93_17  
Context: Drug interactions are more common in cancer patients because they consume several medicines such as hormonal substances, anticancer drugs, and adjuvant drugs to treat comorbidities. Objectives: To assess the pattern of potential drug–drug interactions (pDDIs) in an oncology unit of a tertiary care teaching hospital. Materials and Methods: A prospective observational study was carried out for 8 months (August 2016 to March 2017). Data on drugs were collected by reviewing the patients' medical records. The drug interactions fact software version such as Micromedex electronic database system, drugs.com interaction checker, and Medscape multidrug interaction checker tool were used to identify and analyze the pattern of pDDIs. Results: A total of 180 patients were enrolled during the study period. Among them, 152 study patients had 84.44% of pDDIs. Male predominance (64.4%) was noted over female (35.6%). According to the severity of classification of pDDIs, majority of them were moderate (63.1%) followed by major (26.1%) and minor (10.1%) interactions. The interactions that potentially cause QT interval prolongation and irregular heartbeat were the common outcomes of pDDIs. Conclusions: The incidence of pDDIs among cancer patients was 84.44%. The most common interacting drug pair in the study population was found to be dexamethasone + aprepitant [41 (26.9%)] followed by cisplatin + dexamethasone [32 (21.05%)] and other interacting pairs. To avoid harmful effects, screening of pDDIs should take place before administering the therapy.
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Aleukemic leukemia cutis: Case report and review of literature p. 443
Dhauna Karam, Bharat Agrawal
DOI:10.4103/ijmpo.ijmpo_75_17  
Aleukemic leukemia cutis (LC) is an extremely rare clinical presentation. All patients eventually develop acute leukemia, mostly monocytic and myelomonocytic types. It is a diagnostic challenge, resolved by careful immunophenotyping and cytochemistry. The diagnosis indicates a poor prognosis. Here, we report a case of an 85-year-old white male with LC, who had normal peripheral blood and bone marrow histology. The fragility of our patient precluded any definite anti-leukemic therapy.
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Incidence of urogenital neoplasms in India p. 446
Satyanarayana Labani, Dishank Rawat, Smita Asthana
DOI:10.4103/ijmpo.ijmpo_76_17  
Objective: To study and compare the national and regional incidences and risk of developing of neoplasms of individual urogenital sites using 2012 – 2014 reports from the National Cancer Registry Programme (NCRP) data. Materials and Methods: A number of incident cases, age-adjusted rates (AARs), and cumulative risk (0 – 64 years) pertaining to urogenital neoplasms, along with the ICD-10 codes, were extracted. Data on indicators, namely number of incident cases, AARs and one in a number of persons develop cancer were summarized for both the sexes in each of the cancer registries and presented region-wise in the form of ranges. Results: The proportion of all urogenital neoplasms in comparison to all cancers was 12.51% in women and 5.93% in men. Risk of development of urogenital cancers for women was maximum (1 in 50) in the North-eastern region, followed by Rural West, South, and North. For men, the risk of developing neoplasms of urogenital sites was highest (1 in 250). For the neoplasms of the renal pelvis and ureter, both the incidence and risk were quite low for all genders across all the regions. Cervical neoplasms had the highest incidence (4.91 – 23.07) among female genital neoplasms, while prostate had the highest incidence (0.82 – 12.39) among male genital neoplasms. Conclusion: Making people aware of urogenital neoplasms and their risk factors are important for the public health awareness point of view. Centers that deal with either management of urogenital cases or/and screening of genital neoplasms could serve as the designated centers for creating such awareness.
