A comparative study in left-sided breast cancer treated with moderate deep inspiratory breath hold versus free breathing

BACKGROUND

The moderate deep inspiratory breath hold (mDIBH) is a modality famed for cardiac sparing. Prospective studies based on this are few from the eastern part of the world and India. We intend to compare the dosimetry between mDIBH and free-breathing (FB) plans.

METHODS

Thirty-two locally advanced left breast cancer patients were taken up for the study. All patients received a dose of 50 Gy in 25 fractions to the chest wall/intact breast, followed by a 10-Gy boost to the lumpectomy cavity in the case of breast conservation surgery. All the patients were treated in mDIBH using active breath coordinator (ABC). The data from the two dose volume histograms were compared regarding plan quality and the doses received by the organs at risk. Paired t-test was used for data analysis.

RESULTS

The dose received by the heart in terms of V5, V10, and V30 (4.55% vs 8.39%) and mean dose (4.73 Gy vs 6.74 Gy) were statistically significant in the ABC group than that in the FB group (all p-values < 0.001). Also, the dose received by the LADA in terms of V30 (19.32% vs 24.87%) and mean dose (32.99 Gy vs 46.65 Gy) were significantly less in the ABC group. The mean treatment time for the ABC group was 20 min, while that for the free-breathing group was 10 min.

CONCLUSIONS

Incorporating ABC-mDIBH for left-sided breast cancer radiotherapy significantly reduces the doses received by the heart, LADA, and left and right lung, with no compromise in plan quality but with an increase in treatment time.

PD-L1 Expression in Colorectal Carcinoma Correlates with the Immune Microenvironment

INTRODUCTION/BACKGROUND

Colorectal carcinoma (CRC) is a common malignancy, with its diverse clinical, pathological, and molecular features. The immune microenvironment of a tumor comprises of interplay between various cells and molecules, and has a significant role in deciding the tumor behavior and overall prognosis. PD-L1 (programmed cell death ligand-1) has been implicated in the regulation of the tumor immune microenvironment (TIME). There is limited data regarding the correlation of PD-L1 expression with immune cell profile in CRCs, especially in the Indian setting. The study aimed to assess the PD-L1 expression in CRC tumor cells and its association with TIME, mismatch repair (MMR), and various other clinicopathological parameters.

METHODS

This is a hospital-based, cross-sectional observational study. PD-L1 expression was assessed at the protein level by immunohistochemistry and mRNA level by qRT-PCR. Immune cell markers (CD4, CD8, CD20, FOXP3, and CD163) were interpreted using the ImageJ Fiji platform.

RESULTS

Of the 104 cases, 21% were PD-L1 positive and were more common in right-sided CRCs. PD-L1 positive cases showed significantly higher concentrations of all T-cell subsets (CD4+ , CD8+ , and FOXP3+), CD20+ B-cells, and CD163+ macrophages were noted. No statistical significance was seen between PD-L1 expression with clinical profile, pathological subtype, grade or stage, mismatch repair status (proficient vs deficient), and survival.

CONCLUSIONS

The present study showed a relatively lower frequency of PD-L1 in CRC from the Eastern Indian cohort. The immune cell concentration in the present study was calculated using image analysis-based objectivised methods. Significant correlation of PD-L1 expression in tumor cells with the tumor-infiltrating immune cells indicated its crucial role in the pathobiology of CRC especially by regulating the TIME. Considering the therapeutic implication of PD-L1 in various malignancies, it may be one of the crucial therapeutic targets in a proportion of cases.

Mono iso-centric VMAT planning for SBRT of multiple liver metastasis- A case report

INTRODUCTION

Hepatocellular carcinoma (HCC) is the second most common cause of cancer mortality worldwide. The risk factors associated with the development of HCC are chronic Hepatitis B, Hepatitis C, and alcoholic cirrhosis. The standard care for HCC is surgical resection but the scope is limited for some patients. Continuous advancement of radiation therapy enabled the technique of stereotactic body radiotherapy (SBRT) as an option for the treatment of those cases for which surgery cannot be done. According to recent literature and meta-analysis, SBRT is an optimum treatment method with high local control with low toxicity. In SBRT, radiation is delivered with a smaller number of fractions than conventional radiation and employs high-precision delivery and accuracy with the help of image guidance. From a series of retrospective and prospective studies, it has been confirmed that SBRT achieves excellent local control in patients with early-stage inoperable, intermediate-stage, and advanced diseases.

BACKGROUND

A 42-year-old male patient related to HBeAg infection and high AFP levels developed HCC BCLC Stage A was admitted to our department. There were two lesions with PTV volumes of 41.07 cc and 9.573 cc with a distance between them of 3.51 cm. These two lesions were treated with a mono-isocentric VMAT planning with SBRT technique. In this case, we present an unusual clinical practice of mono-isocentric treatment planning for treating multiple liver lesions. Since radiation therapy was viewed as the primary form of treatment because the patient wasn't an ideal candidate for surgery, SBRT was selected as the patient's primary modality of treatment because of the tiny volume of the two lesions and the normal liver volume (>700cc). Triple-phase 4DCT was performed for simulation to account for the motion of target volume and normal structures. After delineating the target volume and other normal structures, treatment planning was done with a dose of 45 Gray which was to be delivered in 5 fractions. Two PTVs were created with a margin of 3.0 mm to IGTV. Considering the positions of the lesions, a single isocentre plan was created using a 6MV FFF photon beam for both the PTVs with the VMAT technique. The treatment was carried through with 3 arcs, one coplanar, and the other 2 non-coplanar. At the time of treatment, after the proper positioning of the patient, one CBCT image was taken to match with the planned CT image acquired at the time of the simulation. After applying the translational and rotational errors, the patient was treated.

