Oncology Gold Standard™ practical consensus recommendations 2016 for treatment of advanced clear cell renal cell carcinoma.

The Oncology Gold Standard (OGS) Expert Group on renal cell carcinoma (RCC) developed the consensus statement to provide community oncologists practical guidelines on the management of advanced clear cell (cc) RCC using published evidence, practical experience of experts in real life management, and results of a nationwide survey involving 144 health-care professionals. Six broad question categories containing 33 unique questions cover major situations in the routine management of RCC. This document serves as a ready guide for the standard of care to optimize outcome. The table of "Take Home Messages" at the end is a convenient tool for busy practitioners.

Treatment of Stage I Seminoma testis with extended field adjuvant radiation.

With an aim to analyze and document the outcome of Stage I Seminoma patients we undertook a retrospective analysis of patients treated between January 1990 and December 1998. The treatment charts of patients treated between January 1990 and December 1998 were reviewed. Patient and tumor characteristics, treatment details, relapse rates, late toxicities, or occurrence of second primary was noted. Royal Marsden Staging System was utilized because of its simplicity and wide-use in the above period. Out of 137 patients, 41 (30%) patients did not receive any further treatment, 96 (70%) patients received prophylactic radiotherapy to para-aortic and pelvic nodes. The observation group patients had a median follow-up 20 months, 9 patients had nodal relapse with 7 in retroperitoneal nodes and 2 patients in inguinal nodes. Of these, 7 patients received BEP chemotherapy and 2 patients Chemoradiation. Four patients had complete remission while remaining 5 patients had partial response. The histopathologies of all the 5 patients with partial response were reviewed to reconfirm the diagnosis. Patients of prophylactic radiotherapy group had a follow-up of 33 months, 6 patients relapsed, RP nodal disease in 5 patients and distant metastasis in 1 patient. All these patients received BEP chemotherapy. One had complete response and remaining 5 patients had partial response. The group of patients under observation had a significantly higher relapse rate and lower disease free compared to the adjuvant radiotherapy group (73.5% vs. 91% at five years, p value 0.004). Disease specific survivals for the two groups were however similar (89% vs. 93%) at five years, p value 0.18). We conclude that Stage I Seminoma patients treated with prophylactic radiation to paraaortic and pelvic region had better outcome.

Uterine smooth muscle tumors of uncertain malignant potential and atypical leiomyoma: a morphological study of these grey zones with clinical correlation.

OBJECTIVES: To study the histological features in uterine STUMP, and atypical leiomyomas (AL), and to correlate with clinical outcome. MATERIALS AND METHODS: From January 2004 to August 2010, a total of 21 cases were retrieved from records, labeled as STUMP(7), AL (5), AL with low risk of recurrence (2), smooth muscle tumor of low malignant potential (STLMP) (2), and symplastic leiomyoma (5). The slides were reviewed for coagulative tumor cell necrosis (CTCN), hyaline necrosis/ infarction type necrosis, presence and degree of cytological atypia, mitotic activity, epithelioid morphology and myxoid features. The other characteristics (such as size, circumscription, individual tumor cell necrosis), were noted, wherever available. RESULTS: The mean age was 45 years (median 46; range 24-67 yrs). CTCN was seen in 2 cases on examination of additional material; wherein a revised diagnosis of leiomyosarcoma had been given. Infarction type necrosis and individual cell necrosis was seen in 2 and 3 cases, respectively. Mitoses were less than 5/10 hpf in all the cases. One of the tumours labeled as STUMP also had concurrent endometrial adenocarcinoma. Follow up: Follow-up was available in 11 cases (52.3%). One patient had died. (cause not known). In 10 patients, the follow-up ranged from 4 to 56 months (mean 20.9 months; median 15 months) nine patients were alive and well. One patient (labeled STLMP) had metastatic liver disease 3 yrs after the primary surgery, at the last follow-up. CONCLUSIONS: 1) There is an overlap in using the terminologies as STUMP, AL, AL with low risk of recurrence, AL with low malignant potential. A designation of STUMP does convey a category of borderline malignancy to the gynecological surgeons. Most behave in a benign fashion and follow-up without adjuvant therapy is currently recommended. Critical evaluation of coagulative tumor necrosis is essential. Follow-up remains a challenge in our setting.

Complimentary role of FDG-PET imaging and skeletal scintigraphy in the evaluation of patients of prostate carcinoma.

