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   Table of Contents - Current issue
November-December 2020
Volume 41 | Issue 6
Page Nos. 789-928

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Oncoradiology preparedness in the COVID-19 pandemic: Perspective from a tertiary oncology referral center from Eastern India Highly accessed article p. 789
Argha Chatterjee, Bivas K Biswas, Anisha Gehani, Jayanta Das, Saugata Sen, Sumit Mukhopadhyay, Aditi Chandra, Priya Ghosh, Bharat Gupta, Dayanand Lingegowda
At the time of writing this article, more than 18 million people worldwide have been infected by the severe acute respiratory syndrome-associated coronavirus-2 and about 700,000 people have died from coronavirus disease 2019 (COVID-19). In India, about 190,000 people have been infected and nearly 39,000 people have succumbed to this infection. Infection among health-care workers has emerged as one of the key problems in facing this pandemic. The purpose of this article is to describe the measures taken by the department of oncoradiology at our institution to control the infection and minimize staff exposure during the current lockdown period with reduced patient load and in the post-lockdown period with increased demand for radiology services. The key focus of this article is the continued delivery of cancer imaging services with practical precautions and optimized resources. We have also discussed algorithms and protocols unique to the practice of oncoradiology in the time of the COVID-19 pandemic.
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Clinical research in hematology-oncology in India during the COVID-19 era p. 799
Nishant Jindal, Pankaj Malhotra, Amol N Patil, Deepesh P Lad
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Immunotherapy in rare cancers Highly accessed article p. 801
Venkata Pradeep Babu Koyyala, Padmaj Kulkarni
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Multidisciplinary joint clinics: Talent wins games, but teamwork wins championships p. 804
Rima Sanjay Pathak, TS Shylasree, Jyoti Bajpai
Cancer is among the leading causes of deaths worldwide. The treatments of cancer across most sites involve using surgery, systemic therapy, and radiation therapy. The treatment protocols are complex and require careful planning at the beginning of the therapy and coordination between the treating teams, the patient, and the caregivers to ensure compliance and avoid unnecessary treatment delays. This commentary provides an insight into the role the multidisciplinary joint clinics play in providing personalized cancer care. While such joint clinics are advantageous, they are not devoid of drawbacks and these are also enumerated. In this era, when communication platforms are increasingly digitized, we have highlighted the need for virtual tumor boards. The commentary aims to motivate the development of multidisciplinary joint clinics for ensuring holistic cancer care across the country.
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Gastrointestinal stromal tumor – An overview p. 809
Anant Ramaswamy, Vikram Chaudhari, Prabhat Bhargava, Manish Bhandare, Rajiv Kumar, Shailesh V Shrikhande, Vikas Ostwal
Gastrointestinal stromal tumors (GISTs) are rare tumors but are most common mesenchymal tumors of the digestive tract. They are commonly seen in the stomach (60%) and small intestine (30%). GISTs are likely derived from the interstitial cells of Cajal or their stem cell precursors. They are best characterized by computerized tomography and have a specific staining pattern on immunohistochemistry, i.e., C-Kit and DOG-1. The treatment of GIST is based on the risk assessment for relapse, and patients with localized GIST require resection with or without adjuvant imatinib mesylate (IM). Advanced unresectable tumors are usually treated with IM, with a number of further options available for patients post progression on IM. There is an increasing emphasis on identifying C-Kit and platelet-derived growth factor receptor alpha mutations in all patients with GIST, as these are driver mutations with current and future therapeutic implications.