RESULTS

The patient was treated successfully. After treatment, the condition of the patient was normal, and no toxicities have been observed in follow-up.

CONCLUSION

Mono isocentric VMAT planning can be used for closely spaced lesions considering the position of lesions and other normal structures in the vicinity.

Inclusion of Perineural Invasion with AJCC-TNM Staging: Outcomes from a South Asian Cohort of Curatively Treated Gastric Cancer Patients

BACKGROUND

The incidence of perineural invasion (PNI) in patients with gastric cancer (GC) is high, and patients with PNI positive disease have a poor prognosis compared to PNI-negative disease. The present study aims to study the incidence and evaluate the impact of PNI on the survival outcome of a cohort of South Asian GC patients.

MATERIAL AND METHODS

All consecutive patients undergoing curative gastrectomy were included in the study. The incidence of PNI and correlation with different clinico-pathological features and overall survival was performed.

RESULTS

A total of 59.54% had PNI-positive disease and the median OS of PNI + ve patients was 29.3 months, while it was not reached in PNI-ve patients. The PNI positivity was a significant prognostic factor for overall survival both on univariate and multivariate analysis. On TNM-PNI staging, those with TNM stage I/II patients with PNI + ve disease had similar OS to all stage III patients (p = 0.835) and were worse than that of PNI-ve patients (p < 0.05).

CONCLUSION

The incidence of PNI in gastric cancer is high. The inclusion of PNI with AJCC-TNM staging may better stratify prognostic staging in curatively treated gastric cancer patients.

A rare case of cavernous sinus thrombosis following oral squamous cell carcinoma - The etiology and management dilemma

Intracranial cavernous sinus metastases of oral squamous cell carcinoma (OSCC) are rare, with a reported incidence of 0.4 %. Due to their extremely infrequent presentation the etiology and management modalities of such complications are not clearly represented in the literature. Here we present a case of a 58-year-old male diagnosed with OSCC of Right Lower Alveolus with underlying bone invasion, cT4aN1M0, Stage IV. He underwent Right Hemi-mandibulectomy with Modified Neck Dissection, Pectoralis Major Myocutaneous Flap, and 60 Gy/30# adjuvant radiotherapy. Six months later, the patient was diagnosed with recurrence involving the right infratemporal fossa with associated right cavernous sinus thrombosis. Immunohistochemistry block review showed PDL1 - Positive. The patient was subjected to Cisplatin and Pembrolizumab immunotherapy. After receiving 35 cycles of Pembrolizumab over a period of 2 years the patient is doing well with no recurrence.

Metastatic Renal Cell Carcinoma Masquerading as a Laryngeal Tumor: A Case Report

Renal cell carcinoma (RCC) commonly metastasizes to various organs such as the lungs, liver, bones, and brain. However, isolated metastases to the head and neck region, especially the larynx, are very rare. This report presents a case of laryngeal growth that was eventually confirmed to be a metastatic deposit from an undiagnosed RCC. We report a case of a 66-year-old male who presented to the clinic with painless neck swelling and a change in voice. The scan showed a soft tissue mass in the thyroid cartilage. Histopathology of the resected laryngeal tumor confirmed metastatic clear cell carcinoma. A metastatic workup revealed a renal mass, and the patient underwent laparoscopic adrenal-sparing left cytoreductive nephrectomy. The histopathological examination established the diagnosis of clear cell RCC. Subsequently, the patient was treated with pembrolizumab and lenvatinib. Follow-up imaging showed no residual or recurrent lesions. This case highlights the rarity of laryngeal metastasis from RCC and the importance of an accurate diagnosis through advanced imaging and histopathological examination.

Cutaneous Metastasis in a Treated Case of Cervical Cancer With Extraordinary Response to Chemotherapy: A Case Report of a Rare Event and Review of the Literature

Cervical cancer usually metastasizes to the lung, liver, bone, and brain. Metastasis to the skin from cervical cancer is relatively uncommon. The management options are systemic therapy, palliative radiotherapy, or best supportive care. Here, we report the case of a female patient with cervical cancer, stage IIB, who received radical treatment with radiotherapy and chemotherapy and later presented with disseminated skin nodules. She was treated with combination chemotherapy (nano-dispersible paclitaxel and carboplatin), bevacizumab, and a bone-stabilizing agent (zoledronic acid). There was a complete metabolic response to the therapy. There was also a dramatic improvement in the general condition of the patient. Skin metastasis in cervical cancer often presents as non-tender skin nodules. A biopsy is mandatory to establish the diagnosis. There are no specific guidelines about management. The intention of management is palliative. The combination of chemotherapy and bevacizumab produces substantial clinical improvement.

Chemotherapy-induced hand foot syndrome: comparative efficacy and safety of pharmacological prophylaxis - systematic review and Bayesian network meta-analysis

BACKGROUND

Hand-foot syndrome (HFS) is one of the most common toxicities experienced by patients receiving systemic chemotherapy agents such as capecitabine and multikinase inhibitors such as sorafenib. Several randomised controlled trials (RCTs) have investigated the efficacy and safety of prophylactic agents such as pyridoxine, celecoxib, urea cream and cystine/theanine in managing HFS. This network meta-analysis (NMA) evaluated data from high-quality trials to provide strong evidence in forming recommendations to prevent systemic cancer therapy-induced HFS.