Prostate cancer is one of the most common malignancies of elderly males. Management depends on the accurate estimation of disease both at initial diagnosis and in its subsequent course. In the present study, we evaluated the diagnostic utility of positron emission tomography with 18 F-fluorodeoxyglucose (FDG-PET) in patients having prostate cancer. The findings were compared with the results of bone scan (BS) for the detection of bone metastases. Sixteen patients (age range, 55-83 years) with confirmed diagnosis of prostate cancer were included in the prospective study. Three patients had undergone bilateral orchidectomy, 1 had hormonal therapy, 9 had undergone both, and 3 had no therapy. All the patients underwent wholebody BS and FDG-PET within 1 week. Interpretation of BS and FDG-PET were performed qualitatively. Osseous abnormalities detected by both methods were compared. Involvement of the disease in other sites as seen on FDG-PET was also noted. BS detected 197 osseous lesions, whereas FDG-PET could detect 97 (49%) bone lesions. However, in 3 patients without any prior therapeutic intervention, FDG-PET results were superior or equivalent to that of BS. FDG-PET also detected extensive involvement of the disease in the bone marrow in 4 patients, lymph node metastases at various sites in 8, liver metastases in 2, and lung metastases in 1 patient. FDG-PET could demonstrate less number of osseous metastases in comparison with BSs, but the results have to be interpreted in the background of prior treatment administered and the tumor biology of the lesion. It is evident that FDG-PET could detect the unknown soft tissue involvement of the disease with good sensitivity, which might play an important role in the management of prostate cancer. Overall, in the absence of novel PET tracers, both skeletal scintigraphy and FDG-PET imaging can play a complimentary role in the management of prostate cancer.

Transrectal ultrasound-guided biopsy of recurrent cervical carcinoma.

The objective of this study was to evaluate the feasibility, safety and diagnostic accuracy of transrectal ultrasound (TRUS)-guided core biopsy for recurrent carcinoma of the uterine cervix in patients with non-diagnostic vaginal cytology and transvaginal punch biopsy.17 patients with clinical and imaging suspicion of recurrent carcinoma of the cervix, and with negative cytology and punch biopsy, were referred for TRUS-guided biopsy of a recurrent mass. Data were collected with respect to demography, previous diagnosis, treatment received, size and location of the recurrent lesion, and biopsy results. Adequate samples were obtained for all patients. TRUS-guided biopsy was technically successful in all of the patients and provided histological diagnosis of recurrence in 16 patients. One of the patients had post-radiation fibrosis. There were no procedure-related complications. In conclusion, TRUS-guided biopsy for recurrent cervical cancer is a feasible, safe and accurate method for establishing a histopathological diagnosis. It should be considered in patients with non-diagnostic vaginal cytology and punch biopsy.

Carcinoma penis: How late can inguinal nodal metastases occur?

Inguinal nodal metastasis is the single most important prognostic factor for survival in a patient with carcinoma penis. In patients without inguinal lymph nodal metastasis at presentation, options include close surveillance or prophylactic inguinal lymph nodal dissection. The majority of patients on surveillance who develop inguinal nodal metastases do so within two to three years of treatment of the primary. Here we report a case who developed inguinal nodal metastasis 10 years after the treatment of primary. This raises questions about the natural history and biology of the disease, the optimum surveillance and whether a patient of carcinoma penis can ever be considered risk-free for metastasis.

Diagnostic dilemma in an elderly woman with intractable ascites and elevated CA-125 level.

In patients with intractable ascites, careful consideration should be given to the patient's past history with emphasis on cardiac, liver and renal disorders. Ascitic fluid cytology indicating the presence of malignant cells should be unequivocal; cytology should be repeated before embarking on potentially toxic anti-cancer treatment in ambiguous cases. Elevated serum CA-125 levels should not be relied upon to make the diagnosis of ovarian/peritoneal carcinoma. We report a case of tricuspid stenosis with severe ascites in an elderly woman who was initially mis-diagnosed and treated as peritoneal/ovarian carcinoma.

Hypofractionated radiotherapy in carcinoma cervix IIIB: Tata Memorial Hospital experience.