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Opportunistic screening for detection and socio-epidemiological risk assessment of oral cancer patients in rural Jodhpur, India p. 452
Jitendra Kumar Meena, Anjana Verma, Sandeep Kumar Upadhyay
DOI:10.4103/ijmpo.ijmpo_90_17  
Background: Globally, India has a high burden (20%) of oral cancer with 1% prevalence of premalignant lesions. Most cases are attributed to modifiable risk factors such as substance abuse (tobacco and alcohol), dietary deficiencies, and environmental exposures (solar radiation and air pollution) aggravated by delayed detection and care especially in rural areas. Objective: The objective of the study was to study the risk factors of oral cancer pathogenesis among the rural residents of Jodhpur, India, through opportunistic oral screening approach at primary care facilities. Methodology: An unmatched case–control study was done at two randomly chosen rural health centres in Jodhpur, India. A total of 84 cases and 168 controls were included during 6 months study period (2016). Randomly selected outpatient department attendees were interviewed and screened for oral cancer and premalignant lesions. A structured questionnaire interview along with comprehensive oral, head and neck examination was conducted. Data were analyzed using multivariate logistic regression, and confidentiality of data was maintained. Results: The majority of the study participants were rural residents (82.9%) with poor socioeconomic status. Opportunistic oral screening revealed a variety of cancerous and precancerous lesions. Most common case pathologies were submucosal fibrosis (40.5%), inadequate mouth opening (35.7%), cheek bites (28.6%), leukoplakia (23.8%) etc. Multivariate analysis suggested that tobacco intake (adjusted odds ratio = 13.6, P ≤ 0.01) dietary deficiency (7.4, <0.01), oral sepsis (7.0, <0.01), oral lesions (6.8, <0.01), and sun radiation exposure (9.5, <0.01) were significantly associated with oral cancer pathology. Conclusion: The study provides strong evidence that tobacco, dietary deficiency, oral sepsis and lesions, and sun radiation exposure are independent risk factors for oral cancer. It also reiterates the importance and application of opportunistic oral cancer screening at primary care level.
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Ecological analysis to study association between prevalence of smokeless tobacco type and head-and-neck cancer p. 456
Devyani Dilip Gholap, Pankaj Chaturvedi, Rajesh Prabhakar Dikshit
DOI:10.4103/ijmpo.ijmpo_97_18  
Context: Head-and-neck cancers (HNCs) are most common cancer in Indian cancer registries. However, there is a huge variation and heterogeneity in use of different types of smokeless tobacco (SLT) consumption across India. Aims: The aims and objectives of this study were to investigate how different types of SLT use are distributed across Indian states and examined its association with different subsites of HNC incidence rates. Settings and Design: Ecological analysis of correlation between SLT prevalence and incidence rates from population-based cancer registries. Methods: Incidence data was extracted from population-based cancer registries report from the National Cancer Registry Programme database 2012–2014. The current SLT uses the prevalence of all Indian States and Union territories from Global Adult Tobacco Survey 2009–2010. Statistical Analysis Used: Pearson's correlation coefficient was used to estimate an ecological correlation between the prevalence of types of SLT uses in different region of India and age-adjusted incidence rate of different subsites of HNC. Results: In our brief analysis, we found a significant correlation between certain types of SLT use and subsite of HNC. Betel quid and tobacco use are correlated (r = 0.53) with oropharynx cancer incidence. Khaini use is correlated with hypopharynx cancer incidence (r = 0.48). Gutka use is correlated with mouth cancer incidence (r = 0.54). Oral tobacco is correlated with mouth cancer incidence (r = 0.46). Other SLT use is correlated for hypopharynx cancer incidence (r = 0.47). Conclusions: The variations in SLT use across Indian states account for differences in incidence rates of HNC subsites across the states. The inferences from this brief analysis can be used as a base to modify and design observational epidemiological studies in the future.
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Compliance of cigarettes and other tobacco products act among tobacco vendors, educational institutions, and public places in Bengaluru City p. 463
Naveen Chandrahas Khargekar, Arpan Debnath, Nitin Ravindra Khargekar, Punith Shetty, Vandana Khargekar
DOI:10.4103/ijmpo.ijmpo_136_17  
Background: Tobacco has been the arch criminal of most head-and-neck cancers in the world. Many laws have been implemented to control this menace, but still this slow poison persists. Effectiveness of these laws has always been a matter of concern to the authorities. The present study was conducted to observe the compliance of Cigarettes and Other Tobacco Products Act (COTPA) among public places, educational institutions, and tobacco vendors in Bengaluru city. Methodology: A cross-sectional, observational study was done to assess the violations at public places, educational institutions, and tobacco vendors. Violations for Sections 4, 5, 6, and 7 of COTPA were assessed from 25 each of these places in the eight zones of Bengaluru city. The study areas were chosen by convenience sampling method, and using a questionnaire, the violations were recorded. Data were analyzed in Microsoft Excel to find out the percentage of violations. Results: The COTPA Sections 4 and 5 violation was 134 (67%) and 94 (47%), respectively. A total of 124 (62%) of the educational institutions had tobacco vendors within 100 yards, and only 30 (15%) had signboard for the prohibition of tobacco use. Around 14 tobacco vendors had beedis without proper pictorial warning with them which violated Section 7 of COTPA. Conclusion: For proper implementation of COTPA laws, we should create awareness about the laws, what amounts to violations and also the health hazards to tobacco use among general population. The law enforcing personnel should act on those who violate the law. There is a need for a sensitization workshop and advocacy for all the stakeholders.