OBJECTIVE

To examine the comparative efficacy and safety of interventions for preventing systemic chemotherapy-induced HFS in patients with cancer.

METHODS

We searched PubMed, Embase and clinical trial registry for RCTs of interventions for preventing HFS. Bayesian NMA was performed to estimate the OR with 95% credible intervals (CrI) from both direct and indirect evidence. The outcome measures were the incidence of HFS (grade ≥1) and moderate to severe HFS (grade ≥2). Adverse drug reactions were discussed descriptively.

RESULTS

A total of 15 RCTs with 2715 patients with 12 prophylactic strategies were included. The analysis showed only celecoxib could significantly prevent the incidence of moderate to severe HFS (grade ≥2) (OR 0.29, 95% CrI 0.13 to 0.68). But none of the preventive interventions could prevent the incidence of HFS (grade ≥1).

CONCLUSION

Only celecoxib (200 mg two times per day) showed significant prevention of the incidence of moderate to severe HFS. Pyridoxine (400 mg once daily) and urea cream (10%) have to be evaluated further in larger randomised trials.

CMTM6 attenuates cisplatin-induced cell death in OSCC by regulating AKT/c-Myc-driven ribosome biogenesis

CMTM6, a type 3 transmembrane protein, is known to stabilize the expression of programmed cell death ligand 1 (PD-L1) and hence facilitates the immune evasion of tumor cells. Recently, we demonstrated that CMTM6 is a major driver of cisplatin resistance in oral squamous cell carcinomas (OSCC). However, the detailed mechanism of how CMTM6 rewires cisplatin resistance in OSCC is yet to be explored. RNA sequencing analysis of cisplatin-resistant OSCC lines stably expressing Nt shRNA and CMTM6 shRNA revealed that CMTM6 might be a potential regulator of the ribosome biogenesis network. Knocking down CMTM6 significantly inhibited transcription of 47S precursor rRNA and hindered the nucleolar structure, indicating reduced ribosome biogenesis. When CMTM6 was ectopically over-expressed in CMTM6KD cells, almost all ribosomal machinery components were rescued. Mechanistically, CMTM6 induced the expression of C-Myc, which promotes RNA polymerase I mediated rDNA transcription. In addition to this, CMTM6 was also found to regulate the AKT-mTORC1-dependent ribosome biogenesis and protein synthesis in cisplatin-resistant lines. The nude mice and zebrafish xenograft experiments indicate that blocking ribosome synthesis either by genetic inhibitor (CMTM6KD) or pharmacological inhibitor (CX-5461) significantly restores cisplatin-mediated cell death in chemoresistant OSCC. Overall, our study suggests that CMTM6 is a major regulator of the ribosome biogenesis network and targeting the ribosome biogenesis network is a viable target to overcome chemoresistance in OSCC. The novel combination of CX-5461 and cisplatin deserves further clinical investigation in advanced OSCC.

Effect of treatment interruptions and outcomes in cancer patients undergoing radiotherapy during the first wave of COVID-19 pandemic in a tertiary care institute

Introduction

COVID-19 patients with cancer had poorer outcomes due to immunosuppression during cancer care, poor general condition, and other comorbidities. The study was conducted to present the real-world analysis of the effect of treatment interruptions on the outcomes of patients treated with radiation therapy during the first wave of the COVID-19 pandemic in a tertiary care institute in India.

Materials and methods

The study is a retrospective observational cohort study on cancer patients undergoing radiation therapy from March 2020 to January 2021. The study’s primary outcome was to analyze the effect of treatment interruptions on the outcomes of patients treated with radiation therapy during the first wave of COVID-19 pandemic.

Results

Between March 2020 to January 2021, 218 eligible patients undergoing radiation therapy were found for the study. Among the 218 patients, 25 patients (11.47%) were found positive for COVID-19, while 193 patients (88.53%) were negative for COVID-19. Among COVID-19-positive patients, ten patients had < 3 weeks of treatment interruption, while 15 patients had > 3 weeks of treatment interruptions. After recovering from COVID-19, treatment was resumed and completed for 15 (60.00%) of the COVID-19-positive patients. In comparison, 13 patients (52.00%) were lost to follow-up. Three of the COVID-19-positive patients died. The disease was clinically controlled in 12 (48.00%) of the COVID-19-positive patients, and the patients reported locoregional disease progression in 10 (40.00%). Among the 193 COVID-19-negative patients, 32 patients (16.58%) had treatment interruption. Twelve patients (37.50%) had treatment interruptions for less than 1 week. There was a significant difference in the delay of radiation treatment delivery by 2 weeks (11 fractions) in COVID-19-positive patients compared to only two fractions delay in COVID-19-negative patients.

Conclusion

COVID-19 impacted the treatment outcomes in both COVID-19-positive and COVID-19-negative cohorts of patients. There was a longer duration of treatment interruptions in the COVID-19-positive patients, leading to fewer patients completing the radiation treatment and thereby increased locoregional disease progression. There was a significant difference in the delay in treatment between the two groups.

Metastatic primary gastric melanoma: a rare clinical presentation and a review of literature

Primary gastric melanoma is a rare clinical finding. It presents with upper gastrointestinal symptoms like abdominal pain, weight loss and melaena. It is often difficult to differentiate a primary gastric melanoma from primary cutaneous melanoma with gastric metastasis. Upper gastrointestinal endoscopy and biopsy of the lesion for histopathology and immunohistochemistry help to reach a definite diagnosis. We report a case of primary gastric melanoma with metastases to the liver and bone. The patient was treated with palliative radiotherapy, palliative chemotherapy and a bone-stabilising agent.