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Efficacy of antiemetic regimens for prevention and treatment of chemotherapy-induced nausea and vomiting in patients of breast cancer receiving highly emetogenic chemotherapy p. 819
Soumya Vij, Dilip Chander Dhasmana, Suman Bala, Sanjiv Kumar Verma
Background: Chemotherapy is fraught with serious and troublesome adverse effects, of which nausea and vomiting appears earliest and is the most disturbing. Therefore, this study was planned to investigate the antiemetic drug regimens used for chemotherapy-induced nausea vomiting (CINV) in patients with breast cancer receiving highly emetogenic chemotherapy (HEC). Subjects and Methods: An observational follow-up study was conducted to assess the efficacy of antiemetic regimens in breast cancer patients receiving HEC. A total of 71 newly diagnosed patients with breast cancer were included in the study. Patients were assessed for nausea by the visual analog scale, and a history of emetic episodes and need for rescue medication were recorded at 0 h, 6 h, 24 h, 48 h, and 120 h post-chemotherapy till three cycles. Results: The patients were prescribed a combination of ondansetron and dexamethasone (n = 23, n = 17, and n = 13 in first, second, and third cycle, respectively) or a combination of aprepitant, ondansetron, and dexamethasone (n = 48, n = 54 and n = 56 in the first, second, and third cycle, respectively). The intensity of nausea was higher for the patients who were prescribed ondansetron and dexamethasone regimen as compared to patients prescribed aprepitant additionally. Complete response, i.e., no emesis and no rescue medication, was higher in triple-drug regimen (52% vs. 0.4%, 63% vs. 17.6%, and 69% vs. 23% in three cycles, respectively). Conclusion: The control of CINV was better with a combination of aprepitant, ondansetron, and dexamethasone as compared to a regimen without aprepitant.
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Patient-reported shoulder morbidity and fatigue among breast cancer survivors: An insight from a tertiary care cancer hospital Highly accessed article p. 825
Abhishek Basu, Janmenjoy Mondal, Bhukya Swetha, Shinjini Chakrabarty, Debjit Ghosh, Subhendu Gangopadhyay, Bidyut Mandal
Context: Breast cancer is the most common cancer in Indian women with an annual mortality of around 87,000. Treatment for breast carcinoma may lead to swelling of the ipsilateral arm, shoulder stiffness, arm pain, and cancer-related fatigue. Very few centers in India have reported the arm and shoulder morbidity treated in their hospitals. Aims: The aim was to evaluate the predictive factors of arm and shoulder morbidity and fatigue among breast cancer survivors. Settings and Design: This was a retrospective analysis based on a prospectively maintained database. Materials and Methods: Early and locally advanced cases of breast cancer patients were screened for the study during 2015–2018. Eligible participants were invited to fill up the predetermined questionnaire, and their demographic and treatment-related information was accrued from a file archive. Follow-up period was estimated from the date of tissue diagnosis to last contact/time of interview. Results: Shoulder stiffness was the most common complaint followed by arm numbness. Obesity and diabetes played a crucial role in most of the morbidities and fatigue. The median fatigue score was 34, and the median time of appearance of lymphedema was 13 months. Modified radical mastectomy and radiotherapy to axilla were statistically significantly (P = 0.04 and 0.01, respectively) associated with greater shoulder stiffness and arm swelling. Conclusions: Obesity, diabetes, type of surgery, the extent of axillary dissection, and radiation plan are the major predictive factors of arm and shoulder morbidity. Further prospective validation is necessary for future breast cancer survivorship programs.
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Does neoadjuvant chemotherapy increase the survival in patients with locally advanced gastric cancer patients? – A real-world evidence p. 832
Murugesan Janarthinakani, Selvaraj Kalaiselvi, Rajamani Priyadarshini, Seshachalam Arun, K Shashidhar, R Krishnakumar, N Manjunath, Sirigeri Roopa, SG Raman
Background: In locally advanced gastric cancer (LAGC), perioperative chemotherapy has shown to improve the survival to a larger extent compared to surgery alone. In India, the treatment followed for gastric carcinoma widely varies based on the type of health-care provider and treatment access. There is a paucity of data on the role of neoadjuvant chemotherapy on survival among LAGC patients in the Indian context. Aim: The aim of this study was to compare the disease-free survival (DFS) and overall survival (OS) between neoadjuvant and adjuvant chemotherapies among LAGC patients. Subjects and Methods: This was a retrospective cohort study involving clinical record review of LAGC patients enrolled between 2015 and 2017 from four tertiary cancer centers in South India. The date for the following events, namely diagnosis, recurrence, death, and last day of visit, was extracted in a mobile-based open-access tool. The median duration of OS and DFS between the neoadjuvant and adjuvant groups was compared using Kaplan–Meier survival curves. Results: Of the 137 patients, 70 (51%) had received neoadjuvant chemotherapy followed by surgery and 67 (49%) had adjuvant chemotherapy following the surgery. The mean (standard deviation) age of participants was 55.4 (11.4) years. Seventy-eight percent of the patients were diagnosed at Stage 3 or 4. Regional lymph nodes were involved in 83.9%. The median duration of follow-up was 15 months. The OS in the neoadjuvant and adjuvant groups was 18.6 months and 8.3 months, respectively. Nonregional lymph node involvement and adjacent organ involvement had independently increased the risk of death. Conclusion: Among LAGC patients, the neoadjuvant chemotherapy indicated a better median and DFS compared to the adjuvant group. However, these findings were statistically not significant. The current study has contributed an important finding to the existing evidences of clinical practice in an Indian setting. Further large-scale studies are required to validate the promising trend of using neoadjuvant chemotherapy in LAGC.