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Weekly versus tri-weekly cisplatin concurrent with radiotherapy in the treatment of locally advanced carcinoma cervix: A prospective study p. 467
Bhaskar Sandeep, Jain Sandeep, Rastogi Kartick, Bhatnagar Aseem-Rai, Sharma Neeraj
DOI:10.4103/ijmpo.ijmpo_89_17  
Context: Different schedules of concurrent chemotherapy with definitive radiotherapy in locally advanced carcinoma cervix. Aims: The aim is to evaluate toxicity, compliance, and response of weekly versus tri-weekly cisplatin given concurrently with radiotherapy in locally advanced squamous cell carcinoma cervix. Subjects and Methods: One hundred and ten newly diagnosed histopathologically confirmed squamous cell carcinoma cervix patients with International Federation of Gynecologists and Oncologists stage IIB to IVA were randomly distributed among study group receiving 75 mg/m2 of cisplatin every 3 weeks for three cycles and control group receiving 40 mg/m2 of weekly cisplatin for six cycles. Results: Patients in both the arms tolerated treatment well. At the time of completion of chemoradiotherapy, 83.63% of patients of the study group and 80% of the control group had a complete response whereas 16.37% of study and 20% of the control group had a partial response, both statistically insignificant (P > 0.05). Compliance was similar in both the groups. The average time to complete radiotherapy was 54.63 days in the study group and 51.34 days in the control group. In the study group, 87.27% of patients completed all cycles of tri-weekly chemotherapy, whereas, in control group, 80% completed all 6 cycles of weekly chemotherapy. The difference was not statistically significant (P = 0.30). Toxicity in terms of vomiting, grade 3–4 leukopenia and neutropenia were more in the study group which was statistically significant (P < 0.001, P = 0.04, and P = 0.03, respectively). Conclusions: Although the 3-weekly cisplatin schedule has longer intervals and sounds convenient, the weekly cisplatin regime shows lower hematologic toxicity with similar disease response and compliance.
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The correlation between the level of doxorubicin-induced cardiac damage and serum soluble Fas in an experimental rat model p. 473
Dogan Kose, Hulya Ozdemir, Zeliha Esin Celik, Ali Unlu, Hasibe Artac, Yavuz Koksal
DOI:10.4103/ijmpo.ijmpo_82_17  
Aim: This study was planned to research the relationship between doxorubicin cardiomyopathy and the soluble Fas (sFas) level. Materials and Methods: Two groups of rats were included in the study. The control group was given physiological saline, while the study group was given doxorubicin. The rats, whose blood samples were taken weekly, were sacrificed and their myocardial tissues were removed. The tissues were examined in terms of morphological changes and surface Fas expression, while the blood samples were examined in terms of sFas level. Results: In the study group, the sFas levels at 2nd–9th weeks were higher than those found at 1st week before administrating the drug, and the increase at 2nd–7th weeks was meaningful. In addition, sFas levels were gradually increased each week during 1st–5th weeks when compared to the values of a previous week, and the increase during the first 4 weeks was meaningful. After the 5th week, the values gradually decreased each week. The mean values of the study group at 1st–8th weeks were higher than those of the control group, and the increases at 2nd–8th weeks were meaningful. The severe forms of interfibrillar hemorrhage, vascular dilatation, myocardial necrosis, inflammatory infiltration, and splitting of muscle fibers occurred with 15, 15, 17.5, 20, and 22.5 mg/kg dose of medicine, respectively. Conclusions: As the tissue injury increased, the increasing cell-surface Fas expression and sFas plasma level at the acute phase of doxorubicin-related cardiotoxicity decreased. The sFas level determined at acute phase may be helpful in predicting the existing injuries and possible late-term problems.
