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Ganguly S, Sasi A, Khan SA, Kumar VS, Kapoor L, Sharma MC, Mridha A, Barwad A, Thulkar S, Pushpam D, Bakhshi S. Formulation and validation of a baseline prognostic score for osteosarcoma treated uniformly with a non-high dose methotrexate-based protocol from a low middle income healthcare setting: a single centre analysis of 594 patients. Front Oncol 2023; 13:1148480. [PMID: 37188186 PMCID: PMC10175811 DOI: 10.3389/fonc.2023.1148480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023] Open
Abstract
Introduction The outcomes of osteosarcoma in low middle income countries (LMICs) are different due to patients presenting in advanced stages, resource constraints and the use of non-high-dose-methotrexate (HDMTX)-based regimens. This study derived and validated a prognostic score for osteosarcoma that integrates biologic and social factors and is tailored for patients from an LMIC setting using a non-HDMTX-based protocol. Materials and methods A retrospective study including osteosarcoma patients enrolled for treatment at a single tertiary care centre in India between 2003-19 was conducted. Baseline biologic and social characteristics were extracted from medical records and survival outcomes were noted. The cohort was randomised into a derivation and validation cohort. Multivariable Cox regression was used to identify baseline characteristics that were independently prognostic for survival outcomes in the derivation cohort. A score was derived from the prognostic factors identified in the derivation cohort and further validated in the validation cohort with estimation of its predictive ability. Results 594 patients with osteosarcoma were eligible for inclusion in the study. Around one-third of the cohort had metastatic disease with 59% of the patients residing in rural areas. The presence of metastases at baseline (HR 3.39; p<0.001; score=3), elevated serum alkaline phosphatase (SAP) >450 IU/L (HR 1.57; p=0.001; score=1) and baseline tumour size > 10 cm (HR 1.68; p<0.001; score=1) were identified to be independent factors predicting inferior event free survival (EFS) and were included in development of the prognostic score. Patients were categorized as low risk (score 0), intermediate risk (score 1-3) and high risk (4-5). Harrell's c-indices for the score were 0.682, 0.608 and 0.657 respectively for EFS in the derivation, validation and whole cohort respectively. The timed AUC of ROC was 0.67 for predicting 18-month EFS in the derivation, validation and whole cohorts while that for 36-month EFS were 0.68, 0.66 and 0.68 respectively. Conclusions The study describes the outcomes among osteosarcoma patients from an LMIC treated uniformly with a non-HDMTX-based protocol. Tumor size, baseline metastases and SAP were prognostic factors used to derive a score with good predictive value for survival outcomes. Social factors did not emerge as determinants of survival.
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Affiliation(s)
- Shuvadeep Ganguly
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Archana Sasi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Shah Alam Khan
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Love Kapoor
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Mehar Chand Sharma
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Asit Mridha
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Adarsh Barwad
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radiodiagnosis, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Deepam Pushpam
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
- *Correspondence: Sameer Bakhshi,
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Mittal A, Pushpam D, Ganguly S, Kumar VS, Khan SA, Bakhshi S. Controversies and Challenges in the Management of Osteosarcoma-an Indian Perspective. Indian J Surg Oncol 2022; 13:939-955. [PMID: 36687236 PMCID: PMC9845467 DOI: 10.1007/s13193-021-01486-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 11/30/2021] [Indexed: 01/25/2023] Open
Abstract
Osteosarcoma (OGS) is the most common primary bone tumor in children and adolescents which requires a multidisciplinary approach to management. Although chemotherapy and surgery can cure more than half of localized OGS cases, the unique challenges faced by resource-limited countries like India make this outcome difficult to achieve. Various questions in the management of OGS including role of high-dose methotrexate (HDMTX) in neoadjuvant setting, triplet vs doublet chemotherapy, intensification of chemotherapy based on response in setting of doublet, and indigenous prosthesis in setting of limb salvage need to be defined. Similarly, in the metastatic and recurrent setting, questions regarding intent of treatment, indications of chemotherapy, timing of surgery, and role of targeted therapies need clarification. Lack of randomized trials from India makes definite conclusions difficult, but an attempt can be made to define the best approach in the Indian scenario from available evidence. Hence, a critical review of literature from India and the West was done to define possible management approaches and highlight the lacuna for future research.