Inguinal lymph node metastasis in treated breast cancer: an extremely rare presentation and review of literature

Metastasis to inguinal lymph nodes from breast cancer is extremely rare and only a handful of cases have been reported in the literature to date. We report a case of a postmenopausal female patient who was a treated case of right breast cancer and developed inguinal metastases after 9 months. An excisional biopsy of the lesion confirmed the diagnosis. A positron emission tomography–CT scan revealed retropectoral and pelvic lymphadenopathy. The patient was treated with palliative radiotherapy to the inguinal and pelvic regions followed by palliative chemotherapy. The patient survived for 4 months after the detection of inguinal metastasis.

A Dosimetric Study Comparing 3D-CRT vs. IMRT vs. VMAT in Left-Sided Breast Cancer Patients After Mastectomy at a Tertiary Care Centre in Eastern India

Introduction

Post-mastectomy radiation in left-sided breast cancer in women continues to pose a significant risk to the underlying lungs and heart. This study analyzed the difference in planning target volume (PTV) coverage and dose to the organs at risk (OAR) by using three different planning methods for the same patient - three-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT), and volumetric-modulated arc therapy (VMAT).

Material and methods

Thirty-five left-sided breast cancer patients’ post-mastectomy were included in this study, and three different plans for adjuvant radiation were created using 3D-CRT, IMRT, and VMAT. The prescribed dose was 50Gy in 25 fractions. Kruskal-Wallis analysis of variance (ANOVA) was done, followed by a pairwise t-test to establish a hierarchy of plan quality and dosimetric benefits. The plans were compared with PTV₉₅, homogeneity index (HI), conformity index (CI), hotspot (V_107%), left lung V_20Gy, mean lung dose, heart V_25Gy, mean heart dose, and integral dose (ID) to the body.

Results

Both VMAT and IMRT led to improved PTV_95% coverage (95.63±1.82%, p=0.000 in VMAT; 93.70±2.16 %, p=0.000; 81.40±6.27% in 3D-CRT arm) and improved CI (0.91±0.06 in IMRT [p<0.05] and 0.96±0.02 for VMAT plans [p<0.05]) as compared to 3D-CRT (0.66±0.11), which was statistically significant on pairwise analysis. In contrast, the difference in HI and reduction in hotspots were not significantly different. Left lung V₂₀ was statistically very different between the three arms with the highest values in IMRT (36.64±4.45) followed by 3D-CRT (34.80±2.24) and the most negligible value in VMAT (33.03±4.20). Mean lung dose was also statistically different between the three arms. There was a statistically significant difference in mean heart dose between the three arms on pairwise analysis. Both the inverse planning methods led to a statistically significant increase in low dose volume (V₅ and V₁₀) of the ipsilateral lung, opposite lung, and heart, and increased ID to the body excluding the PTV.

Conclusion

While both the inverse planning modalities led to increased coverage, better CI, and better HI and decreased high dose volumes in OARs, there was increased low volume irradiation of heart, lungs, and body with VMAT faring marginally better than IMRT in coverage and decreasing lung irradiation with comparable heart irradiation.

Osteosarcoma of the Right Lower Femur With Breast and Axillary Lymph Node Metastasis: A Rare Case Presentation

Osteosarcoma is the most common skeletal malignancy and commonly metastasis to lung and bone. Here we report a case of osteosarcoma of the right knee with metastasis to the lower and inner quadrant of the breast along with axillary, mediastinal, retroperitoneal and inguinal lymphadenopathy with lung and liver metastasis. The diagnosis of breast metastasis was confirmed by ultrasonography-guided biopsy and immunohistochemistry (IHC). So this report highlights the rarest metastasis to breast and axillary lymph node from an osteosarcoma of the right knee primary.

High-Dose-Rate Intracavitary Brachytherapy Under Conscious Sedation a Viable Practical Alternative to Spinal Anaesthesia in Carcinoma Cervix: A Retrospective Study in a Tertiary Care Centre in Eastern India

Introduction

Intracavitary brachytherapy (ICBT) is an integral component in the management of locally advanced cervical cancer. Spinal anaesthesia is the preferred mode of pain management during brachytherapy procedures. In high volume, resource constraint settings, it is difficult to provide spinal anaesthesia to all patients. This study attempts dosimetric comparison of high-dose-rate ICBT with spinal anaesthesia to that under conscious sedation to find out whether brachytherapy under conscious sedation is comparable with spinal anaesthesia.

Methods

Retrospective data of total of 56 cervical cancer patients who received ICBT after completion of external beam radiotherapy (EBRT) were collected. Among these 56 patients, 28 patients received brachytherapy under spinal anaesthesia (SA group) and the rest under conscious sedation (CS group). Brachytherapy dose was 7 Gray per fraction weekly for three weeks. Thus, 84 brachytherapy plans of each group were analysed with respect to doses received by points A, B, P and Organs at Risk.

Results

The mean doses received by points A, B and P were comparable in SA and CS groups (p-value >0.05). Similarly, the mean doses received by Organs at Risk (rectum, urinary bladder, and sigmoid colon) were also comparable in both the groups (p-value>0.05).

Conclusion

ICBT under CS is dosimetrically non-inferior to SA, which makes it an alternative option.