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Oral cancer with verrucous pattern is not associated with human papilloma virus in Indian population p. 479
Swagnik Chakrabarti, Devmalya Banerjee, Burhanuddin Nuruddin Qayyumi, Deepa Nair, Sudhir Nair, Subhada Kane, Pankaj Chaturvedi
DOI:10.4103/ijmpo.ijmpo_122_17  
Background: The etiology of verrucous lesions of the oral cavity is debatable, and many western studies attribute it to human papillomavirus (HPV) infection. Although most Indian studies have found a strong association with tobacco chewing, the role of HPV has not been studied in the Indian context. Materials and Methods: A prospective study was conducted on the clinicopathological profile of 21 consecutive patients of verrucous lesions of the oral cavity. The patients were evaluated on the basis of addictions, pretreatment biopsy, p16 immunohistochemistry (IHC), and histopathological parameters. Results: Preoperative incisional biopsy revealed no dysplasia in 52.38%, mild-to-moderate dysplasia in 19.04%, and invasive carcinoma in 28.57% of the patients. About 67% of patients underwent surgical excision in our institute all of whom had invasive malignancy on final histopathology. This included 42.85% patients whose initial biopsy was no or mild dysplasia. All of the patients were negative for p16 IHC. Conclusions: Verrucous lesions in Indian population are caused by smokeless tobacco unlike that in the western countries where HPV is the main etiology. Clinical distinction between benign and malignant lesions is difficult, and we recommend complete surgical excision of the lesion with adequate margins whenever possible.
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Second malignant neoplasms in children and adolescents treated for blood malignancies and solid tumors: A single-center experience of 15 years p. 483
Nikolaos Katzilakis, Maria Tsirigotaki, Maria Stratigaki, Eleni Kampouraki, Emmanouil Athanasopoulos, Erasmia Athina Markaki, Antonis Kattamis, Eftichia Stiakaki
DOI:10.4103/ijmpo.ijmpo_102_17  
Context: The occurrence of second malignancies is not rare in children treated for primary tumors. Objectives: The aim of this study was to investigate the occurrence and the outcomes of second malignancies in children and adolescents from a large tertiary pediatric hematology-oncology center. Materials and Methods: A retrospective study was performed looking into the characteristics and outcomes of second malignant neoplasms in children and adolescents treated for primary malignancies in a single center over a 15-year period. Results: Among 270 children and adolescents treated for hematological malignancies and solid tumors from 2000 to 2015, five cases of second malignancy were diagnosed including cancer of the parotid gland, renal cell carcinoma, Hodgkin's lymphoma, thyroid carcinoma, and transitional liver cell carcinoma in patients previously treated for acute myeloid leukemia, glioblastoma multiforme, B-acute lymphoblastic leukemia, Langerhans cell histiocytosis, and medulloblastoma, respectively. Primary malignancies were treated with chemotherapy in all cases and four out of five patients had also received radiotherapy. Mean age at diagnosis of second malignancy was 10 years and 4 months. Overall survival after diagnosis of second malignancy was 80% at 12 months and 75% at 5 years. Conclusions: Close surveillance and long-term follow-up are mandatory for the identification of late effects in children treated for malignancy.
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Multidisciplinary treatment of pediatric low-grade glioma: Experience of children cancer hospital of Egypt; 2007-2012 p. 488
Mohamed Ahmed Fawzy, Ahmed Ibrahim El-Hemaly, Madeeha Awad, Mohamed El-Beltagy, Mohamed Saad Zaghloul, Hala Taha, Amal Rifaat, Amal Mosaab
DOI:10.4103/ijmpo.ijmpo_79_17  
Background: Pediatric gliomas comprise a clinically, histologically, and molecularly heterogeneous group of central nervous system tumors. The survival of children with gliomas influenced by histologic subtype, age, and extent of resection. Tumor grade emerged as the most determinant of survival except in the young age groups. The aim of this study was to evaluate the role of multidisciplinary therapeutic approach including surgery and chemotherapy, and their impact on the outcome in pediatric patients with low-grade glioma (LGG). Procedure: Study patients were prospectively enrolled onto the study. All patients were below 18-year-old, diagnosed as LGG between July 2007 and June 2012. Upfront surgical resection was attempted in all tumors other than optic pathway sites. Systemic chemotherapy was given according to CCG-A9952 protocol. Results: Total/near-total resection in 105/227 (46.3%) without adjuvant treatment, while 49/227 patients (21.5%) underwent subtotal tumor resection followed by chemotherapy for big residual (n = 26). Follow-up only was indicated for asymptomatic/small residual (n = 23). The radiological diagnosis was set in 18/227 (7.9%) patients; 13/18 had optic pathway glioma. The 3-year overall survival (OS) was 87.3% versus 65.5% event free survival (EFS) for the whole study patients with a follow-up period of 1–5 years. The OS and EFS for patients who did surgery with no adjuvant treatment (n = 128) were, respectively, 95.2% and 77.3% versus 87.4% and 65.1% for adjuvant chemotherapy group (n = 99); (P = 0.015 and P = 0.016 for OS and EFS, respectively). Conclusion: Pediatric LGGs comprise a wide spectrum of pathological and anatomical entities that carry a high rate of prolonged survival among children and adolescents. Surgical resection is the mainstay of treatment in most of tumors. Combined chemotherapy can be an acceptable alternative when surgery is not safely feasible.
