Tata Memorial Centre Evidence Based Management of Colorectal cancer

ABSTRACT

This review article examines the evidence-based management of colorectal cancers, focusing on topics characterized by ongoing debates and evolving evidence. To contribute to the scientific discourse, we intentionally exclude subjects with established guidelines, concentrating instead on areas where the current understanding is dynamic. Our analysis encompasses a thorough exploration of critical themes, including the evidence surrounding complete mesocolic excision and D3 lymphadenectomy in colon cancers. Additionally, we delve into the evolving landscape of perioperative chemotherapy in both colon and rectal cancers, considering its nuanced role in the context of contemporary treatment strategies. Advancements in surgical techniques are a pivotal aspect of our discussion, with an emphasis on the utilization of minimally invasive approaches such as laparoscopy and robotic surgery in both colon and rectal cancers, including advanced rectal cases. Moving beyond conventional radical procedures, we scrutinize the feasibility and implications of endoscopic resections for small tumors, explore the paradigm of organ preservation in locally advanced rectal cancers, and assess the utility of total neoadjuvant therapy in the current treatment landscape. Our final segment reviews pivotal trials that have significantly influenced the management of colorectal liver and peritoneal metastasis.

MRI in rectal cancer patients on 'watch and wait': patterns of response and their evolution

PURPOSE

Evaluate MR patterns of response and their evolution in rectal cancer patients on watch and wait (WW).

METHODS

We retrospectively reviewed 337 MRIs of 60 patients (median follow-up: 12 months; range: 6-49 months). Baseline MRIs (available in 34/60 patients) were evaluated for tumor morphology, location, thickness, circumferential involvement, nodal status and EMVI. First post-treatment MRIs (in all patients) were additionally evaluated for pattern of response on T2 and DWI. Change in post-treatment scar thickness and scar depth angle between the first and second post-treatment scans was also evaluated. Evolution of the response pattern/recurrence were evaluated till the last available scan.

RESULTS

On the baseline scans, 20/34 (59%) patients had polypoidal tumor with 12/20 having ≤ 25% circumferential wall involvement. We saw five patterns of response-normalized rectal wall (2/60-3%), minimal fibrosis (23/60-38%), full thickness fibrosis (16/60-27%), irregular fibrosis (11/60-18%) and split scar (6/60-10%), with 2/60 (3%) showing possible residual disease. On the first post-treatment scans, 12/60 (20%) had restricted diffusion, with 3/12 having persistent restriction till last follow-up. Post-treatment fibrosis/split scar remained stable in 44/60 (73%) cases and improved further in the rest. 9/60 (15%) patients developed regrowth/recurrence. Patients with recurrence had < 10 mm scar thickness and < 21° change in scar angle between the first and second post-treatment MRIs.

CONCLUSION

Most patients on WW protocol developed minimal or full thickness fibrosis, majority of which remained stable on follow-up.

Outcomes of coronary artery bypass grafting based on myocardial perfusion imaging

Introduction

Coronary artery disease (CAD) is the foremost single cause of mortality and loss of disability-adjusted life years globally and a large percentage of this burden is found in low and middle income countries, with the treatment strategies based on revascularisation, based on studies that have shown that on revascularisation of viable myocardium there is an improvement of function over a period of time.

Aim

To evaluate the utilization of myocardial perfusion imaging (MPI) for identifying viable myocardium and assessing the improvement.

Material and methods

This prospective observational study was conducted in patients having CAD planned for coronary artery bypass grafting. The patients were evaluated using 2D ECHO and MPI preoperatively and postoperatively after 1 year.

Results

Mean ejection fraction preoperatively was 40.6 ±9.72% and postoperatively it improved to 41.32 ±10.64% and ejection fraction was calculated using MPI and an average improvement from 35.98 ±12.72% to 45.51 ±12.61% (p ≤ 0.0001). Summed rest score was calculated and an improvement was noted from 24.28 ±8.47 to 18.02 ±8.75 (p ≤ 0.0001). Total perfusion deficit was calculated and was found to have reduced from 32.44 ±11.98 to 25.61 ±12.23 (p ≤ 0.0001).