PURPOSE OF THE STUDY: To analyze the role of hypofractionated radiotherapy in advanced carcinoma of cervix. BASIC PROCEDURE: Medical records of 62 women with advanced carcinoma cervix III3 treated during 1994-1996 were reviewed. Patients were treated with standard pelvic portals to a total dose of 39Gy in 13 fractions over 17 days followed by intracavitary brachytherapy. Forty-eight patients completed the planned treatment and were considered suitable for analysis of late reactions and survival. MAIN FINDINGS: The 5-year disease free survival was 59% and the overall survival was 50% at the mean follow up of 40 months. Twenty-one (44%) patients developed acute gastrointestinal toxicity of which 5 patients had grade III and one patient had grade IV reaction. Ten patients (21%) developed acute genitourinary complications, 13 patients (27%) had late rectal reactions and 10 patients (20%) had late bladder complications. Three patients had grade I, five had grade II and five had grade III late rectal toxicity. CONCLUSION: Survival in patients treated hypofractionated radiotherapy appears comparable to that of standard fractionation. The acute gastrointestinal and skin reactions were mainly grade I or grade II. Hypofractionated radiotherapy can certainly be considered in a select group of patients where the local disease is extensive and is unsuitable for conventional treatment.

Effect of cisplatin-based chemotherapy on emergence of cisplatin resistance, and its correlation with intracellular glutathione levels and accumulation of p53 protein in human ovarian cancer.

Forty-seven ovarian cancer cases in which 20 were previously treated with cisplatin (cisPt) based chemotherapy, were checked for in vitro chemosensitivity using MTT assay. The drugs included in the study were cisPt, adriamycin (ADR), epirubicin (EPR) and etoposide (ETO). The logarithemic concentrations (0.1, 1.0, 10.0 and 100.0 micrograms/ml) of these drugs were used in the MTT assay. The IC50 values for these drugs in the above tumor samples were calculated. The effect of pretreatment with cisPt based chemotherapy on the emergence of drug resistance, expression of p53 protein (detected using immunohistochemical method by employing monoclonal antibody to p53) and intracellular glutathione (GSH) levels was also studied. Our results demonstrated the superiority of EPR in terms of its efficacy as compared to the other drugs used in the study. EPR was effective in both, previously cisPt-exposed and cisPt-unexposed ovarian cancer cases indicating its importance as a second line chemotherapy in the refractory ovarian carcinoma cases. Pre-exposure to cisPt based chemotherapy appears to result in the emergence of cisPt resistance, elevated intracellular GSH levels as well as p53 positivity. A statistically significant correlation was also observed between ADR and EPR resistance and p53 positivity (P < 0.01 and 0.05 respectively).

Embryonal rhabdomyosarcoma of prostate in an adult--a diagnostic dilemma.

Embryonal rhabdomyosarcoma of the prostate is a rare. Highly malignant tumour. The median age of occurrence is five years, but sporadic cases have been reported in adults' To the best of our knowledge, till date, fewer than ten cases have been reported of which only two are above the age of sixty years. We report a case of embryonal rhabdomyosarcoma of prostate in a patient more than sixty years of age. If one is not aware of this entity, one can make a mistake in the diagnosis as well as treatment.

Radical cystoprostatectomy: an extraperitoneal retrograde approach.

PURPOSE: We describe a new technical approach for the surgical management of bladder cancer. MATERIALS AND METHODS: Patients with invasive bladder cancer underwent radical cystoprostatectomy using a technically different approach than the conventional method. The important features of this modification include a small infraumbilical incision, completely extraperitoneal dissection to maintain the bowel loops away from the operating field, urethral dissection performed earlier in the operation rather than at the end to preserve the striated urethral sphincter with the neurovascular bundles, completely retrograde dissection of the rectovesical plane for increased safety and reperitonealization done at completion to isolate the urinary anastomoses from the bowel anastomosis. RESULTS: More than 50 consecutive patients with early bladder cancer underwent this operation during a 2-year period. The technique was safe and satisfactory. CONCLUSIONS: Radical retrograde extraperitoneal cystoprostatectomy is based on a finer knowledge of anatomy. It requires accurate dissection, making it inherently superior to the conventional method.

Primary carcinoma of fallopian tube--a case study.

Primary carcinoma of fallopian tube is a rare entity. We report an interesting case of primary carcinoma of fallopian tube with contralateral lymph node involvement. The clinicopathological findings and its management is presented.

Borderline epithelial tumours of the ovary--a retrospective analysis of 31 cases.