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Affiliation(s)
- Abhenil Mittal
- Department of Medical Oncology, DR BRAIRCH, AIIMS, New Delhi, 110029 India
| | - Deepam Pushpam
- Department of Medical Oncology, DR BRAIRCH, AIIMS, New Delhi, 110029 India
| | - Shuvadeep Ganguly
- Department of Medical Oncology, DR BRAIRCH, AIIMS, New Delhi, 110029 India
| | | | - Shah Alam Khan
- Department of Orthopedics, AIIMS, New Delhi, 110029 India
| | - Sameer Bakhshi
- Department of Medical Oncology, DR BRAIRCH, AIIMS, New Delhi, 110029 India
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Gao Q, Yao Y, Xu Q. Guideline and Implementation of Osteosarcoma Nursing Care for Children and Adolescents. Appl Bionics Biomech 2022; 2022:2021162. [PMID: 36267672 PMCID: PMC9578899 DOI: 10.1155/2022/2021162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/07/2022] [Accepted: 08/09/2022] [Indexed: 11/29/2022] Open
Abstract
Clinical trials on pediatric oncology use therapeutic techniques with the overwhelming majority of children's cancer patients obtaining therapy via clinical investigation procedures. Medical treatment is scheduled according to a specific protocol for enrolled patients. These protocols often do not refer to nursing care. Nursing care, on the other hand, must complement the medical care specified in the medical research protocol. Safe treatment administration, assessment of treatment responses, patients' and families' education, and communication with the whole medical team are just a few of the critical nursing tasks that should be properly managed. Nursing care standards have been developed in this study to strike a good balance between the procedure for clinical research and the nursing care connected with it. These recommendations outline the nursing activities and considerations that must be made while caring for pediatric cancer patients who are engaged in a specific clinical investigation procedure. The objective of this study is to outline the procedure through which nursing care guidelines could be developed and evaluated. The goal of this study was to find out the involvement of nurses in the process of health education for osteosarcoma and family patients.
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Affiliation(s)
- Qian Gao
- Nursing Department, Department of Bone Oncology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 310009, China
| | - Yuhong Yao
- Nursing Department, Department of Bone Oncology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 310009, China
| | - Qi Xu
- Nursing Department, Department of Thoracic Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, 310009, China
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Samuel G, Yadav A, Mounisamy P, Kayal S. An Audit of Delays in the Management of Non-Metastatic Osteosarcoma at a Tertiary Care Center in South India. Cureus 2022; 14:e27744. [PMID: 36106218 PMCID: PMC9446663 DOI: 10.7759/cureus.27744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/05/2022] Open
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Rajeswari B, Guruprasad CS, Nair M, Prasanth VR, Sugath BS, Thankamony P. High dose methotrexate containing regimen in pediatric non-metastatic extremity osteosarcoma patients: experience from a tertiary cancer center in India. Pediatr Hematol Oncol 2022; 39:225-232. [PMID: 34378476 DOI: 10.1080/08880018.2021.1963021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Methotrexate containing chemotherapy is less commonly used for treatment of osteosarcoma in resource limited settings. We present our experience with the administration of high dose methotrexate (HDMTX) containing chemotherapy over a period of three years. Children between 1 and 14 years of age with newly diagnosed nonmetastatic extremity osteosarcoma, registered in Pediatric Oncology Department of a tertiary care cancer center in South India between 1st January 2016 and 31st December 2018 and receiving MAP chemotherapy were included. Patients in this study received HDMTX at 12 g/m2. Twenty two patients were included. After neoadjuvant chemotherapy, 20 patients underwent surgery (limb salvage surgery in 16, amputation in 4). The median time from initiation of chemotherapy to surgery was 97.5 days. Eighteen of 22 patients (81.8%) completed planned chemotherapy in our cohort, one patient was lost to follow up after progression and three patients required change of chemotherapy due to toxicities. Of a total of 227 cycles of HDMTX infusions in 22 patients, delayed clearance occurred in 22 cycles (9.7%). Major toxicities were myelosuppression (30 episodes in 17 patients), blood stream infections (24 episodes in 15 patients) and mucositis (15 episodes in 10 patients). Hearing loss was documented in 7 patients. There was no treatment related mortality. Chemotherapy was completed in a median duration of 38.5 weeks. Administration of high dose methotrexate containing chemotherapy is feasible in pediatric patients with osteosarcoma, even in resource limited settings, if there are facilities for hydration, determination of methotrexate levels and good supportive care.
