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Rao AR, Noronha V, Ramaswamy A, Kumar A, Pillai A, Gattani S, Sehgal A, Kumar S, Castelino R, Dhekale R, Krishnamurthy J, Mahajan S, Daptardar A, Sonkusare L, Deodhar J, Ansari N, Vagal M, Mahajan P, Timmanpyati S, Nookala M, Chitre A, Kapoor A, Gota V, Banavali S, Badwe RA, Prabhash K. Correlation of the Geriatric Assessment with Overall Survival in Older Patients with Cancer. Clin Oncol (R Coll Radiol) 2024; 36:e61-e71. [PMID: 37953073 DOI: 10.1016/j.clon.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/09/2023] [Accepted: 11/02/2023] [Indexed: 11/14/2023]
Abstract
AIMS Global guidelines recommend that all older patients with cancer receiving chemotherapy should undergo a geriatric assessment. However, utilisation of the geriatric assessment is often constrained by its time-intensive nature, which limits its adoption in settings with limited resources and high demand. There is a lack of evidence correlating the results of the geriatric assessment with survival from the Indian subcontinent. Therefore, the aims of the present study were to assess the impact of the geriatric assessment on survival in older Indian patients with cancer and to identify the factors associated with survival in these older patients. MATERIALS AND METHODS This was an observational study, conducted in the geriatric oncology clinic of the Tata Memorial Hospital (Mumbai, India). Patients aged 60 years and older with cancer who underwent a geriatric assessment were enrolled. We assessed the non-oncological geriatric domains of function and falls, nutrition, comorbidities, cognition, psychology, social support and medications. Patients exhibiting impairment in two or more domains were classified as frail. RESULTS Between June 2018 and January 2022, we enrolled 897 patients. The median age was 69 (interquartile range 65-73) years. The common malignancies were lung (40.5%), oesophagus (31.9%) and genitourinary (12.1%); 54.6% had metastatic disease. Based on the results of the geriatric assessment, 767 (85.4%) patients were frail. The estimated median overall survival in fit patients was 24.3 (95% confidence interval 18.2-not reached) months, compared with 11.2 (10.1-12.8) months in frail patients (hazard ratio 0.54; 95% confidence interval 0.41-0.72, P < 0.001). This difference in overall survival remained significant after adjusting for age, sex, primary tumour and metastatic status (hazard ratio 0.56; 95% confidence interval 0.41-0.74, P < 0.001). In the patients with a performance status of 0 or 1 (n = 454), 365 (80.4%) were frail; the median overall survival in the performance status 0-1 group was 33.0 months (95% confidence interval 24.31-not reached) in the fit group versus 14.4 months (95% confidence interval 12.25-18.73) in the frail patients (hazard ratio 0.50; 95% confidence interval 0.34-0.74, P = 0.001). In the multivariate analysis, the geriatric assessment domains that were predictive of survival were function (hazard ratio 0.68; 95% confidence interval 0.52-0.88; P = 0.003), nutrition (hazard ratio 0.64; 95% confidence interval 0.48-0.85, P = 0.002) and cognition (hazard ratio 0.67; 95% confidence interval 0.49-0.91, P = 0.011). DISCUSSION The geriatric assessment is a powerful prognostic tool for survival among older Indian patients with cancer. The geriatric assessment is prognostic even in the cohort of patients thought to be the fittest, i.e. performance status 0 and 1. Our study re-emphasises the critical importance of the geriatric assessment in all older patients planned for cancer-directed therapy.