An unusual response of recurrent breast cancer axillary lymphadenopathy to palliative radiotherapy: A case report

INTRODUCTION

Radiotherapy has played a pivotal role in palliation of symptoms in progressive incurable stages of malignancies. Ionizing radiation has been employed to decrease cancer induced bone pain, control bleeding and mass effects from inoperable tumor with significant success. The advent of new systemic anti-neoplastic drugs has broadened options available for management of cancers in palliative intent. The outcome of systemic anti-neoplastic therapy in the role of palliation has received variable acceptance while radiotherapy has generally remained the workhorse for palliation.

CASE REPORT

A young female with a diagnosis of left-sided breast cancer who had received adjuvant anthracycline based chemotherapy, but not whole breast radiotherapy, following lumpectomy had an axillary lymphnode recurrence three years later. Though the recurrence was salvaged with a radical mastectomy and followed up with a combination of taxane and platin-based chemotherapy, there was a recurrence of axillary lymph nodes during the course. Following six cycles of combination chemotherapy, the mass progressed to form a large ulcer with pain and discharge. The recurrent malignancy was diagnosed to be triple negative subtype upon microscopic and immunohistochemical study.

OUTCOME

The ulcerated mass not only responded to palliative radiotherapy by complete healing of the ulcer, but it also led to improvement in overall performance score and quality of life as measured objectively.

DISCUSSION

In triple negative subtype of breast cancer [TNBC], axillary lymphnodal recurrence is not uncommon after loco-regional surgery and peri‑operative chemptherapy; particularly when adjuvant radiotherapy is omitted. Chemotherapy refractory axillary lymphnodal recurrence showing good response to palliative radiotherapy signifies the differing molecular signatures within TNBC subtype.

CONCLUSION

Radiotherapy is an effective modality for loco-regional palliation of recurrent breast cancer, particularly TNBC subtype. It holds potency even when the disease is chemotherapy refractory and can improve subjective as well as objective quality of life parameters significantly.

RRBP1 rewires cisplatin resistance in oral squamous cell carcinoma by regulating Hippo pathway

BACKGROUND

Chemoresistance is one of the major factors for treatment failure in OSCC. Identifying key resistance triggering molecules will be useful strategy for developing novel treatment methods.

METHODS

To identify the causative factors of chemoresistance, we performed RNA sequencing and global proteomic profiling of human OSCC lines presenting with sensitive, early and late cisplatin-resistance patterns.

RESULTS

From the common set of dysregulated genes from both the analysis, RRBP1 was identified to be upregulated in both early and late cisplatin-resistant cells with respect to the sensitive counterpart. Analysis of OSCC patient sample indicates that RRBP1 expression is upregulated in chemotherapy-non-responder tumours as compared to chemotherapy-responder tumours. Genetic (knockout) or pharmacological (Radezolid, represses expression of RRBP1) inhibition of RRBP1 restores cisplatin-mediated cell death in chemo-resistant OSCC. Mechanistically, RRBP1 regulates Yes-associated protein1 (YAP1), a key protein in the Hippo pathway to induce chemoresistance. The PDC xenograft data suggests that knockout of RRBP1 induces cisplatin-mediated cell death and facilitates a significant reduction of tumour burden.

CONCLUSION

Overall, our data suggests that (I) RRBP1 is a major driver of cisplatin-resistance in OSCC, (II) RRBP1 regulates YAP1 expression to mediate cisplatin-resistance, (III) Radezolid represses RRBP1 expression and (IV) targeting RRBP1 reverses cisplatin-induced chemoresistance in advanced OSCC.

Tweaking of radiation and chemotherapy schedules is the new normal during the COVID-19 crisis: perspective from oncologists at a tertiary care health institute

Patients with cancer are at a higher risk of infection with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) than the general population. In India, it has become a significant health problem of utmost importance, and India’s Government has issued health advisories. Lockdown brought many unforeseen problems for patients and hospitals, leading to confusion and chaos. The aim of this article is to identify various issues related to our hospital, follow-up, nutrition, treatment and psychosocial issues. Multiple changes were made in the hospital, departmental and treatment policy for cancer patients’ convenience and safety. As India is in the peak of COVID-19, these types of modifications and modifications of treatment schedules will be the ‘New Normal’.

CMTM6 drives cisplatin resistance by regulating Wnt signaling through the ENO-1/AKT/GSK3β axis

Rewiring tumor cells to undergo drug-induced apoptosis is a promising way to overcome chemoresistance. Therefore, identifying causative factors for chemoresistance is of high importance. Unbiased global proteome profiling of sensitive, early, and late cisplatin-resistant oral squamous cell carcinoma (OSCC) lines identified CMTM6 as a top-ranked upregulated protein. Analyses of OSCC patient tumor samples demonstrated significantly higher CMTM6 expression in chemotherapy (CT) nonresponders as compared with CT responders. In addition, a significant association between higher CMTM6 expression and poorer relapse-free survival in esophageal squamous cell carcinoma, head and neck squamous cell carcinoma, and lung squamous cell carcinoma was observed from Kaplan-Meier plot analysis. Stable knockdown (KD) of CMTM6 restored cisplatin-mediated cell death in chemoresistant OSCC lines. Upon CMTM6 overexpression in CMTM6-KD lines, the cisplatin-resistant phenotype was rescued. The patient-derived cell xenograft model of chemoresistant OSCC displaying CMTM6 depletion restored the cisplatin-induced cell death and tumor burden substantially. The transcriptome analysis of CMTM6-KD and control chemoresistant cells depicted enrichment of the Wnt signaling pathway. We demonstrated that CMTM6 interaction with membrane-bound Enolase-1 stabilized its expression, leading to activation of Wnt signaling mediated by AKT–glycogen synthase kinase-3β. CMTM6 has been identified as a stabilizer of programmed cell death ligand 1. Therefore, as CMTM6 facilitates tumor cells for immune evasion and mediates cisplatin resistance, it could be a promising therapeutic target for treating therapy-resistant OSCC.

