Our Experience of OSAKA Regimen (Bladder Preservation) in Patients with Advanced Bladder Cancer.

Introduction and Objectives: OSAKA regimen is a novel bladder preservation therapy involving balloon-occluded selective arterial infusion of radio-sensitizing chemotherapeutic agent with concurrent hemodialysis (HD), followed by radiation therapy. Objectives are to study the feasibility of this novel regimen in patients with advanced cancer bladder (Ca Bladder). Methods: Two patients having advanced Ca Bladder with cisplatin ineligibility and poor performance status were managed with OSAKA regimen. Patients undergo super selective catheterisation of the anterior division of the internal iliac artery, followed by concurrent instillation of cisplatin (100 mg) via microcatheters and hemodialysis. Within 72 h, definitive radiation therapy is given. Image-guided radiation therapy (IGRT) with Helical Tomo using an Accuracy Radixact Tomography machine was used. 60 Gray/30 fractions is given to the bladder and nodes (50 Gray to bladder and nodes plus margin, with a boost of 10 Gray to bladder plus margin). Response is monitored by 3 monthly fluorodeoxyglucose positron emission tomography (FDG PET) imaging. Results: Our first patient tolerated the procedure well and showed a complete response at 3 months of FDG PET imaging, but unfortunately, 1 year of FDG PET showed bony metastases, and the patient was managed accordingly. Our second patient also tolerated the regimen well, showed a complete response at 3 and 12 months of FDG PET imaging, and is under follow-up. Conclusions: The OSAKA regimen, as a bladder preservation strategy, is feasible and safe in selective advanced Ca Bladder patients.

ExPert ConsEnsus on the management of Advanced clear-cell RenaL celL carcinoma: INDIAn Perspective (PEARL-INDIA).

In advanced Renal Cell Carcinoma (aRCC), systemic therapy is the mainstay of treatment, with no or little role for surgery in these patients. Tyrosine kinase inhibitors (TKIs) and immune-oncological (IOs) therapies, either alone or in combination, are recommended in these patients depending on patient and tumour factors. The sequencing of therapies is critical in RCC because the choice of subsequent line therapy is heavily dependent on the response and duration of the previous treatment. There are additional barriers to RCC treatment in India. Immunotherapy is the cornerstone of treatment in ccRCC, but it is prohibitively expensive and not always reimbursed, effectively putting it out of reach for the vast majority of eligible patients in India. Furthermore, in advanced RCC (particularly the clear cell variety), Indian oncologists consider the disease burden of the patients, which is particularly dependent on the quantum of the disease load, clinical symptoms, and performance status of the patient, before deciding on treatment. There are no India-specific guidelines for clear cell RCC (ccRCC) treatment or the positioning and sequencing of molecules in the management of advanced ccRCC that take these country-specific issues into account. The current consensus article provides expert recommendations and treatment algorithms based on existing clinical evidence, which will be useful to specialists managing advanced ccRCC.

Recurrent extramedullary plasmacytomas without multiple myeloma: A case report with review of the literature.

BACKGROUND: Extramedullary plasmacytoma (EMP) is an uncommon presentation and usually occurs in conjunction with multiple myeloma (MM). An EMP without developing MM at any point is an extremely rare presentation, and only seven such cases have been reported in the literature to date. PRESENTATION OF CASE: We present a case of EMP, who presented with multiple recurrent lesions in rare sites like nasal cavity, testis and skin without the involvement of bone marrow at any point of disease course. He was treated with multiagent chemotherapy (DT-PACE) and continues to be in remission at 29 months post-chemotherapy, which is the longest amongst all the cases reported so far. DISCUSSION AND CONCLUSIONS: There are no clearly defined guidelines to treat EMP. Our case had a clinical presentation at very unusual sites and was treated with DT-PACE regimen as against the previous seven reported cases and had the most prolonged period of remission.

Pretreatment neutrophil-to-lymphocyte ratio predicts lymph node metastasis in triple-negative breast cancer.

Background: The purpose of the study was to investigate the value of pretreatment neutrophil-to-lymphocyte ratio (NLR) as a prognostic marker in triple-negative breast cancer (TNBC) and to see its bearing on the clinical and pathological stage of the disease. Methods: This was a retrospective analysis of cases of TNBC treated at our center from 2006 to 2013. The pretreatment complete blood count was recorded from which the NLR was calculated as the percentage of neutrophils divided by the percentage of lymphocytes. The association between pretreatment NLR with the stage of the disease, clinical and pathological lymph node status, and disease-specific survival was analyzed. Results: A total of 208 patients were eligible for the analysis. The median follow-up period was 48 months. The NLR was found to have a strong correlation with the pathological nodal status and the clinical stage (75% cases node-positive in the high NLR group versus 36% in the low NLR group; P < 0.01). At the time of analysis, 74% of our study population was alive and well. There was no significant correlation between the NLR and the overall survival. Conclusions: Based on our study, we conclude that the pretreatment NLR is strongly associated with lymph node metastasis and clinical stage in TNBC patients. It is probably not useful as a prognostic marker, as it does not seem to have any significant bearing on the overall survival.