Conclusions

MPI was able to accurately assess the improvement, which correlated not only with the 2D echocardiography data but also with the clinical wellbeing of the patients. Being a non-invasive, quick procedure, it should be added to the arsenal of the cardiac surgeon for evaluation of patients with diffuse diseases, low ejection fractions, patients who might generally be considered inoperable.

Deep learning based clinico-radiological model for paediatric brain tumor detection and subtype prediction

Aim

Early diagnosis of paediatric brain tumors significantly improves the outcome. The aim is to study magnetic resonance imaging (MRI) features of paediatric brain tumors and to develop an automated segmentation (AS) tool which could segment and classify tumors using deep learning methods and compare with radiologist assessment.

Methods

This study included 94 cases, of which 75 were diagnosed cases of ependymoma, medulloblastoma, brainstem glioma, and pilocytic astrocytoma and 19 were normal MRI brain cases. The data was randomized into training data, 64 cases; test data, 21 cases and validation data, 9 cases to devise a deep learning algorithm to segment the paediatric brain tumor. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the deep learning model were compared with radiologist's findings. Performance evaluation of AS was done based on Dice score and Hausdorff95 distance.

Results

Analysis of MRI semantic features was done with necrosis and haemorrhage as predicting features for ependymoma, diffusion restriction and cystic changes were predictors for medulloblastoma. The accuracy of detecting abnormalities was 90%, with a specificity of 100%. Further segmentation of the tumor into enhancing and non-enhancing components was done. The segmentation results for whole tumor (WT), enhancing tumor (ET), and non-enhancing tumor (NET) have been analyzed by Dice score and Hausdorff95 distance. The accuracy of prediction of all MRI features was compared with experienced radiologist's findings. Substantial agreement observed between the classification by model and the radiologist's given classification [K-0.695 (K is Cohen's kappa score for interrater reliability)].

Conclusions

The deep learning model had very high accuracy and specificity for predicting the magnetic resonance (MR) characteristics and close to 80% accuracy in predicting tumor type. This model can serve as a potential tool to make a timely and accurate diagnosis for radiologists not trained in neuroradiology.

Imaging Recommendations for Diagnosis, Staging, and Management of Pancreatic Cancer

Pancreatic cancer is the fourth most prevalent cause of cancer-related death worldwide, with a fatality rate equal to its incidence rate. Pancreatic cancer is a rare malignancy with a global incidence and death ranking of 14th and 7th, respectively. Pancreatic cancer cases are divided into three categories without metastatic disease: resectable, borderline resectable, or locally advanced disease. The category is determined by the tumor's location in the pancreas and whether it is abutting or encasing the adjacent arteries and/or vein/s.

The stage of disease and the location of the primary tumor determine the clinical presentation: the pancreatic head, neck, or uncinate process, the body or tail, or multifocal disease. Imaging plays a crucial role in the diagnosis and follow-up of pancreatic cancers. Various imaging modalities available for pancreatic imaging are ultrasonography (USG), contrast-enhanced computed tomography (CECT), magnetic resonance imaging (MRI), and 18-fluoro-deoxy glucose positron emission tomography (FDG PET).

Even though surgical resection is possible in both resectable and borderline resectable non-metastatic cases, neoadjuvant chemotherapy with or without radiotherapy has become the standard practice for borderline resectable cases as it gives a high yield of R0 resection.

Mebendazole plus lomustine or temozolomide in patients with recurrent glioblastoma: A randomised open-label phase II trial

BACKGROUND

Recurrent glioblastoma (GBM) has dismal outcomes and limited treatment options. Mebendazole (MBZ) has activity in glioma both in-vivo and in-vitro, and is well tolerated in combination with lomustine (CCNU) and temozolomide (TMZ). In this study, we sought to determine whether the addition of MBZ to CCNU or TMZ would improve overall survival (OS) in recurrent GBM.

METHODS

In this phase II randomized open-label trial, adult patients with ECOG PS 0-3, with recurrent GBM who were not eligible for re-radiation, were randomized 1:1 to the CCNU-MBZ and TMZ-MBZ arms. CCNU was administered at 110 mg/m² every 6 weeks with MBZ 800 mg thrice daily and TMZ was administered at 200 mg/m² once daily on days 1-5 of a 28 days cycle with MBZ 1600 mg thrice daily. The primary endpoint was OS at 9 months. A 9-month OS of 55% or more in any arm was hypothesized to warrant further evaluation and a value below 35% was too low to warrant further investigation. OS was analyzed using intention to treat (ITT) and per-protocol (PP) analyses. Per-protocol analysis was used for safety analysis. Clinical Trials Registry-India number, CTRI/2018/01/011542.