DDX3 modulates cisplatin resistance in OSCC through ALKBH5-mediated m6A-demethylation of FOXM1 and NANOG

Platinum based drugs alone or in combination with 5FU and docetaxel are common regimen chemotherapeutics for the treatment of advanced OSCC. Chemoresistance is one of the major factors of treatment failure in OSCC. Human RNA helicase DDX3 plays an important role in cell proliferation, invasion, and metastasis in several neoplasms. The potential role of DDX3 in chemoresistance is yet to be explored. Enhanced cancer stem cells (CSCs) population significantly contributes to chemoresistance and recurrence. A recent study showed that m⁶A RNA regulates self-renewal and tumorigenesis property in cancer. In this study we found genetic (shRNA) or pharmacological (ketorolac salt) inhibition of DDX3 reduced CSC population by suppressing the expression of FOXM1 and NANOG. We also found that m⁶A demethylase ALKBH5 is directly regulated by DDX3 which leads to decreased m⁶A methylation in FOXM1 and NANOG nascent transcript that contribute to chemoresistance. Here, we found DDX3 expression was upregulated in both cisplatin-resistant OSCC lines and chemoresistant tumors when compared with their respective sensitive counterparts. In a patient-derived cell xenograft model of chemoresistant OSCC, ketorolac salt restores cisplatin-mediated cell death and facilitates a significant reduction of tumor burdens. Our work uncovers a critical function of DDX3 and provides a new role in m⁶ demethylation of RNA. A combination regimen of ketorolac salt with cisplatin deserves further clinical investigation in advanced OSCC.

Primary malignant mediastinal germ cell tumors: A single institutional experience

Background:

Primary mediastinal malignant germ cell tumour (PMMGCT) is rare with unsatisfactory prognosis and pose difficulty in management due to lack of guidelines.

Methods:

All cases of PMMGCT diagnosed and treated between years 2014 to 2018 were retrospectively evaluated for clinico-pathological features, multimodality treatment and follow up.

Results:

Among a total of five PMMGCT cases, three were seminomatous and two were non seminomatous tumour [Yolk- sac tumour (n-1) and Mixed tumour (n-1)]. Four of these cases were non - metastatic with locally advancement and another one presented with metastasis to supraclavicular lymph node. All patients received platinum based induction chemotherapy. Post-induction chemotherapy, two cases of non seminomatous tumours underwent surgery. Among the three seminoma cases, one patient showed complete metabolic response; one with metastasis succumbed to the disease and the in-operable case of seminoma received local radiotherapy.

Conclusion:

PMMGCT needs a multi-disciplinary approach for appropriate diagnosis and management. Clinicopathological features like tumour site, extension, histopathological type, tumour stage and serum tumour marker are necessary for prognostication and decision making of further treatment plan.

Concomitant echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase rearrangement and epidermal growth factor receptor mutation in non-small cell lung cancer patients from eastern India

Background

In non-small cell lung cancer common driver mutations such as epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) are usually mutually exclusive. This study aimed to elucidate the concurrence of EGFR mutation and ALK rearrangement in eastern India patients with primary lung adenocarcinoma and assess the response of EGFR tyrosine kinase inhibitor (TKI) therapy after 6 months in primary lung adenocarcinoma.

Methods

We retrospectively analyzed 198 adenocarcinomas for EGFR and ALK mutations. EGFR and ALK tests were done by real-time polymerase chain reaction and immunohistochemistry (IHC) techniques, respectively. Radiological response was assessed by Response Evaluation Criteria in Solid Tumors (version 1.1).

Results

EGFR/ALK co-alteration was found in 4 adenocarcinoma patients. All were males with advanced disease. Younger patients had exon 19 deletion whereas older ones showed exon 21 mutation. The initial option of ALK-TKI in all four patients was excluded straightaway due to the high-cost burden of ALK-TKI. Two of them showed a partial response while other two had stable disease after 6 months of EGFR TKI therapy.

Conclusion

EGFR/ALK co-alterations in adenocarcinomas albeit rare do exist. The challenge of monetary hurdle in developing countries with ALK TKI therapy can be handled by giving only EGFR TKI in these cases of concomitant mutations. Future perspective in research could be finding an agent with the potential of dual inhibition of ALK and EGFR.

Metastasis to Breast From Carcinoma Gallbladder: A Case Report and Review of Literature

Gallbladder cancer (GBC) is the commonest malignancy among biliary tract cancers. Locoregional spread in GBC is more common than distant metastasis. The liver and abdominal lymph nodes is the most common site of distant metastasis. Breast metastasis is a rare site of dissemination. GBC is an aggressive tumor and carries a poor prognosis, with a five-year survival rate of less than 10%. Metastasis to the breast from a gallbladder is significantly less and accounts for very few cases. Here, we are reporting a rare case of carcinoma gallbladder metastasis to the breast who survived for 38 months from the diagnosis of GBC and around 25 months after breast metastasis.