Recurrence of renal cell carcinoma after three decades in an octogenarian: Small molecules adding life to years.

Renal cell carcinoma (RCC) is the most common primary renal neoplasm. About a half of our patients relapse after primary treatment. We present here a case of RCC with solitary metastasis to the pleura which occurred 32 years after nephrectomy. Our patient is an 86-year-old male who presented to us with a cough of 2 months and a history of having undergone a right nephrectomy 32 years back. Imaging of the chest showed left pleural effusion with a left pleural nodule. Computed tomography-guided fine-needle aspiration cytology from the pleural nodule was suggestive of malignancy with a clear cell morphology, suggestive of clear cell RCC. The patient was started on sunitinib 25 mg once daily. After the 1st month, the patient's performance status improved markedly, with no cough and improved appetite. He had developed Grade II hand-foot syndrome, which was managed conservatively, and the dose was deescalated to 25 mg once daily - 5 days on and 2 days off. An X-ray of the chest taken 6 weeks after the start of therapy showed complete resolution of the pleural fluid and regression of the pleural nodule. The patient is alive and well 5 years into therapy. The case highlights the unusual propensity for very late metastasis in RCC. Metastasis after 30 years is extremely rare. Another highlight of the case is the good tolerability of the dose-modified schedule of sunitinib. Wise patient selection and dose modification can certainly add "life to the years" in our very elderly patients.

Prevalence of the use of traditional complementary and alternative medicine amongst cancer patients in a tertiary care center in Kerala, India.

BACKGROUND: Unmet needs of cancer patients prompt them to seek care from Traditional, Complementary and Alternative Medicine (TCAM) practitioners. OBJECTIVE: To investigate the prevalence of TCAM use in a multi-specialty tertiary cancer center in South India. MATERIALS AND METHODS: A cross-sectional survey of cancer patients who used TCAM during the study period. The patients were recruited based on covenience sampling method. RESULT: 320 cancer patients were approached, out of which 279 (87.2%) patients responded, and the prevalence of TCAM use was 34.4%. Home remedies (36%) figure prominently, with family advice (40%) being the primary influence for the TCAM use. The key expectation was an improvement in the quality of life (49%). TCAM use was pronounced during the chemotherapy phase (50%). Most patients (76%) using TCAM reported satisfaction with the treatment. Majority of the patients did not disclose concomitant use of TCAM to their treating physicians (71%). CONCLUSION: TCAM use by cancer patients is prevalent in Kerala. The study results point towards a need for large scale surveys, implementation of pharmacovigilance, patient education and research to identify and integrate TCAM interventions in cancer care that are safe and have beneficial effects.

Triple intrathecal chemotherapy for leptomeningeal carcinomatosis in solid tumors: Treatment outcomes, response and their determinants.

BACKGROUND: Leptomeningeal carcinomatosis (LC) is the metastatic infiltration of leptomeninges by malignant cells originating from an extrameningeal primary tumor site, either extraneural or intraneural. In the absence of treatment, survival is usually measured in weeks, however with treatment this may be extended to a few months. Our institutional protocol has been to offer intrathecal chemotherapy (ITC) to patients having solid tumors with cerebrospinal fluid (CSF) cytology positive leptomeningeal carcinomatosis. This study was performed to describe the oncological outcomes in this cohort and their determinants. METHODS: A retrospective review of data of patients treated at Amrita Institute of Medical Sciences, Kochi, India was performed. Patients with CSF cytology positive solid tumors treated with triple ITC (methotrexate, cytosine arabinoside and hydrocortisone) were assessed for patient characteristics, treatment response, survival and the factors affecting them. RESULTS: Twenty patients of LC treated with triple ITC were included in the study. The median age of the study group was 49 years with a slight female preponderance (55%). All patients had positive CSF cytology with mean CSF glucose of 60 mg/dL, mean CSF protein of 92 mg/dL and mean cell count of 5. Breast cancer was the most common primary tumor (45%), followed by lung (35%) and stomach (5%). Symptomatic improvement was reported in 70% of patients after initiating ITC. Median overall survival (OS) at 6 and 12 months was 38% and 14%, respectively. Median progression-free survival (PFS) was 2 months. Patients with brain parenchymal metastasis had poor 6 month OS (25% vs 50%, P = 0.013) and 6 month PFS (0% vs 20%, P = 0.023). CONCLUSION: A triple drug combination of methotrexate, cytosine arabinoside and hydrocortisone when given intrathecally for patients with LC showed good control of symptoms and reasonable survival. It may be beneficial in patients with no brain parenchymal involvement.