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Affiliation(s)
- A R Rao
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - V Noronha
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - A Ramaswamy
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - A Kumar
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - A Pillai
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - S Gattani
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - A Sehgal
- Department of Clinical Pharmacology, Advanced Centre for Treatment Research and Education in Cancer, Mumbai, India
| | - S Kumar
- Department of Clinical Pharmacology, Advanced Centre for Treatment Research and Education in Cancer, Mumbai, India
| | - R Castelino
- Department of Clinical Pharmacology, Advanced Centre for Treatment Research and Education in Cancer, Mumbai, India
| | - R Dhekale
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - J Krishnamurthy
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - S Mahajan
- Department of Physiotherapy, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - A Daptardar
- Department of Physiotherapy, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - L Sonkusare
- Department of Psycho-oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - J Deodhar
- Department of Psycho-oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - N Ansari
- Department of Occupational Therapy, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - M Vagal
- Department of Occupational Therapy, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - P Mahajan
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - S Timmanpyati
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - M Nookala
- Department of Clinical Pharmacology, Advanced Centre for Treatment Research and Education in Cancer, Mumbai, India
| | - A Chitre
- Department of Physiotherapy, Mahamana Pandit Madan Mohan Malviya Cancer Center & Homi Bhabha Cancer Hospital, Varanasi, India
| | - A Kapoor
- Department of Medical Oncology, Mahamana Pandit Madan Mohan Malviya Cancer Center & Homi Bhabha Cancer Hospital, Varanasi, India
| | - V Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment Research and Education in Cancer, Mumbai, India
| | - S Banavali
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - R A Badwe
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - K Prabhash
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India.
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Kumar S, Castelino R, Rao A, Gattani S, Dhekale R, Krishnamurthy J, Ramaswamy A, Prabhash K, Noronha V, Gota V. Comparison of validated screening tools for the assessment of potentially inappropriate medications in older Indian patients with cancer. J Geriatr Oncol 2022. [DOI: 10.1016/s1879-4068(22)00384-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Noronha V, Gattani S, Ramaswamy A, Castelino R, Dhekle R, Krishnamurthy J, Gota V, Banavali S, Badwe R, Prabhash K. Patients’ expectations from therapy and disclosure of diagnosis/ prognosis in older adults with cancer: A retrospective cohort study. J Geriatr Oncol 2021. [DOI: 10.1016/s1879-4068(21)00369-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Gandhi VV, Gandhi KA, Kumbhare LB, Goda JS, Gota V, Priyadarsini KI, Kunwar A. 3,3'-Diselenodipropionic acid (DSePA) induces reductive stress in A549 cells triggering p53-independent apoptosis: A novel mechanism for diselenides. Free Radic Biol Med 2021; 175:1-17. [PMID: 34425189 DOI: 10.1016/j.freeradbiomed.2021.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 02/06/2023]
Abstract
The aim of present study was to investigate the anticancer mechanisms of 3,3'-diselenodipropionic acid (DSePA), a redox-active organodiselenide in human lung cancer cells. DSePA elicited a significant concentration and time-dependent cytotoxicity in human lung cancer cell line A549 than in normal WI38 cells. The cytotoxic effect of DSePA was preceded by an acute decrease in the level of basal reactive oxygen species (ROS) and a concurrent increase in levels of reducing equivalents (like GSH/GSSG and NADH/NAD) within cells. Further, a series of experiments were performed to measure the markers of intrinsic (Bax, cytochrome c and caspase-9), extrinsic (TNFR, FADR and caspase-8) and endoplasmic reticulum (ER) stress (protein ubiquitylation, calcium flux, Bip, CHOP and caspase-12) pathways in DSePA treated cells. DSePA treatment significantly increased the levels of all the above markers. Moreover, DSePA did not alter the expression and phosphorylation (Ser15) of p53 but caused a significant damage to mitochondria. Pharmacological modulation of GSH level by BSO and NAC in DSePA treated cells led to partial abrogation and augmentation of cell kill respectively. This established the role of reductive stress as a trigger for the apoptosis induced by DSePA treatment. Finally, in vitro anticancer activity of DSePA was also corroborated by its in vivo efficacy of suppressing the growth of A549 derived xenograft tumor in SCID mice. In conclusion, above results suggest that DSePA induces apoptosis in a p53 independent manner by involving extrinsic and intrinsic pathways together with ER stress which can an interesting strategy for lung cancer therapy.
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Affiliation(s)
- V V Gandhi
- Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India; Radiation and Photochemistry Division, Bhabha Atomic Research Centre, Mumbai, 400085, India
| | - K A Gandhi
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi, Mumbai, India
| | - L B Kumbhare
- Chemistry Division, Bhabha Atomic Research Centre, Mumbai, 400085, India
| | - J S Goda
- Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India; Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi, Mumbai, India
| | - V Gota
- Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India; Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi, Mumbai, India
| | - K I Priyadarsini
- UM-DAE Centre for Excellence in Basic Sciences, Kalina Campus, Mumbai, 400098, India
| | - A Kunwar
- Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India; Radiation and Photochemistry Division, Bhabha Atomic Research Centre, Mumbai, 400085, India.