Thirty one cases of epithelial borderline tumours of the ovary recorded over a period of six years were reviewed. The incidence of borderline tumours was 6% in relation to ovarian epithelial malignancies, with serous and mucinous types comprising three fourth of the lesions. The serous tumours were bilateral in 39%, revealed surface growth in 17% and had peritoneal implants in 11% of cases. The mucinous tumours were bilateral in 11% and had associated pseudomyxoma peritonei in 22% of cases. Nuclear grade appeared to correlate with extraovarian spread and surface growth in the serous borderline tumours, but not in the mucinous borderline tumours. The endometrioid borderline tumours and mixed epithelial borderline tumours were rare lesions. Twenty one patients (68%) presented in Stage-la. Surface growth correlated with recurrences. The prognosis remained good in serous borderline tumours even in the presence of implants as these were non-invasive. The mean disease free survival was 43.03 months. There was no statistical difference in disease free survival of patients with and without implants.

Adenocarcinoma of bladder.

Forty-eight patients with adenocarcinoma (21 urachal and 27 non-urachal) of the bladder were treated at the Tata Memorial Hospital between 1976 and 1992. The study group consisted of 32 men and 16 women. The urachal tumours were more common in younger patients (mean age: 49 years) than were non-urachal tumours (mean age: 58 years). The overall 5-year survival in this series was 37%. Stage and grade were powerful predictors of outcome. Patients with non-urachal tumours showed an overall survival rate of 29.9% compared with 45.7% in patients with urachal tumours (P= 0.14). Radical cystectomy was the most common treatment modality in patients with non-urachal tumours and yielded an overall 5-year survival of 35%. Patients with urachal tumours were treated with either partial cystectomy or radical cystectomy. The 5-year survival following partial cystectomy was 56.3% compared with 25.9% following a radical cystectomy and the difference between the two was not statistically significant (P = 0.76).

Improved management of abdominal undescended testicular tumors with bulky confluent retroperitoneal nodal metastases.

PURPOSE: Germ cell tumors of the abdominal undescended testis associated with confluent bulky retroperitoneal metastases are challenging problems. We report the results of neoadjuvant cisplatin based chemotherapy after diagnosis of germ cell tumors by fine needle aspiration cytology of the abdominal testicular mass. After chemotherapy all patients underwent abdominal orchiectomy with retroperitoneal lymph node dissection for residual nonseminomatous germ cell tumors or radiotherapy for pure seminomas. MATERIALS AND METHODS: Between 1980 and 1991, 57 of 425 patients (13.4%) with germ cell tumors of the testicle had malignancy in an undescended testis, while 39 (68.4%) had tumor in an abdominal testis with confluent bulky metastasis. Metastatic evaluation included tumor marker studies, chest x-ray and computerized tomography of the abdomen. Among the tumors 29 (74.4%) were large volume seminomas (stages IIc, III and IV) and 10 (25.6%) were large volume nonseminomas. All 39 patients received 3 cycles of induction chemotherapy, and orchiectomy was deferred until its completion (14 received vinblastine, actinomycin D and bleomycin-6, and 25 received bleomycin, etoposide and cisplatin). After evaluation of response, the testis was excised. Overall followup was 2 to 12 years (median 4.6). RESULTS: Of 29 seminomas 14 (48.3%) showed a complete and 11 (37.9%) showed a partial response. The latter tumors were treated subsequently with radiotherapy. Four patients with progressive disease died, for an actuarial survival rate of 86%. Of the 10 patients with nonseminomatous germ cell tumor 2 (20%) had a complete response and 4 had a partial response. All patients with a partial response underwent retroperitoneal lymph node dissection. Overall, 4 patients with progression and 2 with a partial response died, for an actuarial survival rate of 39%. Of 39 post-chemotherapy orchiectomy specimens 24 (61.5%) showed viable tumor cells. Furthermore, 16 of 39 patients (41%) had additional ilioinguinal metastases requiring adjuvant radiotherapy or surgery. CONCLUSIONS: Surgical removal of the primary tumor in an undescended testis with bulky metastasis is difficult. We believe that initial chemotherapy followed by 1-stage surgical removal of the primary and residual metastasis is a favorable option to improve compliance and decrease the incidence of loss to followup. Atypically altered ilioinguinal metastases may necessitate a change in radiotherapy ports and/or retroperitoneal lymph node dissection boundaries. The significantly poorer survival with nonseminomatous germ cell tumor could be due to the fact that 50% of the lesions were stage IV at presentation. However, multivariate analysis showed only tumor histology to be the significant parameter and not initial stage at presentation.