Primary cutaneous adenoid cystic carcinoma - An onerous task for clinicians and pathologists

Adenoid cystic carcinoma (ACC) is an uncommon malignant neoplasm usually confined to the salivary glands, lungs, and breasts. Primary cutaneous adenoid cystic carcinoma (PCACC) is an extremely rare entity with solitary cases reported at sites away from the scalp and chest. Hence, one must follow the multidisciplinary approach to exclude any primary ACC elsewhere in the body. We report a rare case of PCACC arising from the skin of the left lower limb in a 55-year-old woman with a history of recurrent swelling, clinically diagnosed as a metastatic tumor.

Clinical Characteristics and prognostic analysis of Triple-negative Breast Cancer: Single institute experience

BACKGROUND

Triple-negative breast cancer (TNBC) is a poor prognostic subset of breast cancer that lacks the benefit of specific targeted therapy.

MATERIALS AND METHODS

A prospective study of the clinical profile of triple negative breast cancer cases at a tertiary referral centre. The duration of the study period was 26 months and the median follow up period was ten months. A total of 111 invasive breast cancer patients were evaluated from 1st August 2009 to 31st October 2011. We examined TNBC patients with respect to clinicopathological parameters, adjuvant chemotherapy regimens and relapse free survival.

RESULTS

In our study, patients were young (median age at presentation, 47yrs), premenopausal (54%), tumour size was discordant with lymph node positivity, the histology was predominantly intraductal carcinoma (90%), histological grade higher than two (90%). Relapses were early and preferential visceral (32%) and CNS metastasises (11.7%). 91% of patients were eligible for adjuvant therapy but only 80% of the patients could complete full course of adjuvant chemotherapy. Anthracycline-based regimens (43%), sequential anthracycline and taxane-based regimen (24%) and other regimes like CMF (13%) were used as adjuvant chemotherapy in eligible TNBC patients. Median relapse free survival in patients following adjuvant chemotherapy was around 10 months at last follow-up.

CONCLUSIONS

Patients with TNBC have aggressive clinicopathological characteristics with early and higher rate of disease relapse and therefore derive inadequate benefit from current adjuvant chemotherapy. So, new treatment strategies in adjuvant chemotherapy for TNBC are needed.

Three years experience of infantile Wilms tumour at a single institute in a developing country

20028

Background: Wilms tumor (nephroblastoma) is the second most common malignant retroperitoneal tumor. It is the most common primary renal tumour of childhood and is a paradigm for multimodal treatment of a pediatric malignant solid tumor. The median age at diagnosis is 4 years and it is uncommon in infancy. We present a three year retrospective analysis of Wilms tumor in infants treated at out institute. Methods: A total of 16 cases of Wilms tumor were diagnosed in pediatric patients aged one and below between January 2003 to December 2005. Out of these, 11 patients were evaluable. All of them were given treatment as per the National Wilms Tumor Study- 5 protocol. Results: The median age of presentation was 10.8 months, one child was 5 months old rest all were between 10 and 12 months. The male to female ratio was 2.3:1. The most common presenting complaint was mass per abdomen, which was seen in 10 patients, one patient presented with pain in abdomen and hematuria. None of the patients had evidence of any other systemic involvement. 7 patients were in Stage I, 2 each were in stage II and stage III. Triphasic classical type (favorable) was the histopathological subtype in 9 patients and 2 had unfavorable histopathological subtypes. All the 10 cases underwent total Nephrectomy [three at our institute and the rest elsewhere] of the diseased kidney followed by treatment as per the National Wilms Tumor Study- 5 protocol with 50% dose reduction. 7 cases (70%) showed complete remission and presently are under observation. Three cases were lost to follow up after surgery. One patient with stage three disease was given anterior chemotherapy but was lost to follow up after 9 weeks of chemotherapy. Conclusion: Wilms tumor presenting in infancy when treated appropriately has a good outcome although not as good as in older children.

No significant financial relationships to disclose.

Results of cisplatin-based chemotherapy in inoperable hepatoblastoma during last two years at a single institute