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Gattani S, Noronha V, Castelino R, Dhekle R, Mahajan S, Daptardar A, Menon N, Patil V, Gota V, Banavali S, Prabhash K. 1705P The correlation of the ECOG performance status with vulnerabilities in the geriatric assessment: A retrospective cohort study. Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.1677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Bhargava P, Ostwal V, Ramaswamy A, Srinivas S, Mandavkar S, Naughane D, Gota V, Patkar S, Goel M, Banavali S, Shetty N. P-24 A prospective phase 1b dose de-escalation open-label clinical study to evaluate the safety and efficacy of sorafenib with metformin and atorvastatin in advanced hepatocellular carcinoma (SMASH). Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.05.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Bhardwaj P, Goda J, Gota V, Banerjee R. Augmentation of Radiotherapy Using a Novel Loco-regional Hydrogel Based Radiosensitizer Delivery Platform for Head and Neck Squamous Cell Carcinoma. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gandhi KA, Goda JS, Gandhi VV, Sadanpurwala A, Jain VK, Joshi K, Epari S, Rane S, Mohanty B, Chaudhari P, Kembhavi S, Kunwar A, Gota V, Priyadarsini KI. Oral administration of 3,3'-diselenodipropionic acid prevents thoracic radiation induced pneumonitis in mice by suppressing NF-kB/IL-17/G-CSF/neutrophil axis. Free Radic Biol Med 2019; 145:8-19. [PMID: 31521664 DOI: 10.1016/j.freeradbiomed.2019.09.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 12/15/2022]
Abstract
The incidence of symptomatic radiation induced lung pneumonitis (RILP), a major dose limiting side effect of thoracic radiotherapy, is in the range of 15-40%. Therapeutic options for the prevention and treatment of RILP are limited. Hence there is a need for developing novel radioprotectors to prevent RILP which can be patient compliant. This study sought to evaluate the efficacy of oral 3,3'-diselenodipropionic acid (DSePA), a novel selenocystine derivative to prevent RILP. C3H/HeJ (pneumonitis responding) mice received a single dose of 18 Gy, whole thorax irradiation and a subset were treated with DSePA orally (2.5 mg/kg), three times per week beginning 2 h post irradiation and continued till 6 months. DSePA delayed onset of grade ≥ 2 RILP by 45 days compared to radiation control (~105 versus ~60 days). It also reversed the severity of pneumonitis in 3/10 radiation treated mice leading to significant improvement in asymptomatic survival compared to radiation control (~180 versus ~102 days). DSePA significantly (p < 0.05) reduced the radiation-mediated infiltration of polymorphonuclear neutrophils (PMN) and elevation in levels of cytokines such as IL1-β, ICAM-1, E-selectin, IL-17 and TGF-β in the bronchoalveolar lavage fluid. Moreover DSePA lowered PMN-induced oxidants, maintained glutathione peroxidase activity and suppressed NF-kB/IL-17/G-CSF/neutrophil axis in the lung of irradiated mice. Additionally, this compound did not protect A549 (lung cancer) derived xenograft tumor from radiation exposure in SCID mice. DSePA offers protection to normal lung against RILP without affecting radiation sensitivity of tumors. It has the potential to be developed as an oral agent for preventing RILP.