FINDINGS

Participants were recruited from 14^th March 2019 to 18^th June 2021, 44 patients were randomised on each arm. At 17.4 months, 68 events for OS analysis had occurred, 33 in the TMZ-MBZ and 35 in the CCNU-MBZ arm. The 9-month OS was 36.6% (95% CI 22.3-51.0) and 45% (95% CI 29.6-59.2) in the TMZ-MBZ and CCNU-MBZ arms respectively, in the ITT population. ECOG PS was the only independent prognostic factor impacting OS (HR-0.48, 95% CI 0.27-0.85; P = 0.012). Grade 3-5 adverse events were seen in 8 (18.6%; n = 43) and 4 (9.5%; n = 42) patients in the TMZ-MBZ and CCNU-MBZ arms respectively. There were no treatment related deaths.

INTERPRETATION

The addition of MBZ to TMZ or CCNU failed to achieve the pre-set benchmark of 55% 9-month OS. This was probably due to 28.6% of patients having poor PS of 2-3.

FUNDING

Brain Tumor Foundation (BTF) of India, Indian Cooperative Oncology Network (ICON), and India Cancer Research Consortium (ICRC) under ICMR (Indian Council of Medical Research).

DIPG-32. Paediatric histone-mutant diffuse midline glioma: real world outcomes from a low-middle income country (LMIC) setting

BACKGROUND: Histone-mutant diffuse midline glioma (H3K27M) is a distinct high-grade central nervous system (CNS) tumor arising in the midline structures of the brain and/or spinal cord in children and young adults with dismal clinical outcomes. Real world data on this entity, particularly from the low-middle income countries (LMICs) is lacking. We report outcomes of pediatric histone-mutant diffuse midline gliomas treated between 2014-2021 at our comprehensive cancer centre in India. METHODS: Children (&lt;16 years) with biopsy-proven diffuse midline glioma demonstrating histone mutation (H3K27M) on gene expression profiling were identified through electronic search of neuro-pathology database. Clinico-demographic characteristics, histo-molecular features, treatment details, and survival outcomes were retrieved retrospectively from institutional records. All children had undergone biopsy and occasionally debulking surgery prior to definitive radiotherapy (RT). Upfront temozolomide (TMZ) either concurrent and/or adjuvant was at the discretion of treating oncologist. Progression-free survival (PFS) and overall survival (OS) were calculated using Kaplan-Meier methods and expressed as point estimates with 95% confidence interval (CI). RESULTS: Median age of the study cohort (N=51) was 11 years (inter-quartile range 6-14 years) with no gender predilection. Metastatic disease (leptomeningeal dissemination, sub-ependymal spread, or distant brain involvement) was seen at presentation in 7 (13.7%) patients and at first progression after definitive RT in 10 (19.6%) patients. At a median follow up of 10.3 months, 1-year Kaplan-Meier estimates of PFS and OS were 21.5% (95%CI: 12.2-37.9%) and 45.6% (33.1-62%) yielding median PFS and OS of 7.8 months (95%CI: 5.6-11 months) and 11.3 months (95%CI: 9.4-14.9 months) respectively. CONCLUSIONS: We report aggressive biological course and dismal outcomes in pediatric histone-mutant diffuse midline gliomas (H3K27M) treated in a LMIC setting. High incidence of metastatic CNS failure in our cohort suggests a potential role for testing neuraxial irradiation and aggressive systemic therapy to improve survival.

A Radiologist's Perspective on Treatment-Related Pseudoprogression: Clues and Hues

Pseudoprogression refers to the initial apparent increase in tumor burden observed on imaging after cancer therapy, with subsequent delayed response to the same treatment, thus giving a false initial appearance of disease progression. It is essential to differentiate pseudoprogression from true progression to prevent the patients from getting deprived of the benefits of their ongoing cancer therapy owing to their early withdrawal. It also affects their recruitment for clinical trials. Pseudoprogression, albeit uncommon, has been observed after various types of cancer therapy; however, this phenomenon has gained momentum of late due to the emergence of immunotherapy for the treatment of various malignancies. Besides immunotherapy, pseudoprogression has predominantly been of concern in a few patients after radiation therapy for brain tumors and metastasis, after molecular targeted therapy for a variety of tumors, and after chemotherapy in metastatic bone lesions. This article reviews the available data on imaging of pseudoprogression from various types of cancer therapies, highlighting ways to suspect or identify it on imaging.