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Treating acute myeloid leukemia among children with down syndrome p. 841
Rajan Kapoor, Karthik Ram Mohan, Shuvendu Roy, Suman Kumar Pramanik, Sanjeev Khera, AK Simalti
Background: Down Syndrome (DS) children with acute myeloid leukemia (AML) have unique differences in clinical features, epidemiologic nature, and biologic patterns of disease compared with AML in children without DS. Aims and Objective: AML in DS children should be considered distinct disorder from AML in Non DS population and treatment needs to be customized for this population. In this retrospective study spanning from 2014 to 2019 we present our experience of managing leukemia in children with DS. Materials and Methods: From 2014 and 2019, 72 children aged below 18 years were managed at our institute with acute myeloid leukemia (AML). Out of these 72 children with AML, 7 children were with DS which was confirmed by karyotyping. Majority of these children had M7 while M2 and M4 subtypes were seen in one child each. On conventional karyotyping in addition to trisomy 21 additional cytogenetic abnormalities were seen in 4 patients. Two children had trisomy 8. One child had deletion of 11 chromosomes and one had translocation between 8 and 21 chromosomes. Results: All 7 children were administered intensive chemotherapy with curative intent after informed parental consent. All 7 children achieved complete remission. Four out of 7 children had complications related to severe neutropenia. Conclusion: All patients of DS with AML should be offered chemotherapy with curative intent. Endeavour should be to give less aggressive chemotherapy protocol to bring down treatment related mortality.
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Daratumumab plus carfilzomib: An optimistic approach in relapsed/refractory multiple myeloma p. 846
AP Dubey, Sameer Khatri, Sachin Maggo, Nilabh K Singh, Durgesh Sharma
Background: Although with the introduction of novel agents, clinical outcomes have significantly improved in patients of multiple myeloma (MM); however, nearly all relapse, requiring subsequent treatment. Patients who have been heavily treated for relapsed/refractory MM (RRMM) have limited options and poor survival outcomes. Carfilzomib plus daratumumab combination have been evaluated in a phase 1b study in patients of RRMM progressing after 1–3 lines of therapies including bortezomib and an immune-modulatory drug. However, data are lacking evaluating the efficacy of this combination in RRMM patients who have progressed or have suboptimal response on either of these drugs (carfilzomib or daratumumab). Methods: Prospective analysis of data of 19 RRMM patients who progressed after multiple lines of therapy (including bortezomib and lenalidomide/pomalidomide) and had suboptimal response/stable/progressive disease after receiving carfilzomib or daratumumab based combination as last therapy. All patients received combination of carfilzomib plus daratumumab along with dexamethasone (DKd) after prior consent. Daratumumab (16 mg/kg IV) was administered weekly (days 1, 8, 15, and 22) during cycles 1 and 2, every 2 weeks (days 1 and 15) during cycles 3–6, and every 4 weeks thereafter. Carfilzomib was administered weekly on days 1, 8, and 15 of each 28-day cycle. Patients received an initial carfilzomib dose of 20 mg/m2 on day 1,2; 27 mg/m2 on day 8, 9, 15, 16 of cycle 1, which increased to 70 mg/m2 on day 1, 8, 15 from cycle 2 onwards if deemed tolerable. Dexamethasone was given as fixed-dose of 40 mg weekly. Results: Eighteen of 19 patients (including 3 high risk cytogenetics) to DKd (CR-4, very good partial response-10, partial response-02). After median follow-up of 16 months, progression-free survival (PFS) was 95%. Median PFS was not reached. Three patients who were transplant eligible received high-dose chemotherapy followed by autologous stem-cell transplantation and achieved minimal residual disease negativity. The most frequent all grade side effects were hematological, which included neutropenia 30%, anemia 70%, and thrombocytopenia 42%. Most frequent non hematological side effects were nausea 40%, vomiting, cough, respiratory tract infections, asthenia, and loss of appetite. Conclusion: Carfilzomib plus daratumumab based combination in RRMM patients has shown promising results in phase Ib study, where patients with prior exposure to either of these drugs were excluded. Our data show similar or better response of this combination in patients who had progressive disease/stable disease/minimal response to either of carfilzomib or daratumumab. This combination can be a better option in heavily treated RRMM (with prior exposure to either of carfilzomib or daratumumab) producing deeper and durable responses. A larger study may be required to prove this benefit.