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Affiliation(s)
- Binitha Rajeswari
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | | | - Manjusha Nair
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | | | | | - Priyakumari Thankamony
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
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Mailankody S, Kumar VS, Khan SA, Banavali SD, Bajpai J. Resource-appropriate selection of osteosarcoma treatment protocols in low- and middle-income countries. Pediatr Blood Cancer 2022; 69:e29540. [PMID: 34971016 DOI: 10.1002/pbc.29540] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 10/30/2021] [Accepted: 12/08/2021] [Indexed: 02/01/2023]
Abstract
Osteosarcoma is a rare malignancy; however, it is still the most common primary bone tumor in adolescents and young adults. Chemotherapy improves survival indubitably in osteosarcoma; nevertheless, the concern is the stagnant progress since the last several decades. There are a handful of active agents and unresolved issues, especially in choosing the ideal chemotherapy regimen. The oncology community is in equipoise regarding the position of high-dose methotrexate (HDMTX), mandatory or adjunct. The choice of therapy becomes widely relevant, including in low- and middle-income countries (LMIC), where HDMTX administration brings additional complexities. Research into novel non-HDMTX-based protocols adapted to the available resources is pivotal in improving disease outcomes, especially in LMIC. The current review focuses on real-world challenges in decision-making and provides a comprehensive overview of the evolution of treatment protocols in LMIC.
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Affiliation(s)
- Sharada Mailankody
- Department of Medical Oncology, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal, Karnataka, India.,Manipal Academy of Higher Education, Manipal, Karnataka, India
| | | | - Shah Alam Khan
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India
| | - Shripad D Banavali
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute (HBNI), Mumbai, Maharasthra, India
| | - Jyoti Bajpai
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute (HBNI), Mumbai, Maharasthra, India
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Bajpai J, Chandrashekharan A, Banavali SD, Gupta S. Osteosarcoma Journey in India: Each Step Reveals a New Horizon! Indian J Med Paediatr Oncol 2021. [DOI: 10.4103/ijmpo.ijmpo_15_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jyoti Bajpai
- Tata Memorial Centre, Tata Memorial Hospital, Mumbai, Maharashtra, India
- Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
| | - Arun Chandrashekharan
- Department of Medical Oncology, Aster Malabar Institute of Medical Sciences, Kozhikode, Kerala, India
| | - Shripad D Banavali
- Department of Medical and Pediatric Oncology, TMC-Rural Outreach Program, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Tata Memorial Centre, Tata Memorial Hospital, Mumbai, Maharashtra, India
- Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai, Maharashtra, India
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Raghavan V, Jithin TK, Narayanan VV, Nayanar SK, Balasubrahmanian S. Predictors of Survival in Children with Osteogenic Sarcoma Undergoing Limb Salvage Surgery: Experience from a Tertiary Cancer Center in Rural India. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_166_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Context: Osteogenic Sarcoma (OGS) is the fifth most common malignancy among adolescents aged 15–19. With multimodality therapy, the long-term survival has improved from 16% in the prechemotherapy era to around 70% in the postchemotherapy era. Aim: This study aims to determine the clinical profile and survival of children with OGS being treated with limb-salvage surgery (LSS). Subjects and Methods: This is a retrospective analysis of all cases of OGS (age ≤ 19) who underwent LSS at our center between June 2009 and February 2017. Baseline characteristics were noted and multivariate analysis was performed for various variables to identify predictors of survival. Results: Among 44 cases studied majority were boys (n = 27). Ninety-three percentage (n = 41) were adolescents. Stage 2 disease was 75% and Stage 3 disease was 25%. The estimated 3-year overall survival (OS) was 69% (95% confidence interval [CI] 55–86) and the estimated 3-year event-free survival (EFS) was 55% (95% CI = 41–74). OS was significantly improved in patients with >90% necrosis postneoadjuvant chemotherapy (NACT) when compared with <90% necrosis (3-year OS = 88% vs. 51%,P= 0.01) and in patients who received ≤4 cycles NACT versus >4 cycles (78% vs. 60%,P= 0.04). EFS was significantly better in patients without lung metastasis at presentation (61% vs. 29%,P= 0.04), Stage 2 disease (59% vs. 38%,P= 0.04) and >90% necrosis in the tumor post-NACT (69% vs. 35%,P= 0.02). Conclusion: Significant response to NACT predicted improved OS and EFS in children with OGS treated with LSS.