Development of a Standardized Semantic Feature-Based Reporting Proforma for Intraoperative Ultrasound Findings in Brain Tumors and Application in High-Grade Gliomas - A Preliminary Study

Purpose A semantic feature-based reporting proforma for intraoperative ultrasound findings in brain tumors was devised to standardize reporting. It was applied as a pilot study on a cohort of histologically confirmed high-grade supratentorial gliomas (Grade 3 and 4) for internal validation.

Materials and Methods This intraoperative semantic ultrasound proforma was used to evaluate 3D ultrasound volumes using Radiant DICOM software by 3 surgeons. The ultrasound semantic features were correlated with histological features like tumor grade, IDH status, and MIB index.

Results 68 patients were analyzed using the semantic proforma. Irregular crenated was the most common margin (63.2%) and lesions were heterogeneously hyperechoic (95.6%). Necrosis was commonly seen and noted as single (67.6%) or multiple (13.2%) in over 80% cases. A separate perilesional zone, which was predominantly hyperechoic in 41.8% and both hypo and hyperechoic in 12.7%, could be identified in 54.5% of cases. Grade 4 tumors were more likely to have an irregular crenated margin (71.2%) with a single large area of necrosis, while Grade 3 tumors were likely to have smooth (31.3%) or non-characterizable margins (31.2%) with no or multiple areas of necrosis. IDH-negative tumors were more likely to have a single large focus of necrosis. Among the GBMs (52 cases), MIB labelling index of>15% was associated with poorly delineated, uncharacterizable margins, when compared with MIB labelling index<15% (23.5 vs. 0%), (p=0.046).

Conclusion A detailed semantic proforma was developed for brain tumors and was internally validated. A few ultrasound sematic features were identified correlating with histological features in high-grade gliomas. It will require further external validation for refinement and acceptability.

Accuracy of MRI for nodal restaging in rectal cancer: a retrospective study of 166 cases

AIM

Assessing metastatic mesorectal nodal involvement is a challenge in rectal cancer, especially in the post chemoradiation setting. We aim to assess the accuracy of MRI for nodal restaging and the validity of SAR criteria (≥ 5 mm size being metastatic).

MATERIALS AND METHODS

This was an IRB-approved retrospective study of 166 patients with locally advanced rectal cancers, operated after neoadjuvant treatment. Two dedicated oncoradiologists reviewed the 166 post-chemoradiation presurgical MRIs in consensus. Nodal size and morphology (shape, margins, and signal intensity) were noted. The most accurate cut-off for size for predicting positive pN status was determined using the Youden index.

RESULTS

MRI understaged 30/166 (18%) and overstaged 40/166 (24%) patients using the SAR criteria. The most accurate cut-off for node size was 5.5 mm, with a sensitivity of 75%, specificity of 60.2%, PPV of 40.7%, NPV of 86.9% (95% CI:78-92.5%), accuracy of 64.2%, and area under the curve (AUC) 0.657 (95% CI-0.524-0.79). Morphological characteristics were not significant to determine involvement, with positive nodes including 42% of round and 31% of oval nodes, 40% of heterogeneous and 45% of homogeneous nodes, and 31% irregularly marginated and 46% nodes with regular margins being positive on pathology. MRI was accurate in predicting pathology for mucinous nodes in 9/29 (31%) cases. Seven cases which were yN2 on MRI and yN0 on pathology demonstrated mucinous changes on MRI and had acellular mucin on histopathology.

CONCLUSIONS

MRI has good negative predictive value, poor positive predictive value and moderate accuracy in nodal restaging. The cut-off of 5.5 mm demonstrated in our study is close to the SAR cut-off of 5 mm in the post-treatment setting. MRI accuracy is lower in patients with mucinous nodes.