20027

Background: Total surgical excision and adjunctive chemotherapy are cornerstones of treatment of hepatoblastoma in children. But many are unsuitable for radical surgery at diagnosis due to extensive intrahepatic and/or extra hepatic disease. We assessed 18 consecutive cases during the last two years, all of whom presented with unresectable tumor, treated in our center with neoadjuvant chemotherapy,in order to analyze the clinical profile and response to treatment. Methods: A retrospective analysis of patients who presented to our institute during January 2004 to January 2006 was carried out. All patients were biopsy proven hepatoblastoma. One patient was operated without anterior chemotherapy outside our institute .Two patients had lung metastasis. Rest all had stage 3 disease. All the patients were given cisplatin [90 mg/m2] and continuous infusion doxorubicin [80 mg/m2 over 4 days]. The response to therapy was assessed. Results: Mean age of presentation was 3 years and 4 months [range 1 year to 11 year]. M:F ratio was 4:1. Most common presenting complaint was an asymptomatic abdominal mass felt by the parent. All the patients had tumour in right lobe. Mean alpha fetoprotein level was 0.14 million and the range was from normal to 1.24 million. None of the patients were positive for hepatits B or hepatitis C. After three cycles of chemotherapy, seven of the seventeen patients had adequate down staging of the disease so as to undergo successful resection. There was one post operative mortality. All of them completed total of six cycles of chemotherapy. Ten patients had unresectable tumour even after six cycles of chemotherapy. All of them had reduction in the size of primary tumor and decreased alpha fetoprotein level .There was no chemotherapy related grade 3 or grade 4 toxicity. Conclusions: Hepatoblastoma occurs at a later age in Indian patients as compared to that seen in western countries. Cisplatin and adriamycin are quite effective in downstaging hepatoblastoma. Since these agents are cheap and have minimal toxicity they should be used frequently.

No significant financial relationships to disclose.

Results of BFM 90 protocol at a single institute in a developing country: Three years experience

17524

Background: In a developing country the affordability status of a patient is the main factor in deciding the type of treatment a patient will receive. Majority of patients [>95%] at our institute have received MCP 841 protocol for acute lymphoblastic lymphoma .We have reviewed the treatment results of patients who had received chemotherapy as per the BFM 90 protocol over last 3 years. Methods: 18 patients (15 males and 3 females) with ALL who had received BFM 90 protocol as therapy during the period between January 2003 to January 2006 were analysed. 15 were of the pediatric age group (2–13 years) and 3 were adult patients (31 & 42 years). Median follow up period was 1 year 9 months. 5 patients were considered as high risk, 4 medium risk and the rest as standard risk. All patients were ph chromosome negative. Results: All paediatric patients are in CR. One patient had CNS relapse but he responded well to reinduction and is in CR. Three patients developed grade 4 toxicity after high dose methotrexate. The rest tolerated it well, however, leucoverin rescue had to be given empirically as methotrxeate level measurement was not available at that time. Two patients turned HCV positive during the course of treatment and had altered liver enzymes due to which maintenance treatment was interrupted. There were three instances of catheter removal and one port had to be removed due to infection. Both the adult patients had bone marrow relapse during treatment [one during maintenance and the other during reinduction] and could not be salvaged. Conclusions: BFM 90 protocol is a viable alternative to MCP 841 in developing countries where high dose methotrexate is given with empirical leucoverin rescue. High rates of catheter infection is of concern. Better patient education and improved techniques will probably improve the situation.

No significant financial relationships to disclose.

Imatinib mesylate therapy in advanced gastrointestinal stromal tumors—A Regional cancer centre experience

19505

Background: The treatment of gastrointestinal stromal tumors has been revolutionised by the advent of Imatinib, a specific tyrosine kinase inhibitor. Post operative local and metastatic recurrences of this tumor have been effectively managed by Imatinib. Here we present our experience of Imatinib in recurrent locally advanced/metastatic gastrointestinal stromal tumors (GIST). Methods: From Nov 2001 to Sep 2005, 33 patients with metastatic and / or locally advanced inoperable CD-117 positive GIST were offered imatinib mesylate therapy at 400 mg/day p.o. A total of 21 patients were evaluable for tumor response. Follow up period ranged from 4 months to 38 months with median follow up period being 18 months. Median age is 58 yrs, M:F ratio is 6:4. ECOG performance status was 0–1 in 70% (23 patients) and 2 in 30% (10 patients). 70% patients had post surgery recurrence. 2 patients (6%) had received adjuvant chemotherapy prior to recurrence. 30% (10 patients) had local recurrence, 40% (13 patients) had metastatic disease while 30% (10 patients) had local recurrence as well as metastatic disease. Results: Response evaluation was done by RECIST criteria. 15% (5 patient) showed CR while PR rates were 30% (10 patients). The overall major response (CR+PR) was 45%. The overall progression free survival was as high as 80%. All the patients who had a progression free survival also had a significant improvement in quality of life. Conclusions: Imatinib mesylate therapy shows significant survival benefits in locally advanced inoperable/metatstatic gastrointestinal stromal tumors. It will be a very long time before PET scan for evaluation and follow up becomes feasible in developing country setting.

No significant financial relationships to disclose.