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Tyrosine kinase inhibitor versus physician choice chemotherapy in second-line epidermal growth factor receptor mutation non-small cell lung cancer: Post hoc analysis of randomized control trial p. 493
Vanita Noronha, Avinash Pandey, Vijay Patil, Amit Joshi, Anuradha Bharat Choughule, Atanu Bhattacharjee, Rajiv Kumar, Supriya Goud, Sucheta More, Anant Ramaswamy, Ashay Karpe, Nikhil Pande, Arun Chandrasekharan, Alok Goel, Vikas Talreja, Abhishek Mahajan, Amit Janu, Nilendu Purandare, Kumar Prabhash
DOI:10.4103/ijmpo.ijmpo_219_17  
Background: There is a paucity of prospective data for patients who progressed after first-line tyrosine kinase inhibitor (TKI) or pemetrexed doublet among epidermal growth factor receptor (EGFR) mutation-positive metastatic non-small cell lung cancer (NSCLC). Aim: The aim of the study was to evaluate the outcome of second-line therapy in patients who progressed on TKI or pemetrexed doublet in EGFR mutation-positive NSCLC. Objective: The objective of the study was to calculate response rates, progression-free survival (PFS), and overall survival (OS) of patients receiving second-line therapy in EGFR mutation NSCLC. Materials and Methods: Post hoc analysis of second-line therapy among patients enrolled in randomized control trial comparing TKI versus pemetrexed doublet in EGFR mutation NSCLC. Kaplan–Meir statistics were used for PFS and OS. Impact of variables was measured with Log-rank test. Results: One hundred and eighty-seven patients who progressed on first-line therapy and received second-line agents were analyzed. Male:female: 110 (56.3%):77 (41.2%). One hundred and thirteen patients received gefitinib, while 74 received chemotherapy. Response rate (complete response + partial response) was 53% versus 24% in gefitinib versus chemotherapy group (RECIST v1.1). PFS was 7.4 months versus 4.4 months (P = 0.001), while OS was 14 months versus 9.7 months (P = 0.007), in gefitinib versus chemotherapy group, respectively. Response to TKI significantly improves PFS (10.8 months vs. 3.9 months, P = 0.001) and OS (21.4 months vs. 8.9 months, P = 0.03). Rash, pruritus, dry skin, fatigue, diarrhea, and paronychia were common toxicities of TKI. Conclusion: Second-line TKI improves outcome in EGFR mutation-positive NSCLC who progressed after first-line chemotherapy. Response to therapy, whether with TKI or chemotherapy, favorably impacts outcomes.
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REVIEW ARTICLES Top

Use of organoids technology on study of liver malignancy p. 499
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/ijmpo.ijmpo_126_17  
The study on liver cancer has been performed in clinical medicine and medical science for a long time. Within the few recent years, there are many new emerging biomedical technologies that help better assess on the liver cancer. Of several new technologies, the advanced cell technologies for the assessment of liver cancer, organoids technology is very interesting. In fact, the organoids is an advanced cell research technique that can be useful for studying of many medical disorders. Organoids can be applied for study on the pathophysiology of many cancers. The application for studying on liver cancer is very interesting issue in hepatology. In this short article, the author summarizes and discusses on applied organoids technology for studying on various kinds of liver cancers. The application can be seen on primary hepatocellular carcinoma, metastatic cancer, cholangiocarcinoma, hepatoblastoma, as well as other rare liver cancers.