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Affiliation(s)
- Vineetha Raghavan
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Kannur, Kerala, India
| | - TK Jithin
- Department of Clinical Hematology and Medical Oncology, Malabar Cancer Centre, Kannur, Kerala, India
| | - Vinin V Narayanan
- Department of Radiation Oncology, Malabar Cancer Centre, Kannur, Kerala, India
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Ganguly S, Kinsey S, Bakhshi S. Childhood cancer in India. Cancer Epidemiol 2020; 71:101679. [PMID: 32033883 DOI: 10.1016/j.canep.2020.101679] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 12/20/2022]
Abstract
India has made significant improvement in childhood cancer services in last few decades. However, the outcome still remains modest as compared to global standards due to significant barriers in recognition, diagnosis and cure. Data regarding comprehensive childhood cancer burden in country is lacking due to low and urban predominant coverage of population-based cancer registry programs. The available data shows lower incidence of childhood cancer incidence especially in leukaemia and CNS tumours which may suggest poor awareness of caregivers and delayed diagnosis with many "missed cases". Incidence data are also skewed towards male preponderance which suggests gender bias in seeking healthcare. The childhood cancer services in India are predominantly restricted to few tertiary care centres in major cities. The outcome in major groups of cancer is complicated by delayed and more advanced stage of presentation and poor supportive care during intensive treatment. Treatment refusal and abandonment remains major hurdles. Last few decades saw development of dedicated paediatric oncology services and training programs in the country. The development of InPOG (Indian Paediatric Oncology group) for conducting collaborative trials will lead to adoption of uniform treatment protocols suited for the country. Financial support through the government promoted health insurance and holistic support through philanthropic organizations have improved treatment adherence and outcome. Moving forward, the focus should be on strengthening the cancer registries for capturing nationwide data, improving awareness of childhood cancer among caregivers and healthcare workers for early recognition and improving accessibility of childhood cancer care services beyond major cities.
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Affiliation(s)
| | - Sally Kinsey
- Department of Paediatric Haematology, University of Leeds, Honorary Consultant Paediatric Haematologist, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Sameer Bakhshi
- Department of Medical Oncology, IRCH, AIIMS, New Delhi, India.
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Pareekutty N, Ankalkoti B, Kattepur A, Kumbakara R, Vazhayil R, Balasubramanian S. Life and limb after limb salvage surgery for osteosarcoma in an Indian tertiary cancer center. CANCER RESEARCH, STATISTICS, AND TREATMENT 2019. [DOI: 10.4103/crst.crst_44_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Puri A. Musculoskeletal Oncology: Finding Its Place in the Sun! Indian J Orthop 2018; 52:1-2. [PMID: 29416162 PMCID: PMC5791224 DOI: 10.4103/ortho.ijortho_674_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Ajay Puri
- Department of Surgical Oncology, Tata Memorial Hospital, HBNI, Mumbai, Maharashtra, India,Address for correspondence: Prof. Ajay Puri, Department of Surgical Oncology, Room No: 45, Tata Memorial Hospital, HBNI, Mumbai, Maharashtra, India. E-mail:
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