Iatrogenic Microperforation Linked to Hemorrhagic Pericardial Effusion Complicated by Cardiac Tamponade.

Pericardial effusions have a wide range of etiologies, including infection, inflammation, and malignancy. A complication of pericardial effusion is cardiac tamponade. In instances of cardiac tamponade, prompt echocardiography and stabilization are paramount in preventing mortality. Here, we report a case of iatrogenic microperforation of the right ventricle during a pacemaker lead adjustment causing a delayed pericardial effusion complicated by cardiac tamponade. Lead removal is recommended in cases of valvular endocarditis, pocket infection, thrombosis, or life-threatening dysrhythmias; however, there are no established guidelines in the setting of perforation. In this case, an emergent pericardiocentesis was performed due to cardiac tamponade, but lead extraction was not performed.

Frequency and Prognosis of Epidermal Growth Factor Receptor Variant III Mutations in Glioblastoma Multiforme among Indian Patients: A Single-Institution Study.

Background Glioblastoma multiforme (GBM) is a disease with poor outcome. Alterations or mutations in epidermal growth factor receptors (EGFRs) are found in GBM and may be targeted to improve outcomes. Aims We analyzed the frequency of EGFR variant III (vIII) mutations in patients with GBM and their outcomes after standard treatment. Materials and Methods This is a retrospective study conducted in a single tertiary cancer center in south India. Forty patients with GBM who had their entire treatment done at this center were identified, and their primary tumor tissue blocks were retrieved. Genomic DNA was extracted, and molecular analysis was performed and analyzed. The results of mutational analysis were correlated with treatment outcome of the patients. Statistical Analysis Survival outcome was analyzed using the Kaplan-Meier method. The log-rank test was used to assess the association between the groups and various parameters. Results Our study showed a similar incidence of EGFR vIII alterations as published in world literature, but we did not find any difference in overall survival (OS) and progression-free survival (PFS) in patients with EGFR vIII mutation compared with nonmutant cohort. Conclusions Contrary to the existing literature which indicated EGFR vIII alterations to be a negative prognostic indicator, our study did not find it to be an independent predictor of prognosis among Indian GBM patients treated with present standard of care.

Chemoport-related Fungemia Caused by Trichosporon asahii.

Trichosporon asahii is a rare opportunistic fungal pathogen that causes fatal systemic infection in immunocompromised patients. Neutropenia developing due to malignancies is an important risk factor for fungal infection. Invasive infections due to T. asahii can be divided into disseminated and localized forms. The disseminated form is more common and usually occurs in neutropenic patients. The patient typically has an acute febrile illness that progresses rapidly to multiorgan failure. Here, we are presenting a case of fungal sepsis by invasive T. asahii in a 1-year-old child with Wilms Tumor. To the best of our knowledge, this is the first time that fungal sepsis due to T. asahii has been reported in a Wilms tumor patient. The incidence of rare invasive fungal infections is increasing in immunocompromised patients in whom management becomes difficult due to their heterogenous antifungal susceptibility pattern and intrinsic resistance to the standard antifungal agents that are routinely given. The patient was admitted with high spiking fever, and his laboratory investigations suggested neutropenia. T. asahii was isolated from the blood culture, for which he was started on inj. voriconozole. After 14 days of treatment, the fungus was cleared out from the patient's blood.

Prognostic significance of residual nodal burden using lymph node ratio in locally advanced breast cancer after neoadjuvant chemotherapy.