Efficacy and safety of nanosomal docetaxel lipid suspension-based chemotherapy in squamous cell carcinoma of the head and neck: A multicenter retrospective study

Squamous cell carcinoma of the head and neck (SCCHN) is the most common cancer in Indian men. Docetaxel alone or in combination with other chemotherapeutic agents is recommended for the management of SCCHN. The present multicenter, retrospective study was conducted to evaluate the efficacy and safety of a novel docetaxel formulation 'nanosomal docetaxel lipid suspension (NDLS)'-based chemotherapy in SCCHN. The medical records of patients with SCCHN, who were treated with NDLS-based chemotherapy and followed up between August 2014 and September 2018, were reviewed. The efficacy endpoints were overall response rate [ORR; complete response (CR) + partial response (PR)] and disease control rate (DCR; CR + PR + stable disease) for patients receiving NDLS-based induction or palliative chemotherapy. Overall survival (OS) and safety were also evaluated. Efficacy evaluation was available in 30/34 patients (induction, 20/23; palliative, 10/11). NDLS-based induction chemotherapy showed an ORR and DCR of 95% and a median OS of 43.5 months (follow-up duration, 0.6-80.3 months). For NDLS-based palliative chemotherapy, the ORR and DCR were 50% and the median OS time was 4.6 months (follow-up duration, 1.8 to 14.3 months). At least one adverse event was reported in 82.6% patients. No new safety concerns were reported. Overall, NDLS-based chemotherapy was effective and well tolerated in the treatment of SCCHN.

Cutaneous and cardiac metastases in carcinoma of anterior tongue

Distant metastases in squamous cell carcinoma of the head and neck are uncommon, and the incidence rises with neck node metastasis. The lung, liver, and bones are the common possible sites for distant metastasis. Cutaneous and cardiac metastases are extremely rare situations with aggressive behaviors and present in the late course of the disease. Here, we report a case of anterior tongue cancer with cutaneous, bone, cardiac, lung, and soft tissue of right suprascapular area metastases after a gap of 2 years of follow-up of completion of treatment with radical surgery and adjuvant concurrent chemoradiation therapy. The present case developed such type of aggressive distant metastases without any locoregional recurrence and died within 6 months of diagnosis of distant metastases.

Efficacy and safety of nanosomal docetaxel lipid suspension based chemotherapy in gastric and gastroesophageal junction adenocarcinoma

The current retrospective multicenter study evaluated the efficacy and safety of nanosomal docetaxel lipid suspension (NDLS; DoceAqualip) based chemotherapy in patients with gastric and gastroesophageal junction (GEJ) adenocarcinoma. The medical charts of patients with gastric and GEJ adenocarcinoma, who were treated with NDLS (50-75 mg/m²; 3 weekly cycles) based chemotherapy and followed-up from April 2014 to September 2018, were analyzed. The study endpoints included overall response rate (ORR) and disease control rate (DCR) in neoadjuvant and metastatic settings. Overall survival (OS) and safety were also evaluated. Of the 43 patients with gastric (n=39) and GEJ (n=4) adenocarcinoma, efficacy evaluation was available in 35 (neoadjuvant, 17/18 patients; metastatic, 18/25 patients). In the neoadjuvant setting, an ORR of 58.82% and a DCR of 94.11% were observed, whereas in the metastatic setting, the ORR was 77.77% and the DCR was 83.33%. In the neoadjuvant setting, at a follow-up ranging from 0.7 to 41.2 months, the median OS was not reached. In the metastatic setting, the median OS was 31.9 months at a follow-up ranging from 0.2 to 50.3 months. At least one adverse event (AE) was reported in 24 patients. Anemia, lymphopenia and thrombocytopenia were the most common hematological AEs, while nausea, vomiting and weakness were the most common non-hematological AEs. NDLS based treatment was well-tolerated without any new safety concerns. Overall, NDLS-based chemotherapy was effective and well-tolerated in the management of gastric and GEJ adenocarcinoma.

Nanosomal Docetaxel Lipid Suspension-Based Chemotherapy in Breast Cancer: Results from a Multicenter Retrospective Study

PURPOSE

The purpose of this study was to evaluate the efficacy and safety of nanosomal docetaxel lipid suspension (NDLS, DoceAqualip)-based chemotherapy in breast cancer.

METHODS

Medical charts of patients with breast cancer, who were treated and followed up with NDLS (75-100 mg/m2; 3-week cycle)-based chemotherapy from August 2014 to September 2018, were analyzed in this multicenter, retrospective study. The study endpoints were overall response rate (ORR: complete response [CR]+partial response [PR]) and disease control rate (DCR: CR+PR+stable disease [SD]) in neoadjuvant and metastatic settings. Overall survival (OS) and safety were evaluated for all settings.

RESULTS

Of 91 patients (neoadjuvant: 12, adjuvant: 61, metastatic: 18), efficacy evaluation in 29 patients (neoadjuvant: 12/12, metastatic: 17/18) demonstrated an ORR and DCR of 100%, respectively, in the neoadjuvant setting, and an ORR of 64.7% and DCR of 70.6%, respectively, in the metastatic setting. At a median follow-up of 21.6 months (range: 2.1 to 49.9 months), median OS was not reached in neoadjuvant and adjuvant settings, and it was 30.4 months in metastatic settings. At least one adverse event (AE) was reported in 59.3% of patients. Anemia, thrombocytopenia, lymphopenia, and neutropenia were the most common hematological AEs reported while hyperglycemia and alteration in liver function tests were the most common non-hematological AEs. NDLS-based treatment was well tolerated without any new safety concerns.