Non Nucleoside Reverse Transcriptase Inhibitors, Molecular Docking Studies and Antitubercular Activity of Thiazolidin-4-one Derivatives

BACKGROUND

Management of Co-existence of Acquired immunodeficiency syndrome and Tuberculosis has become a global challenge due to the emergence of resistant strains and pill burden.

OBJECTIVE

Hence the aim of the present work was to design and evaluate compounds for their dual activity on HIV-1 and Tuberculosis (TB).

METHODS

A series of seven, novel Thiazolidin-4-one derivatives were synthesized and evaluated for their anti-HIV and anti-tubercular activity along with Molecular docking studies. All the seven compounds displayed promising activity against the replication of HIV-1 in cell-based assays. The four most active compounds were further evaluated against X4 tropic HIV-1UG070 and R5 tropic HIV-1VB59 primary isolates. The binding affinity of all the designed compounds for HIV-RT and Mycobacterium tuberculosis Enol Reductase (MTB InhA) was gauged by molecular docking studies which revealed crucial thermodynamic interactions governing their binding.

RESULTS

The CC50 values for the test compounds were in the range of, 15.08-34.9 μg/ml, while the IC50 values were in the range of 16.1-27.13(UG070; X4) and 12.03-23.64 (VB59; R5) μg/ml. The control drug Nevirapine (NVP) exhibited CC50 value of 77.13 μg/ml and IC50 value of 0.03 μg/ml. Amongst all these compounds, compound number 3 showed significant activity with a TI value of 2.167 and 2.678 against the HIV-1 X4 and the R5 tropic virus respectively. In anti-mycobacterial screening, the compounds proved effective in inhibiting the growth of both log phase and starved MTB cultures.

CONCLUSION

Compound 3 has been found to be active against HIV-1 as well as MTB.

A polyherbal formulation, HC9 regulated cell growth and expression of cell cycle and chromatin modulatory proteins in breast cancer cell lines

ETHNOPHARMACOLOGICAL RELEVANCE

HC9, a polyherbal formulation, is based upon a traditional Ayurvedic formulation, Stanya Shodhana Kashaya (SSK, having 10 plant materials), formulated on Stanyashodhana gana, explained by Charaka in Charakasaṃhita Sutrasthana IV and mentioned in other texts as well. Stanyasodhana is the Sanskrit name for a group of medicinal plants, classified for "improving the quality of milk". SSK is used by Ayurvedic practitioners for the cleansing and detoxification of breast milk in lactating mothers as well as for the management of various clinical conditions. HC9 is composed of equal ratios of nine different medicinal plants that include Picrorhiza kurroa Royle ex Benth., Cyperus rotundus L., Zingiber officinale Roscoe, Cedrus deodara (Roxb. ex D.Don) G.Don, Tinospora cordifolia (Willd.) Miers, Holarrhena antidysenterica (Roth) Wall. ex A.DC., Swertia chirata Buch.-Ham. ex Wall., Cissampelos pareira L. and Hemidesmus indicus (L.) R. Br. ex Schult.. It differs from the SSK formulation by having one ingredient [Marsdenia tenacissima (Roxb.)Moon (Murva)] less, due to its unavailability since it is mostly found in tropical hilly tracts of peninsular India and Vindhya ranges as well as in lower Himalayan tracts. All the medicinal plants in the formulation have reported activity against different types of cancers.

AIM OF THE STUDY

The present study is aimed at evaluating the anticancer activity of the polyherbal formulation (HC9) and its mechanism of action against breast cancer cell lines.

MATERIALS AND METHODS

The effect of HC9 on the viability of breast cancer (MCF-7 and MDAMB231) and non-cancerous (MCF-10A) cell lines was evaluated by MTT assay. The effect on cell growth and colony formation potential of cancer cells was determined by trypan blue dye exclusion method and soft agar assay, respectively. Cell cycle arrest was determined by propidium iodide (PI) staining and analyzed by flowcytometer. Scratch wound assay was used for studying cell migration. Cell invasion was determined by using BD BioCoat Matrigel invasion chambers. The gene expression of HIF-1α was examined by RT-PCR. The expression of p53, SMAR1, p16, MMP-2, CDP/Cux, p21, Rb, phospo-Rb (ppRb), VEGF, NFқB and COX-2 proteins was determined by western blotting.