OBJECTIVE: To investigate the prognostic value of lymph node ratio (LNR) after neoadjuvant chemotherapy (NAC) according to breast cancer molecular subtypes. METHODS: From 2004 to 2014, patients with definitive surgery after NAC were identified. LNR was calculated for node positive patients who underwent axillary dissection and at least 10 nodes (LNT) were removed. Disease free and overall survivals were analysed using Kaplan-Meier test and compared using log rank test for ypN0-3, LNR categories (LNRC) ≤0.2 (low), 0.21-0.65 (intermediate), >0.65 (high), and single LNR cut-off value. RESULTS: Of 224 analysed patients: ypN0 72 (32.1%), ypN+ 152 (67.9%). Of 118 LNT ≥10 ypN+ patients LNRC: Low risk 48 (40.7%), intermediate risk 36 (30.5%), high risk 34 (28.8%). Factors significantly different in LNR categories were ypN (P < 0.001); extranodal extension (P < 0.001); present status of patients (P < 0.001); and disease status (P = 0.029). LNRC was inversely associated with 5-year DFS: Low 52.3%, intermediate 40%, and high 12.2% (log rank P < 0.001); and OS: Low 64.4%, intermediate 58.3%, and high 13.6% (log rank P < 0.001). Significant association of LNRC and DFS and OS were demonstrated in TNBC (P < 0.001) and HER2 subtypes (P = 0.045 and 0.005 respectively). A single value of LNR = 0.25 in node positive was found significant for DFS and OS in TNBC (P < 0.001) and Her2+ (P = 0.013 and P = 0.001 respectively) but not for HR+ (DFS: P = 0.132; OS: P = 0.144). CONCLUSION: Residual nodal disease after NAC analysed by LNRC or LNR = 0.25 cut-off value, is prognostic and can discriminate between favourable and unfavourable outcomes for TNBC and Her2+ breast cancers.

Concurrent chemoradiotherapy for head and neck cancers in older patients: Outcomes and their determinants.

INTRODUCTION: Meta-analyses have shown concurrent chemoradiotherapy (CCRT) provides no survival benefit over radiotherapy in patients of head and neck squamous cell carcinoma (HNSCC) aged over 70 years. This study was performed to determine the adverse-effect profile, compliance, functional and oncological outcomes in patients of HNSCC over 70 years of age treated with CCRT. MATERIALS AND METHODS: Retrospective analysis of stage III/IV HNSCC in patients above 70 years of age who received CCRT at our institution (n = 57). Cox-proportional hazards regression model was used for statistical analysis. RESULTS: There were 57 patients of stage III/IV HNSCC who underwent curative CCRT. 61% completed chemotherapy with no deaths and acceptable toxicity. The predictors of recurrence were poorer performance status (P = 0.031) and treatment breaks (P = 0.04). Tube dependence was associated with 2.7 times higher risk of mortality (P = 0.005). CONCLUSION: CCRT should be considered standard of care in those over seventy with good performance status. Patients with tube dependence have a higher risk of persistent disease or treatment related mortality.

Robot-assisted supine extraperitoneal retroperitoneal lymph node dissection: a novel approach for template dissection in post-chemotherapy residual mass in non-seminomatous germ cell tumours.

Robot-assisted retroperitoneal lymph node dissection (RA-RPLND) in testicular cancer is conventionally performed through transperitoneal route. We report a case of robot-assisted supine extraperitoneal RPLND (RASE-RPLND), not previously described in the literature, which was performed for post-chemotherapy residual mass in a case of non-seminomatous germ cell tumour (NSGCT). RASE-RPLND apart from providing the benefits of robotic assistance has a significant advantage over transperitoneal approach, as the procedure can be performed in supine position without any bowel handling. Herein, we provide a detailed description of the novel surgical technique employed by us in this case.

Pharmacogenetic landscape of DPYD variants in south Asian populations by integration of genome-scale data.

AIM: Adverse drug reactions to 5-Fluorouracil(5-FU) is frequent and largely attributable to genetic variations in the DPYD gene, a rate limiting enzyme that clears 5-FU. The study aims at understanding the pharmacogenetic landscape of DPYD variants in south Asian populations. MATERIALS & METHODS: Systematic analysis of population scale genome wide datasets of over 3000 south Asians was performed. Independent evaluation was performed in a small cohort of patients. RESULTS: Our analysis revealed significant differences in the the allelic distribution of variants in different ethnicities. CONCLUSIONS: This is the first and largest genetic map the DPYD variants associated with adverse drug reaction to 5-FU in south Asian population. Our study highlights ethnic differences in allelic frequencies.

Spontaneous regression of primary progressive Hodgkin's lymphoma in a pediatric patient: a case report and review of literature.

Spontaneous regression of malignancies is a very rare phenomenon. Our research of existing literature yielded only 16 cases of Hodgkin's lymphoma which regressed spontaneously. The outcome of primary progressive Hodgkin's lymphoma is poor even with salvage chemotherapy and autologous bone marrow transplantation. Here we present a case of primary progressive Hodgkin's lymphoma, which regressed spontaneously after failure of salvage chemotherapy. To our knowledge, this is the first case report of primary progressive Hodgkin's lymphoma undergoing spontaneous regression.