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Human leukocyte antigen associations with acute leukemia: An indian perspective p. 850
Hina Solanki, Vikash C Mishra, Aseem K Tiwari, Nipun Kakkar, Naveen Vashisht, Vimarsh Raina, Girish Sharma
Objective: Acute lymphoid leukemia (ALL) and acute myeloid leukemia (AML) are neoplastic blood disorders in which the cancerous white blood cells accumulate, resulting in a significant morbidity and mortality. Human leukocyte antigen (HLA) association is observed as one of the factors in the development of leukemia. The objective of the present study was to analyze the allele frequency of HLA Class I (HLA-A, HLA-B, and HLA-C) and Class II (HLA-DRB1 and HLA-DQB1) in Indian acute leukemia patients and to compare them with the frequencies in healthy, unrelated Indian individuals. Materials and Methods: We included 500 Indian leukemic patients (AML = 324 and ALL = 176) and 1000 unrelated, healthy, Indian individuals as controls. The HLA typing was performed using polymerase chain reaction with sequence-specific oligonucleotide probes. Results: On univariate analysis, allele frequencies of HLA-A*11 and HLA-DRB1*11 were lower in patients with ALL (P = 0.0181 and P = 0.0025, respectively). Whereas of HLA-A*11, HLA-DRB1*11, and HLA-B*51, these frequencies were relatively lower in patients with acute leukemia (AML + ALL) (P = 0.0382, P = 0.0093 and P = 0.0384, respectively) and HLA-C*01 (P = 0.0304) in AML when compared with control individuals. In contrast, the HLA-B*39 and HLA-C*07 allele frequency was higher in acute leukemia (P = 0.00372 and P = 0.0463, respectively) and in AML (P = 0.0010 and P = 0.0178, respectively) than that in controls. On multivariate analysis, B*39 showed positive associations with acute leukemia (P = 0.006) and AML (P = 0.002). HLA-A*11 and-DRB1*11 showed a negative association with acute leukemia (P = 0.009 and P < 0.0001, respectively) and ALL (P = 0.013 and P < 0.0001, respectively). Conclusions: The HLA-B*39 has a positive association with AML and acute leukemia, whereas HLA-A*11 and HLA-DRB1*11 alleles have negative association with ALL and HLA-B*51 along with these two alleles with acute leukemia. No positive association was observed with ALL. HLA-C*01 frequency was lower in AML patients than that in controls.
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Brain and acute leukemia, cytoplasmic gene overexpression as a prognostic factor in Egyptian de novo adult acute myeloid leukemia patients p. 859
Ahmed A Alnagar, Hesham M Al Hagrassy, Rania M Abdullah, Reham M El Shabrawy, Hossam Salah
Background: Brain and acute leukemia, cytoplasmic (BAALC) gene is identified on chromosome 8q22.3 and implicated in normal hematopoiesis. BAALC gene overexpression is associated with poor outcome. Methods: We aimed to evaluate BAALC expression in de novo Egyptian acute myeloid leukemia (AML) cases and determine its prognostic value. We recruited 70 patients with de novo AML diagnosed and treated at clinical pathology and medical oncology departments, fulfilling inclusion criteria in our prospective study and evaluated BAALC expression level. Patients received induction therapy. The Institutional Review Board approved our study. Results: The mean age was 39.2 years ± 11.87, (18–60) with a male/female ratio of 3/2. The cutoff value of BAALC as a prognostic factor was 2.11 with sensitivity (86.1%), specificity (80%), positive predictive value (88.6%), and negative predictive value (76.2%.) (P < 0.001), 43 (61.4%) patients had high BAALC expression. Seventy-two percent of patients in the low BAALC group achieved complete remission (CR) compared to 42.1% in high BAALC expression group (P = 0.03). Patients with low BAALC (123.1 ± 4.9) had longer mean survival time than high BAALC group (45.85 ± 5.1) (P = 0.000). Conclusion: High-BAALC expression is an adverse prognostic factor, with a higher risk of relapse, lower CR rates, and lower survival in Egyptian de novo AML patients.