RESULTS

HC9 significantly altered growth of breast cancer cell lines, MCF-7 and MDA MB-231. It blocked the cell cycle progression at S phase in MCF-7 by up regulating the expression of p53, p21 and p16 proteins. In MDA MB-231, HC9 induced G1 phase arrest by up regulating the expression of p53, p21 and pRb proteins with simultaneous decrease in ppRb. It significantly reduced migration and invasion in both the cell lines, accompanied by decrease in the expression of MMP-2/9, HIF-1α and VEGF. HC9 decreased the expression of inflammatory markers (NF-қB, COX-2), and modulated the expression of chromatin modulators (SMAR1 and CDP/Cux) in both MCF-7 and MDA MB-231.

CONCLUSIONS

HC9 exhibited potent anticancer activity against breast cancer cells, thereby warranting further pre-clinical and clinical studies in future.

Moyamoya syndrome in hemoglobin E-beta thalassemia: A rare presentation and association

Moyamoya disease is an idiopathic, nonatherosclerotic, noninflammatory, chronic progressive cerebrovascular disease characterized by bilateral stenosis or occlusion of the arteries around the circle of Willis, typically the supraclinoid internal carotid arteries, followed by extensive collateralization, which are prone to thrombosis, aneurysm, and hemorrhage. Secondary moyamoya phenomenon or moyamoya syndrome (MMS) occurs in a wide range of clinical scenarios including prothrombotic states such as sickle cell anemia, but the association with other hemoglobinopathies is less frequently observed. We describe a case of a 25-year-old female with hemoglobin E-beta thalassemia who had a rare presentation of MMS in the form of choreoathetoid movements in the left upper and lower extremities. We describe this association, primarily to emphasize thalassemia as an extremely rare but a potential etiology of MMS. Since MMS is a progressive disease, it is important to diagnose and initiate treatment to prevent worsening of the disease and recurrence of stroke.

Synthesis and biological evaluation of some new tricyclic pyrrolo[3,2-e]tetrazolo[1,5-c]pyrimidine derivatives as potential antitubercular agents

A series of new tricyclic pyrrolo[3,2-e]tetrazolo[1,5-c]pyrimidines 8a-l were synthesized and characterized by IR, NMR (1 H and 13 C), and mass spectral analysis. The newly synthesized compounds 8a-l were inspected for their in vitro antitubercular activity against Mycobacterium tuberculosis (MTB) H37 Ra using an established XTT reduction menadione assay (XRMA). The title compounds exhibited minimum inhibitory concentrations (MIC90 ) ranging from 0.09 to >30 μg/mL. Five compounds (8c, 8i-l) were further confirmed for their dose-dependent effect against MTB. These compounds were evaluated in the THP-1 infection model, where 8i (MIC90  = 0.35 μg/mL), 8j (MIC90  = 1.17 μg/mL), 8k (MIC90  = 2.38 μg/mL), and 8l (MIC90  = 1.17 μg/mL) demonstrated significant antitubercular activity. All the ex vivo active compounds showed insignificant cytotoxicity against the human cancer cell lines, HeLa, MCF-7, and THP-1. Inactivity of all these compounds against Gram positive and Gram negative bacteria indicates their specificity. Molecular docking studies in the active site of the sterol 14alpha-demethylase (CYP51) enzyme revealed a similar binding mode to the native ligand in the crystal structure, thereby helping to understand the ligand-protein interactions and to establish a structural basis for inhibition of MTB. The results suggest novel pharmacophores as selective and specific inhibitors against MTB that can be explored further to synthesize lead compounds against tuberculosis. In summary, the results clearly indicate the identification of some novel, selective, and specific inhibitors against MTB that can be explored further for potential antitubercular drugs.

Molecular modeling studies and in vitro screening of dihydrorugosaflavonoid and its derivatives against Mycobacterium tuberculosis

Novel drug regimens against tuberculosis (TB) are urgently needed and may be developed by targeting essential enzymes of Mtb that sustain the pathogenicity of tuberculosis. Dihydrorugosaflavonoid interacted with the active pocket of MabA and PanK.

Multifocal Tuberculosis Presenting as Metastatic Tumour

A middle aged female presented with multiple lesions in the bone mimicking as multiple metastasis. In such cases detection of lesion should be confirmed by soft tissue diagnosis and appropriate culture. In our case, the lesions were responsive to anti-tuberculous treatment.