CONCLUSION

Nanosomal docetaxel lipid suspension-based chemotherapy was efficacious and well tolerated in the treatment of breast cancer. Further, NDLS is being evaluated prospectively in patients with triple-negative breast cancer (ClinicalTrials.gov: NCT03671044).

Management of primary squamous cell carcinoma of the pancreas with a nanosomal paclitaxel lipid suspension-based regimen: A case report

Squamous cell carcinoma (SCC) of the pancreas is a rare tumor with only a few case reports available. It is an aggressive form of pancreatic cancer with a poor prognosis. The diagnosis and optimal management of SCC of the pancreas is poorly defined due to the lack of standard treatment or guidelines and owing to the rarity of this malignancy. Patients suffering from SCC of the pancreas do not respond well to chemotherapy or radiotherapy and isolated reports are available on the use of gemcitabine and newer taxane formulations. Surgical resection of the tumor is the most effective modality; however, due to a delay in diagnosis, the majority of pancreatic SCCs remain unresectable. Herein, a case of SCC of the pancreatic tail is reported in a 60-year-old patient who was managed with a combination of albumin-free nanosomal paclitaxel lipid suspension (NPLS) and gemcitabine in a neoadjuvant setting. To the best of our knowledge, this is the first such case report of a locally advanced SCC of the pancreatic tail showing an overall survival of 1 year following treatment with an NPLS based regimen. The treatment was well tolerated with no serious safety concerns.

Synovial Sarcoma of Palmar Aspect of Hand and Survival: A Rare Case Report

Synovial sarcomas of the hand are extremely rare entities than most soft tissue sarcomas. The location at finger is further rarer than carpus of the hand. Synovial sarcoma of the hand/finger initially confused with many diagnoses such as myositis, haematoma, synovitis, tendonitis, bursitis, and other inflammatory lesions and therefore needs careful handling of the case with proper evaluation. We report a case of synovial sarcoma of the palmar surface of the right hand at interface of thumb and index finger in a 22-year-old female. The case was initially misdiagnosed as an abscess/haematoma of the finger 10 years back and treated with wide local excision. Synovial sarcoma was diagnosed on microscopic examination of excised specimen. Patient developed recurrent lesion twice locally. During first recurrence, the patient was treated with wide excision followed by radiotherapy and chemotherapy. Second recurrence was with bony destruction at the same site and below elbow amputation was performed.

Choroidal Metastasis as Initial Presentation in Adenocarcinoma of Lung: A Case Report

Vision impairment as an initial presentation detecting choroid metastasis in primary lung cancer is rare. Prevention or treatment of visual loss and improvement in quality of life can be achieved by treatment of intraocular metastasis. The survival of the patient in choroid metastasis with lung primary is poor with the median survival being 3.3 months. However, proper treatment may increase the quality of life and survival to an extent. We report a case of adenocarcinoma of lung in a female patient, presented initially with visual impairment as a result of choroidal metastasis and treated with external beam radiotherapy for choroidal metastasis followed by palliative chemotherapy. The patient was survived with improved vision and quality of life since last 12 months of diagnosis.

Digital Acrometastasis as Initial Presentation in Carcinoma of Lung A Case Report and Review of Literature

Bony metastases develop in 30% of all the cancers, but out of which only 1% to 3% occurs in the hand. Lung is the most common site for acrometastasis, followed by breast and renal cell cancer. Metastases to the digits are with non-specific presentation. We reported a case of 79-year-old male patient with initial presentation of swelling over left index finger, which was found to be squamous cell carcinoma of finger on histopathological examination. He was subsequently diagnosed as a case of squamous cell carcinoma of lung with acrometastasis.

Dosimetric evaluation of 120-leaf multileaf collimator in a Varian linear accelerator with 6-MV and 18-MV photon beams

In this study the dosimetric characteristics of 120-leaf multileaf collimators (MLCs) were evaluated for 6-MV and 18-MV photon beams. The dose rate, percentage depth dose, surface dose, dose in the build-up region, beam profile, flatness, symmetry, and penumbra width were measured using three field-defining methods: (i) 'Jaw only', (ii) 'MLC only', and (iii) 'MLC+Jaw'. Analysis of dose rate shows that the dose rate for 'MLC only' field was higher than that for 'Jaw only" and 'MLC+Jaw' fields in both the energies. The 'percentage of difference' of dose rates between 'MLC only' and 'MLC+Jaw' was (0.9% to 4.4%) and (1.14% to 7%) for 6 MV and 18 MV respectively. The surface dose and dose in the build-up region were more pronounced for 'MLC only' fields for both energies, and no significant difference was found in percentage depth dose beyond dmax for both energies. Beam profiles show that flatness and symmetry for both the energies were less than the 3%. The penumbra width for 'MLC only' field was more than that for the other two field-defining methods by (1 to 2 mm) and (0.8 to 1.3 mm) for 6-MV and 18-MV photon beams respectively. Analysis of 'width of 50% dose level' of the beam profiles at dmax to reflect the field size shows 1 to 2 mm more for 6-MV photons and 2.2 to 2.4 mm morefor 18-MV photons for 'MLC only' fields. The results of this study suggest that the characteristics of 120-leaf MLC system with 6 MV and 18 MV are same in all aspects except the surface dose, penumbra, dose in the build-up region, and width of 50% dose levels.