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Chemotherapy for childhood acute myeloid leukemia and associated infections over two decades in India: Timeline and impact on outcome p. 869
Ramya Uppuluri, Venkateswaran Vellaichamy Swaminathan, Nikila Ravichandran, Kesavan Melarcode Ramanan, Satishkumar Meena, Harika Varla, Balasubramaniam Ramakrishnan, Indira Jayakumar, Revathi Raj
Background: Infection and relapse constitute the two main challenges in the management of acute myeloid leukemia (AML) in children. Real-world data in children treated in low-and-middle income countries are sparse as the cost of supportive care is high. Patients and Methods: We present data on children up to 18 years of age undergoing chemotherapy for AML as per UKMRC AML protocol from 2002 to June 2019 and pattern of sepsis. Results: The incidence of culture-positive sepsis was similar pre- and post-2012 (52.6% vs. 72.4%), Klebsiella pneumoniae being the most common organism. There was a significant increase in carbapenem resistance post 2012 (14% vs. 67%, P = 0.032). Sepsis-related induction mortality has remained at 6.2% despite an increase in drug-resistant bacterial infections over two decades. The overall survival was 53% (n=48), with a plateau in the survival curve after 24 months, relapse being the most common cause of death (69%). Conclusions: Sepsis-related induction mortality can be maintained at less than 10% in children undergoing chemotherapy for AML, despite increasing drug-resistant bacteremia, with adequate supportive care and trained personnel including pediatric intensivists and nurses.
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Application of fractal and euclidean methods to differentiate normal and neoplastic thyroid cells p. 874
Javier Oswaldo Rodriguez, Carlos Grisales, Freddy Barrios, Sandra Correa, Signed Prieto, Jairo Jattin, Jhon Ruiz
Context: The differentiated papillary and follicular thyroid neoplasms can be characterized from the notions of fractal and Euclidean geometry to overcome the challenges faced by the pathologist. This method was previously used in differentiating preinvasive lesions of cervical cancer. Aims: to characterize the irregularity of histologic samples of normal thyroid cells as well as benign and malignant thyroid papillary and follicular carcinomas, through the box-counting method using the principles of fractal and Euclidian geometry. Settings and Design: This is a retrospective study involving the measurement of thyroid cells through pixels in photographs, applying geometric methods. Subjects and Methods: Photographs of histological samples from normal and neoplastic biopsy samples were taken and processed by a software in order to delimit the borders of the nucleus and cytoplasm. Then, the box-counting method was applied by superimposing grids of 5 and 10 pixels to measure the fractal dimension and the occupied spaces of the cellular surface. Results: The set of papillary and follicular cells evaluated from the occupied spaces from the borders and surfaces of the nucleus and cytoplasm in the 5-pixel grid showed that normal cells are included within a range of values, while the neoplastic variations are differentiable from this range. Conclusions: Fractal and Euclidean geometries can differentiate normality from some benign and malignant thyroid lesions, which opens a path to develop methodologies that characterize more precisely distinctive features between normal and neoplastic cells independent of qualitative criteria from traditional pathology and histology.
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Evaluating the role of media in implementation of 85% graphic warnings on tobacco products in India p. 879
Ashima Sarin, Pankaj Chaturvedi, Ravi Mehrotra, Priya Ranjan, Sanjay Seth, Rajiv Janardhanan
Background: In common with many countries globally, India has a history of graphic health warnings (GHWs) being weakened or delayed due to tobacco industry influence. If tobacco is eliminated from society, nearly 30% of all cancers can be prevented. Objectives: This study examines the role of the media in the recent changes to the 85% GHWs implementation in India. Materials and Methods: Media articles from the date of notification of 85% GHW (October 15, 2014) to the date of its implementation (April 1, 2016) were collected and coded as pro, anti, or neutral. These were compared, correlated to significant government actions during the time period to determine if media influenced the government actions on the implementation of GHWs. Results: A total of 3301 media articles regarding 85% GHWs were found during the study period, of which 2961 were pro, 333 were anti, and seven were neutral. The results showed that there was a positive correlation of media on the implementation of GHWs. Conclusion: Media coverage of the issue did appear to have an impact.
