Effectiveness of Immune Checkpoint Inhibitors in Various Tumor Types Treated by Low, Per-Weight, and Conventional Doses at a Tertiary Care Center in Mumbai.

PURPOSE: The cost of immune checkpoint inhibitors (ICIs) limits their accessibility to a small number of patients with cancer in low- and middle-income countries. Early-phase clinical trials have shown target inhibition and high activity at doses lower than those registered and evaluated in clinical trials. Here, we report everyday experience of using ICIs in 100 Indian patients, many of whom received lower doses of ICIs. METHODS: Consecutive patients who received at least one dose of an ICI irrespective of tumor type at a tertiary care hospital in Mumbai, India, that was able to access ICIs for its patients were enrolled. The objectives were to study the doses used over a 3-year time period, and the effectiveness of therapy, assessed primarily by the overall response rate (ORR), overall survival (OS), and progression-free survival were secondary end points. RESULTS: Twenty-five patients were treated with conventional doses of ICIs, 29 patients received lower doses per body weight, and 46 patients received low-dose treatment. The median number of cycles received was 5 (range, 1-28). Seventy-eight patients received ICIs in a palliative setting. The median follow-up time was 10.2, 9.8, and 3.9 months for those receiving fixed approved dosing, per body weight dosing, and low-dose treatment, respectively. There was a trend with time to prescribe lower doses. Response evaluation was available for 92 patients. Twenty-one (five-adjuvant and 16-palliative) patients received ICIs only. The ORR did not differ statistically among different dosing groups, but comparisons are confounded by inclusion of different ICIs, different tumor sites, and concurrent treatments. The median OS was 6.8 (range, 4.6-9.0) months. CONCLUSION: Adoption of per-body weight and lower dosing of ICIs appears to give acceptable outcomes. Lower dosing can improve access and timely delivery of ICIs in low- and middle-income countries.

Pruritus as Unusual Manifestation of Lupus Myelopathy.

Lupus myelopathy is a relatively uncommon manifestation of SLE. Atypical presentation of this rare entity with neuropathic itch has never been reported. We report a young girl who presented with predominant symptom of refractory pruritus which after clinical localization and imaging was detected to have long segment patchy myelitis. Detailed evaluation led to a diagnosis of lupus myelopathy and the patient responded to immunosuppressive therapy with significant clinical and radiological improvement. Maintaining a high level of suspicion for neurological cause in a patient with refractory localized itching resistant to regular antiallergic treatment is important in the right clinical setting.

Inferior Vena Cava Agenesis: A Rare Cause of Pelvic Congestion Syndrome.

Complete absence of Inferior Vena Cava (IVC) is a rare anomaly with a reported incidence of 0.0005% to 1%. This is often asymptomatic with incidental detection during cross-sectional imaging. It may also present with deep venous thrombosis, pulmonary thromboembolism or compressive symptoms in form of nerve root compression. Pelvic Congestion Syndrome (PCS) is an increasingly recognized entity with well laid out diagnostic criteria and evolving management protocols. Complete absence of IVC is a rare cause of pelvic congestion syndrome. We present a case of young female presenting with symptoms typical of pelvic venous congestion who was found to have complete absence of IVC as the underlying cause. She also had associated small left kidney with compensatory hypertrophy of the right kidney which is another rare association.

A Case of Cervical Spine Tuberculosis in an Infant.

Tuberculosis of cervical spine is an extremely rare entity in infants with only few case reports available in the literature. The diagnosis is often delayed due to less dramatic effects of paraplegia or quadriplegia in an infant as compared to older paediatric population. Along with clinical and laboratory investigations, imaging plays a crucial role in defining the extent of involvement, evaluation of complications, providing suitable differential diagnosis and monitoring response to treatment. Tuberculosis typically involves the discovertebral complex while involvement of isolated vertebral body or multiple vertebrae without involving the intervertebral discs is much less common. We present such an unusual case of cervical spine tuberculosis in an infant involving a single vertebral body without adjacent intervertebral disc involvement complicated with tuberculous meningitis (TBM) and communicating hydrocephalus. The early medical intervention in this case resulted in early diagnosis, active treatment and resultant near normal recovery.