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Revised myeloproliferative neoplasms working group consensus recommendations for diagnosis and management of primary myelofibrosis, polycythemia vera, and essential thrombocythemia p. 503
Mohan B Agarwal, Hemant Malhotra, Prantar Chakarborti, Neelam Varma, Vikram Mathews, Jina Bhattacharyya, Tulika Seth, K Gyathri, Hari Menon, PG Subramanian, Ajay K Sharma, Maitreyee Bhattacharyya, Jay Mehta, Sandeep Shah, PK Gogoi, Reena Nair, Usha Agarwal, Subhash Varma, SVVS Prasad, Deepak K Mishra
DOI:10.4103/ijmpo.ijmpo_88_17  
Myeloproliferative neoplasms (MPNs) are clonal disorders, derived from abnormal hematopoietic stem cells and result in an excessive production of blood cells. This MPN group of conditions encompasses different diseases with overlapping clinical and biologic similarities. The majority of the conventional therapies of MPN are palliative in nature. However, with the discovery of Janus Kinase 2 (JAK2) mutation and development of targeted JAK1/2 inhibition therapy, the therapeutic options in treatment landscape have changed dramatically. This article presents the revised Indian MPNs Working Group consensus recommendations. It highlights and brings into attention about the recent findings that have defined the state of the art of the diagnosis and therapy in the MPN area, including identification of the new driver and prognostic mutations, treatment goals in the management of myelofibrosis and polycythemia vera (PV), role of the recently approved, targeted tyrosine kinase inhibitor ruxolitinib in PV, and special issues such MPN consideration in patients with splenic vein thrombosis and the management of the disease in pregnancy.
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PRACTITIONER SECTION Top

Tubercular mastitis masquerading as carcinoma breast in elderly female: A diagnostic dilemma p. 516
Aditi Das, Hemlata Panwar, Nighat Hussain
DOI:10.4103/ijmpo.ijmpo_103_17  
Tubercular mastitis (TM), a great masquerader, is extremely rare in elderly. Diagnosis becomes challenging when patient's age and clinical features favor carcinoma, as in our case, where a 70-year-old female presented with right breast lumps associated with overlying ulcers and right supraclavicular lymphadenopathy. Fine-needle aspiration cytology of breast lump and lymph node followed by special staining and culture confirmed TM and lymphadenitis. Antitubercular therapy was initiated, and the patient got prompt relief. Here, we have discussed clinicocytological aspects of TM mimicking as carcinoma breast and diagnostic approach that should be undertaken. The case highlights the value of precise diagnosis, as specific treatment is indicated for tubercular and other granulomatous mastitis; placing an emphasis on meticulous investigation to rule out possibility of lethal malignancy in elderly; and necessity to always keep possibility of even rare entity like TM, irrespective of age, especially in India, where tuberculosis is endemic.
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Reversible hypopigmentation with pazopanib p. 519
BJ Srinivasa, Bhanu Prakash Lalkota, Pramod S Chindar, Radheshyam Naik
DOI:10.4103/ijmpo.ijmpo_104_17  
Tablet Pazopanib known to cause Hypo pigmentation and Hyperpigmentation as per various literature reports. We report here a case of reversible hypopigmentation with Pazopanib in a patient treated for spindle cell sarcoma. Patient did not have any clinical symptoms except for cosmetic significance.
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An unusual presentation of prostate carcinoma p. 521
Greeshma Sadasivan, R Arul, A Prabaharan
DOI:10.4103/ijmpo.ijmpo_37_17  
Prostate carcinoma is the second most common cancer among men worldwide. Although prostate carcinoma is common, its presentation resembling retroperitoneal fibrosis is uncommon. We report a patient with prostate carcinoma mimicking retroperitoneal fibrosis. An elderly male presenting in a volume overload state with features of obstructive uropathy was diagnosed as a case of prostate carcinoma. Magnetic resonance imaging was suggestive of retroperitoneal fibrosis. The presentation of prostate carcinoma as retroperitoneal fibrosis is rare.
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Pneumomediastinum and subcutaneous emphysema in the neck, axilla, and chest regions in a patient with olfactory neuroblastoma treated with chemoradiotherapy p. 524
Radha Kesarwani, Seema Pandey, Anil Kumar Maurya, Virendra Singh
DOI:10.4103/ijmpo.ijmpo_85_17  
Spontaneous pneumomediastinum and subcutaneous emphysema in the neck, axilla, and chest do not commonly occur after neoadjuvant cisplatin/etoposide chemotherapy, followed by radiotherapy, and adjuvant cisplatin/etoposide chemotherapy in patients with olfactory neuroblastoma. There are few case reports of pneumomediastinum induced by and occurring during bleomycin/etoposide/cisplatin chemotherapy in testicular cancer. The present case differs from the previous cases in that our patient developed spontaneous pneumomediastinum and subcutaneous emphysema in the neck, axilla, and chest approximately 2 months after completion of chemoradiotherapy for olfactory neuroblastoma. These conditions may have been treatment induced or caused by breath-holding after forceful inspiration. The latter would have created a massive pressure gradient between the alveoli and surrounding structures, causing alveolar rupture, and subsequent passage of air into the mediastinum and subcutaneous tissue of the neck, axilla, and chest.