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Phase I clinical trials in oncology p. 885
Prasanth Ganesan
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Antibody drug conjugates p. 889
Stalin Bala, Siva K Prasad
Antibody drug conjugates (ADCs) are chemically engineered drugs consisting of monoclonal antibody (mAb) and cytotoxic compound attached chemically by a linker. Upon attachment to a specific target antigen, ADC enters into the cell and payload is released, which finally leads to cell killing. Payloads are broadly divided into tubulin-disrupting agents and DNA-damaging agents. Most of the current ADCs utilize humanized mAbs, and fully human mAbs are under investigation. ADC development process is accelerated by better designing and bio-engineering methods.
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Scratching the armor p. 893
Suvir Singh
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Life beyond cancer p. 895
Divya Mathur
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Diffuse involvement of small bowel in burkitt's lymphoma with intussusception p. 899
Digamber Chaubey, Sandip Kumar Rahul, Sujit Kumar, Ramdhani Yadav
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Combining immunotherapy with multikinase inhibitors: A cautious new promise p. 901
Raja Pramanik, Atul Sharma, Akash Kumar
Immune check point inhibitors have made a sea change in oncology practice in current times. These drugs have crossed the conventional boundaries of histology and organ of origin. Tumor agnostic approvals for mismatch repair deficient, microsatellite-instability (MSI)-H and recently tumor mutational burden-high solid tumors have been a giant leap. The Oncology community seems poised to embrace the concept of “immunotherapy for all.” Recent studies have evaluated the manipulation of tumor-associated macrophages using multi-kinase inhibitors, to make even MSI low tumor responsive to checkpoint inhibitors. With accelerated food and drug administration approvals, the promise of this combo is palpable but definitely merits caution.
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Case report on pinna: An unusual site for verrucous carcinoma p. 906
Sidra Khan, Shivkumar Balaji Akulwad, Jayant Sonone
Verrucous carcinoma is an uncommon variant of well-differentiated squamous cell carcinoma and is frequently seen in the oral cavity and larynx having some relation with tobacco chewing, whereas, its presentation over the ear is a rare entity. Here, we report the case of a 70-year-old female patient with complaints of cauliflower-like mass over her left pinna which was managed by doing an excisional biopsy and diagnosed as verrucous carcinoma on histopathology.
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Case report on autoimmune hemolytic anemia: A mask of malignancy! p. 909
Abhilasha Sampagar, Neha Giridhar Patil, Sandip Bartakke, S Shrividya
A 10-year-old boy with autoimmune hemolytic anemia (AIHA) was treated at a local setup with repeated blood transfusions and steroids considering an idiopathic etiology. After 7 months of unresponsiveness, the child started developing recurrent fever with night sweats and pain in the abdomen which was diagnosed as tuberculosis on account of granulomatous necrotizing lesion on computed tomography (CT)-guided lymph node biopsy and treated for the same. Four months later, when the child presented to our center in anemic heart failure, work-up with positron emission tomography-CT and excisional biopsy of mesenteric lymph node led to the diagnosis of advanced Hodgkin's lymphoma with B symptoms. AIHA in pediatric age group, unlike in adults, is usually secondary. Our report stresses on a thorough evaluation of AIHA as it can mask a malignancy for a long duration and alter its course if treated with steroids, making the patient resistant to further chemotherapy.