Childhood nasopharyngeal carcinoma: A 4-year single institution experience

9069

Background: Pediatric nasopharyngeal carcinoma (PNC) represents a locally advanced undifferentiated tumor. In this study, clinical experience and therapeutic results of 24 children with newly diagnosed PNC, treated in a single oncology institution in India over a period of 5 years, are analyzed. Methods: 24 patients (23 males and 1 female) 7–14 years old (median = 12) from Jan 2000 to Sep 2005 with PNC were retrospectively evaluated. 18/24 patients were evaluable. 16 patients received induction chemotherapy followed by radiotherapy while 1 patient was offered concurrent chemoradiotherapy, 1 patient received radiotherapy alone. 15/16 patients received postradiation chemotherapy. The agents used in induction and adjuvant therapy were cisplatin (100 mg/m2) on day 1 and 5-fluorouracil 750 mg/m2 for 5 days. The dose of radiotherapy used was 60 gray in 30 fractions. Results: The time of onset of symptoms to diagnosis ranged from 1 month to 9 months with a median of 5.5 months. Histopathology was lymphoepithelioma in 5 patients (27.7%) while 13 patients (72.2%) had poorly differentiated carcinoma. Disease extent was T2 (n = 7), T3 (n = 6), and T4 (n = 5); N1 (n = 5), N2 (n = 7), and N3 (n = 5). 7 patients had intracranial invasion. None had metastatic disease on presentation. 13 patients (72.2%) achieved major response which included 7 (38.8%) complete remission and 6 (33.3%) partial remission after the induction chemotherapy and radiotherapy. 4 (22.2%) had progressive disease. Another 3 (16.6%) attained complete remission after post radiation chemotherapy which consisted of two cycles of cisplatin and 5-flourouracil. The follow up ranged from 5 months to 84 months with a median follow up of 35 months. The disease free survival ranged from 10 months to 53 months with a median of 33 months. The patients who had a better response to induction chemotherapy had a better disease free survival. Out of 7 patients who attained complete remission 2 relapsed with a median time to first relapse of 9.5 months. Toxicity to therapy was modest. Only one patient had grade 4 neutropenia and mucositis. There was no therapy related mortality. Conclusion: Chemoradiotherapy for nasopharyngeal carcinoma in children is an effective treatment modality with minimal toxicity.

No significant financial relationships to disclose.

Central venous access in the pediatric cancer patient—Problems unique to developing countries: 5-year experience at a regional cancer center in Western India

9049

Background: Central venous catheter (CVC) is required in the pediatric cancer patient for chemotherapy administration and supportive care. This study was carried out to review our experience with CVC, with special reference to issues unique to developing countries. Methods: 178 children who underwent 181 CVC insertions at our institute between January 2001 and October 2005 were retrospectively analysed for demographics, diagnosis, type of CVC, infective and non infective complications. Continuous data were assessed using the t test or the Wilcoxon rank sum test and categorical data by the chi square test or the Fisher’s exact test. Results: Median age was 6.5 years (0.6–13 yr). Commonest diagnosis was acute lymphoid leukemia (ALL) (n=60). CVC used were Hickman (n=162), subcutaneous ports (n=9) and peripherally inserted central catheters (n=10). Patients with hickman catheters had 164 insertions for 162 patients with a total of 14,090 catheter days, an average of 86.9 days/catheter. There were 5.36 culture positive infections /1000 catheter days. The commonest isolate was Coagulase negative S. Aureus (CNS) (44/80 cases). CVC infection with CNS was associated with higher risk of recurrent infections (OR=3.5 {95%CI=2.12–8.23} p=0.01). Patients having recurrent CVC infections received antibiotics for a median of 9.4 days as against a median of 10 days for those with non-recurrent infections (p=0.01, Wilcoxon rank sum). In 58 ALL patients, early (within 15 days of induction) insertion of CVC was associated with increased risk of culture positive infection as against late (after 15 days of induction) insertion (OR=2.3, 95%CI=1.0–5.2, p=0.05). Other complications were thrombosis (n=3), exit-site infection (n=5), tunnel infection (n=3), catheter fracture (n=1) and dislodgement (n=3). Conclusions: As most patients do not afford port, Hickman is the most preferred CVC in pediatric oncology in a developing country. Most patients are of low literacy and poor socioeconomic status. This is reflected in significantly high rates of CVC infection. Communication between the inserting doctor, nursing staff and proper counseling of the patient is the key to reduce complications

No significant financial relationships to disclose.

Recombinant alpha-interferon therapy in multiple myeloma

Three patients with multiple myeloma were treated with recombinant alpha-interferon (r IFN-alpha 2b Intron AR) along with combination chemotherapy i.e. melphelan and prednisolone. In one case it was given as an initial therapy, while the other two patients had refractory and relapsing disease respectively. IFN-alpha 2b was given in the dose of 2 x 10(6) Mu/m2 by subcutaneous injection thrice in a week for six months in two patients and for three months in one patient. All three patients experienced improvement in bone pains; partial response with reduction in the paraprotein level was seen in one patient; while there was no radiological, biochemical or haematological improvement in two patients. Side effects noted were flu like syndrome in all three patients and urticaria in one patient. They were treated symptomatically and did not require cessation of interferon therapy.