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Epithelioid sarcoma presenting as recurrent thumb ulcer: A lesson to learn p. 527
Lakkavalli Krishnappa Rajeev, Vikas Asati, Suresh Babu Mallekavu, K Govind Babu, G Champka
DOI:10.4103/ijmpo.ijmpo_87_17  
Epithelioid sarcoma (ES) first described by Enzinger in 1970,[1] is a rare soft-tissue sarcoma typically presenting as a subcutaneous or deep dermal mass in distal portions of the extremities of adolescents and young adults. They are frequently mistaken for ulcers, abscesses, or infected warts that fail medical management. Patients often develop multiple local recurrences of long duration, with subsequent metastases in 30%–50% of cases.[2] We here report a case of left thumb ES that presented as an ulcer and subsequently metastasized to the forearm, arm, axillary lymph nodes, and lungs.
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CASE REPORTS Top

Recurrent metastatic high-grade osteosarcoma: Disease stabilization and successful pregnancy outcome following aggressive multimodality treatment p. 530
Monica Khurana, Barbara Gruner, Bindu Kanathezhath Sathi
DOI:10.4103/ijmpo.ijmpo_83_17  
Prognosis for refractory/recurrent metastatic osteosarcoma (OS) remains dismal with 3-year survival rates <20%. Achievement of more than 5 years of stable, refractory/recurrent metastatic OS disease in our patient is itself unique and attributable to multimodality therapy. Her high-dose chemotherapy regimen with alkylating agents did not lead to infertility, making her case even more unique. Successful disease stabilization and pregnancy outcome in our patient with metastatic multiple relapsed OS is one of the first cases published. We need further understanding and exploration of pathogenesis, chemoresistant mechanisms, and multimodality therapies including immunotherapy for OS.
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Adrenocortical carcinoma: A rare tumor in a 12-year-old girl p. 533
Sandesh V Parelkar, Dwarkanath V Kulkarni, Beejal V Sanghvi, Pooja Tiwari, Kedar P Mudkhedkar, Satej S Mhaskar, Rujuta Shah, Sonali S Mane, Kavimozhy Ilakkiya
DOI:10.4103/ijmpo.ijmpo_128_17  
A 12-year-old girl presented with intra-abdominal mass and cushingoid features. On investigation, she was diagnosed as a case of functioning adrenocortical carcinoma. Two cycles of neoadjuvant chemotherapy followed by excision of mass with right nephrectomy was performed. On 6-month follow-up, recurrence and metastasis were identified which were managed with surgery and chemotherapy.
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Undifferentiated carcinoma of the uterine cervix with evidence of its origin from small-cell neuroendocrine carcinoma p. 536
Rajeshwari K Muthusamy, Sangita S Mehta
DOI:10.4103/ijmpo.ijmpo_23_17  
Neuroendocrine carcinoma (NEC) of the uterine cervix is an uncommon aggressive tumor, comprises <5% of the cervical malignancies. Undifferentiated carcinoma of the cervix, described by the World Health Organization Classification of Tumors as a distinct entity, is extremely rare with no histologic evidence of differentiation. Immunohistochemistry with p63 and neuroendocrine markers helps in delineating the type as undifferentiated squamous cell carcinoma or NEC. NEC of the uterine cervix behaves biologically like any other cervical malignancy, has an association with human papillomavirus, and is similar to NEC of any possible site with early metastasis and poorer survival. We present a case of 45-year-old premenopausal female with undifferentiated carcinoma of the uterine cervix originating from small-cell NEC proven by the presence of differentiated component in the proximity of undifferentiated tumor and by the immunohistochemistry.
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Extensive metastases in prostatic carcinoma with normal prostate-specific antigen and raised carcinoembryonic antigen – Small cell carcinoma of prostate: A rare entity p. 539
Sanjay Mhalasakant Khaladkar, Kunaal Mahesh Jain, Arijit Ghosh, Rajesh Kuber
DOI:10.4103/ijmpo.ijmpo_72_17  
Small cell carcinoma of prostate is a neuroendocrine tumor of prostate seen in 0.5%–2% of men with carcinoma prostate. Prostate-specific antigen (PSA) is a common tumor marker which is often raised in prostatic carcinoma. However, prostatic carcinoma can progress with normal or low serum PSA levels at the time of diagnosis. Carcinoembryonic antigen (CEA) is a tumor marker of different carcinomas. Small cell carcinoma prostate is a highly aggressive tumor which can progress with normal or low serum PSA levels and raised CEA levels. We report a case of 65-year-old male with enlarged prostate with extra-prostatic spread, hepatic metastases, metastatic retroperitoneal and pelvic lymph nodes, osteoblastic metastasis in lumbar spine with normal serum PSA, and raised CEA levels. Prostatic biopsy was suggestive of small cell carcinoma.