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Total pelvic exenteration in leiomyosarcoma - A case report p. 913
Atanu Sarkar, Shweta Rai, Angad Singh, Joydeep Ghosh, Jaydip Bhaumik
Locally advanced high-grade leiomyosarcomas (LMS) with visceral involvement are difficult to manage. Here, we present a case of locally advanced high-grade sarcoma where total pelvic exenteration was undertaken to achieve complete cytoreduction. A 54-year-old lady with a prior history of hysterectomy and bilateral salpingoophorectomy done 8 years back for heavy menstrual bleeding presented to us with an abdomino-pelvic mass. Magnetic resonance imaging of the abdomen suggested large heterogeneous pelvic mass displacing urinary bladder anteriorly and abutting recto-sigmoid posteriorly with no luminal involvement. There was bilateral hydronephrosis. Computed tomography of the thorax revealed no evidence of metastatic disease. A review of previous biopsy and a repeat ultrasound-guided biopsy from the pelvic mass done at our institute suggested spindle-cell neoplasm. In view of pelvis confined disease in a young woman with well-preserved general condition, decision for surgical excision was taken. She underwent total pelvic exenteration with en bloc removal of mass, bladder, and involved portion of recto-sigmoid as the disease was infiltrating both the bladder and the recto-sigmoid. Her postoperative course was turbulent, but she recovered fully and was discharged 20 days after surgery. The operative specimen histopathology revealed high-grade LMS. She received four cycles of adjuvant chemotherapy and thereafter was kept on follow-up. Although she was clinically doing well, her general condition never improved beyond Eastern cooperative oncology Group 2. She also had persistent depressive symptoms. After 14 months of completion of treatment, she recurred with a huge abdominal disease. In view of her general condition and huge disease volume, decision was taken for supportive care only. LMS in advanced stages are difficult to manage. Even after aggressive management with radical exenterative surgery and chemotherapy, we could achieve only temporary control of locally advanced LMS.
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A case report and review of B-lineage acute lymphoblastic leukemias with cannibalistic lymphoblasts: A unique morphologic and molecular genetic entity? p. 917
B K Karthik Bommannan, Man Updesh Singh Sachdeva, Shano Naseem, Alka Khadwal, Neelam Varma
Cannibalism is a type of “cell-in-cell” phenomenon commonly described in myeloid lineage malignancies. Although lymphocytes and their precursors are inherently non-phagocytic, there are sporadic case reports describing cannibalism by leukemic lymphoblasts. In the current manuscript, we report the case of a pediatric B-lineage acute lymphoblastic leukemia (B-ALL) patient showing cannibalistic lymphoblasts and have reviewed the clinical and laboratory characteristics of similar cases documented in literature. Our manuscript highlights that all reported B-ALL patients showing cannibalistic lymphoblasts had intra-cytoplasmic vacuolations, and all such treatment-naïve pediatric patients were ETV6-RUNX1 fusion positive and had aberrant expression of myeloid lineage antigens.
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Diagnosing primary malignancy in leptomeningeal carcinomatosis by using CSF cytology and immunohistochemistry: A case report p. 920
Navaneeth Reddy Hasthavaram, Tina Dadu, Rajan Duggal, Suhail Qureshi, Saphalta Baghmar, Amit Agarwal, Aseem Khurana, Aditya Sarin, Navdeep Singh, Ramesh Kumar
We present a rare case of recurrent carcinoma of gallbladder with leptomeningeal carcinomatosis. Cerebrospinal fluid (CSF) cytology showed atypical cells, which were suspicious for malignancy on initial reporting. Diagnosis of malignancy and primary from hepatobiliary source was confirmed by doing immunohistochemistry on CSF cell block.
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Diffuse anterior retinoblastoma masquerading as complicated cataract - A case report p. 923
Prashant Chhabra, Sabia Handa, Manpreet Singh, Monika Balyan, Nitin Kumar, Manish Rohilla, Kirti Gupta, Amita Trehan
Diffuse anterior retinoblastoma (Rb) is a rare variant of this tumor which may involve the anterior chamber of the eye without any detectable mass in the posterior segment. The initial presentation of this tumor as anterior segment pathology may lead to misdiagnosis and erroneous management eventually delaying the definitive therapy. We describe an 8-year-old child presenting with complicated cataract who underwent lens aspiration and later found to have diffuse anterior Rb.
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Atypical presentations of Bowen's disease: A case series p. 926
Chandra Sekhar Sirka, Kananbala Sahu, Gaurav Dash, Swetalina Pradhan, Arpita Nibedita Rout
Bowen's disease (BD) is a rare premalignant condition. Classically, it presents as a well-demarcated erythematous plaque. Atypical variants in terms of the site (genitals and back) and morphology such as verrucous, hyperkeratotic, atrophic, and pigmented types are rarely described in the literature. This is the first case series of atypical presentation of BD. We herein report five cases of BD diagnosed clinically and histopathologically, presenting with rare morphology over unusual sites. They were treated successfully with both medical and surgical modalities. BD can be a diagnostic challenge for a physicians as it mimics common conditions such as psoriasis and eczema. This case series is reported to bring awareness regarding such unusual presentation and sites of BD for early detection and treatment among dermatologists, thus preventing malignant transformation.
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