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Affiliation(s)
- K A Gandhi
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India
| | - J S Goda
- Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India; Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India.
| | - V V Gandhi
- Radiation and Photochemistry Division, Bhabha Atomic Research Centre, Mumbai, 400085, India; Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India
| | - A Sadanpurwala
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India
| | - V K Jain
- Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India; UM-DAE Centre for Excellence in Basic Sciences, Kalina Campus, Mumbai, 400098, India
| | - K Joshi
- Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India
| | - S Epari
- Department of Pathology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India
| | - S Rane
- Department of Pathology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India
| | - B Mohanty
- Department of Radio Diagnosis, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India; Animal Imaging Division, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India
| | - P Chaudhari
- Department of Radio Diagnosis, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India; Animal Imaging Division, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India
| | - S Kembhavi
- Department of Radio Diagnosis, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India
| | - A Kunwar
- Radiation and Photochemistry Division, Bhabha Atomic Research Centre, Mumbai, 400085, India; Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India.
| | - V Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Navi Mumbai, India; Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India.
| | - K I Priyadarsini
- Chemistry Division, Bhabha Atomic Research Centre, Mumbai, 400085, India; Homi Bhabha National Institute, Anushaktinagar, Mumbai, 400 094, India.
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Kunwar A, Patil A, Kumar S, Deshpande R, Gota V, Goda JS, Jain V, Indira Priyadarsini K. Toxicological safety evaluation of 3,3′-diselenodipropionic acid (DSePA), a pharmacologically important derivative of selenocystine. Regul Toxicol Pharmacol 2018; 99:159-167. [DOI: 10.1016/j.yrtph.2018.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/16/2018] [Accepted: 09/17/2018] [Indexed: 12/15/2022]
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Goda J, Kunwar A, Gota V, Jain V, Priyadarshini K. PO-1041: A novel oral selenocystine prevents pneumonitis in a mouse model exposed to whole lung radiation. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)31351-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Gulia S, Gota V, Kumar SD, Gupta S. Acute renal failure secondary to ingestion of alternative medication in a patient with breast cancer. J Cancer Res Ther 2016; 11:1006-8. [PMID: 26881570 DOI: 10.4103/0973-1482.171362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Complementary and alternative medicine (CAM) use among cancer patients is widely prevalent and often underreported. Advanced stage of disease is significantly associated with CAM use. The concurrent use of alternative medicines and chemotherapy drugs has the potential to lead to toxicities as well as altered therapeutic activity due to unknown interactions. We report a case of early breast cancer who presented to us with non-oliguric acute renal failure related concurrent use of Ayurvedic medicines and adjuvant anthracycline based.
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Affiliation(s)
| | | | | | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
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Gota V, Bonda A, Karanam A, Shriyan B, Gurjar M, Patil A, Singh A, Nookala M, Gupta S. Effect of body mass index on pharmacokinetics of paclitaxel in women with early breast cancer. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw364.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Sengar M, Gota V, Rath S, Jain H, Menon H, Dangi U, Gurjar M, Jadhav K. Correlation of Pharmacokinetics of 6Mp and Its Metabolites with Haematological Toxicity: Step Towards Development of Pharmacokinetics Based Model for Optimal 6 Mp Dosing in Adult All. Ann Oncol 2014. [DOI: 10.1093/annonc/mdu339.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Gujral S, Agarwal A, Gota V, Nair R, Gupta S, Pai SK, Sanger M, Shet T, Subramanian PG, Muckaden M, Laskar S. A clinicopathologic study of mantle cell lymphoma in a single center study in India. INDIAN J PATHOL MICR 2009; 51:315-22. [PMID: 18723950 DOI: 10.4103/0377-4929.42503] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present clinical features, histopathology and results of treatment in cases of mantle cell lymphoma (MCL) at our hospital. We had 93 cases (2.1%) of MCL out of total 4301 cases of non-Hodgkin's lymphoma (NHL) in a 4-year period. It included 68 cases (1.7%) of MCL from 3987 cases of NHL diagnosed on histopathology. Remaining 25 cases (7.9%) diagnosed solely on peripheral blood examination were excluded. Thirty-six (85%) patients had advanced-stage disease. Sixty-three were nodal and five were extranodal (all gastrointestinal tract). Common patterns were diffuse (64%), nodular (25%) and mantle zone type (11%). Sixty-two cases had lymphocytic while six had blastic morphology (all nodal). Tumor cells expressed CD20 (100%), CD43 (94%), CD5 (89%) and cyclin D1 (85%). Bone marrow was involved in 25 (59%) cases. Thirty-two patients could be treated. Median recurrence-free survival was 22.23 months. Diffuse pattern of nodal involvement had a lower overall survival.
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Affiliation(s)
- S Gujral
- Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India.
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