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Lower intestinal langerhans cell histiocytosis masquerading as chronic malabsorption syndrome and failure to thrive in a child: A rare case presented with a succinct review of recent literature p. 543
Mayur Keshav Suryawanshi, Tanush Vig, Dipti Masih, Reny Joseph
DOI:10.4103/ijmpo.ijmpo_73_17  
Langerhans cell histiocytosis (LCH) encompasses a group of disorders characterized by neoplastic proliferation of Langerhans cells causing destruction of tissue, morbidity and mortality. The authors bring forth the case of a 2-year-old child presenting with chronic diarrhea and features of chronic malabsorption that revealed lesions over the ileocolonic mucosa. Histopathological examination with immunohistochemical expression for CD1a confirmed the diagnosis of LCH. Gastrointestinal LCH is quite uncommon, and review of the published English literature revealed about 50 reported cases. The importance of diagnosing this disease is echoed by the grim survival rate of 18 months from the time of diagnosis that is seen in around 60% of cases. Owing to its rarity and unfamiliarity of practicing physicians and pathologists of this disease at this site, the authors wish to discuss the potential pitfalls and differential diagnoses.
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Stauffer's syndrome: A rare paraneoplastic syndrome with renal cell carcinoma p. 546
Mayank Jain, Joy Varghese, KM Muruganandham, Jayanthi Venkataraman
DOI:10.4103/ijmpo.ijmpo_97_17  
An elderly male patient presented with cholestatic jaundice and weight loss. On evaluation, he was found to have left renal mass and hepatomegaly. Diagnosis of Stauffer's syndrome was confirmed based on his clinical history, biochemical evaluation, and liver biopsy. Resolution of jaundice was noted after removal of the renal mass.
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Cytomegalovirus retinitis occurring as a complication of HyperCVAD chemotherapy: Report of two cases p. 548
Geetha Narayanan, Lakshmi Haridas, Lali V Soman
DOI:10.4103/ijmpo.ijmpo_48_17  
Cytomegalovirus (CMV) retinitis is usually diagnosed in patients with acquired immunodeficiency syndrome and in solid organ and hematopoietic stem cell transplant recipients. It produces a characteristic necrotizing retinitis which is a sight-threatening condition in these patients. CMV retinitis occurs rarely in patients undergoing only chemotherapy, and very few cases have been reported during the maintenance phase of acute lymphoblastic leukemia (ALL) in children. We report two patients, one with ALL and the other with Burkitt's lymphoma on HyperCVAD chemotherapy developing CMV retinitis during the course of treatment. Both patients were treated with intravenous ganciclovir, oral valganciclovir and intravitreal ganciclovir. Both patients are alive in remission at 60 and 40 months, respectively, with preservation of normal vision.
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LETTERS TO EDITOR Top

Mixed malarial infection with pancytopenia in a child with acute lymphoblastic leukemia: An unusual presentation p. 551
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/ijmpo.ijmpo_64_17  
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Cyclophosphamide in ovarian cancer subtypes: Time for a comeback p. 551
Ajit Venniyoor
DOI:10.4103/ijmpo.ijmpo_84_17  
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Gemcitabine-associated pseudocellulitis: A great mimicker p. 553
Deepti Ahuja, Sachidanand Jee Bharati
DOI:10.4103/ijmpo.ijmpo_119_17  
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Drinking water from water dispenser: Estimation of cancer risk for consumer in Northeastern Region, Thailand p. 554
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/ijmpo.ijmpo_142_17  
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Rare initial presentation of acute myeloid leukemia as facial palsy p. 555
Shilpi Budhiraja, Prem Sagar, Madhu Rajeshwari, Rajeev Kumar
DOI:10.4103/ijmpo.ijmpo_52_17  
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Concurrent hairy cell leukemia and chronic lymphocytic leukemia: Diagnostic and therapeutic implications p. 557
Parameswaran Anoop, Channappa N Patil, Venkatachalam Sandhya, Sonal Dhande, Kalpana Janardan, Shivali Ahlawat
DOI:10.4103/ijmpo.ijmpo_77_17  
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