Navigating breast cancer brain metastasis: Risk factors, prognostic indicators, and treatment perspectives

In this editorial, we comment on the article by Chen et al. We specifically focus on the risk factors, prognostic factors, and management of brain metastasis (BM) in breast cancer (BC). BC is the second most common cancer to have BM after lung cancer. Independent risk factors for BM in BC are: HER-2 positive BC, triple-negative BC, and germline BRCA mutation. Other factors associated with BM are lung metastasis, age less than 40 years, and African and American ancestry. Even though risk factors associated with BM in BC are elucidated, there is a lack of data on predictive models for BM in BC. Few studies have been made to formulate predictive models or nomograms to address this issue, where age, grade of tumor, HER-2 receptor status, and number of metastatic sites (1 vs > 1) were predictive of BM in metastatic BC. However, none have been used in clinical practice. National Comprehensive Cancer Network recommends screening of BM in advanced BC only when the patient is symptomatic or suspicious of central nervous system symptoms; routine screening for BM in BC is not recommended in the guidelines. BM decreases the quality of life and will have a significant psychological impact. Further studies are required for designing validated nomograms or predictive models for BM in BC; these models can be used in the future to develop treatment approaches to prevent BM, which improves the quality of life and overall survival.

Clinicopathologic Profile and Treatment Outcomes of Colorectal Cancer in Young Adults: A Multicenter Study From India

PURPOSE

Colorectal cancer (CRC) in young adults is a rising concern in developing countries such as India. This study investigates clinicopathologic profiles, treatment patterns, and outcomes of CRC in young adults, focusing on adolescent and young adult (AYA) CRC in a low- and middle-income country (LMIC).

METHODS

A retrospective registry study from January 2018 to December 2020 involved 126 young adults (age 40 years and younger) with CRC. Patient demographics, clinical features, tumor characteristics, treatment modalities, and survival outcomes were analyzed after obtaining institutional ethics committees' approval.

RESULTS

Among 126 AYA patients, 62.70% had colon cancer and 37.30% had rectal cancer. Most patients (67%) were age 30-39 years, with no significant gender predisposition. Females had higher metastatic burden. Abdominal pain with obstruction features was common. Adenocarcinoma (65%) with signet ring differentiation (26%) suggested aggressive behavior. Limited access to molecular testing hindered mutation identification. Capecitabine-based chemotherapy was favored because of logistical constraints. Adjuvant therapy showed comparable recurrence-free survival in young adults and older patients. For localized colon cancer, the 2-year median progression-free survival was 74%, and for localized rectal cancer, it was 18 months. Palliative therapy resulted in a median overall survival of 33 months (95% CI, 18 to 47). Limited access to targeted agents affected treatment options, with only 27.5% of patients with metastatic disease receiving them. Chemotherapy was generally well tolerated, with hematologic side effect being most common.

CONCLUSION

This collaborative study in an LMIC offers crucial insights into CRC in AYA patients in India. Differences in disease characteristics, treatment patterns, and limited access to targeted agents highlight the need for further research and resource allocation to improve outcomes in this population.

Tumor infiltrating lymphocytes in gastric cancer: Unraveling complex interactions for precision medicine

This editorial will focus on tumor immunity and the factors that alter the tumor immune micro-environment. The role of tumor infiltrating lymphocytes (TILs) will also be discussed in detail, including the types, mechanism of action, and role. Gastric cancer (GC) often presents in the advanced stage and has various factors predicting the outcomes. The interplay of these factors and their correlation with the TILs is discussed. A literature review revealed high intra-tumoral TILs associated with higher grade, HER2-, and Helicobacter pylori negativity. Moreover, stromal (ST) TILs correlated with lower grade and lesser recurrence risk in GC. High TILs in ST and invasive border also correlated with mismatch repair deficiency status. Further characterization of the CD3+, CD8+, and other cells is also warranted. In the future, this complex correlation of cancer cells with the immune system can be explored for therapeutic avenues.

Prevalence and impact of endocrine disorders in advanced metastatic cancer patients undergoing cancer-directed therapy: A prospective observational study

BACKGROUND

Noncommunicable diseases (NCDs) contribute significantly to global morbidity and mortality, with cancer being one of the leading causes. In this prospective observational study, we aimed to investigate the prevalence and impact of endocrine disorders, specifically diabetes and thyroid dysfunction, in patients with advanced metastatic cancer undergoing cancer-directed therapy.

METHODS

Over 15 months, we recruited 100 histologically proven advanced metastatic cancer patients from the Department of Medical Oncology Haematology, All India Institute of Medical Sciences, Rishikesh, and conducted institutional-based prospective observational study. All participants over 18 years of age, treatment-naive, and potential candidates for systemic chemotherapy with an expected clinical survival of at least 6 months were included in the study. Patients with prior therapy, secondary neoplasms, and those unable to complete 3 months of palliative chemotherapy were excluded. Patients were assessed for diabetes and thyroid function at presentation, after 3 and 6 months of cancer-directed standard therapy. These data were analyzed, processed, and presented as results.

RESULTS

The mean age of participants was 50.45 years, with a near-equal distribution of males and females. At baseline, 10% of the study population had preexisting endocrine disorders (2% hypothyroidism, 8% diabetes). By the end of 6 months, the prevalence increased to 18%, with females being more affected. Notably, the prevalence of new-onset endocrine disorders during cancer-directed therapy was only 3% for diabetes and 4% for thyroid dysfunction.

CONCLUSION

Analysis of sociodemographic and cancer-related characteristics showed no significant association with changes in diabetic and thyroid status at 3 and 6 months. However, substance use, particularly smoking, was associated with an increased risk of diabetes development (p < .05). Cancer type and treatment regimen did not show statistically significant correlations with endocrine dysfunction.

IMPLICATIONS

Our study highlights the importance of considering endocrine disorders in advanced metastatic cancer patients undergoing therapy. The prevalence of diabetes and thyroid dysfunction increased during cancer-directed therapy, particularly in females. Careful monitoring and timely intervention are essential to improve the quality of life for these patients. Further research is warranted to explore the long-term effects of cancer-directed therapy on endocrine health and develop tailored management strategies for this vulnerable population.

An assessment of childhood cancer care services in India - gaps, challenges and the way forward

Background

Childhood cancers are emerging as an essential concern in India where there is lack of a specific programme component or policy to address childhood cancer control. There is limited information on the status and quality of childhood cancer care services in India. This paper describes the childhood cancer care services available at secondary and tertiary-level hospitals in India through a cross sectional study design.

Methods

The survey was conducted in 137 tertiary-level and 92 secondary-level hospitals in 26 states and 4 Union Territories (UTs), ensuring a uniform representation of public and private care hospitals. The study tool collected data on the organisational infrastructure, type of oncology services, health workforce, equipment, treatment and referral protocols, and treatment guidelines. Descriptive statistics was used to primarily present the health service status and data on childhood cancer care services in proportions and mean.

Findings

A dedicated pediatric oncology department was available in 41.6% of the public, 48.6% of private, and 64% Non Government Organization (NGO) managed tertiary-level hospitals. In 36 (39%) of the 92 hospitals providing secondary care, childhood cancer care was provided. The availability of bone (41.5%) and positron emission tomography (PET) scans (25.9%) was lower in public tertiary hospitals, whereas histopathology, computerised tomography (CT scan), and magnetic resonance imaging (MRI) were lower in public secondary hospitals than private and NGO managed hospitals for the corresponding level of care. Most tertiary hospitals had the required supportive care facilities except for play therapy and hospice care. Less than 50% of the public tertiary hospitals had stocks of the four categories of cancer-treating drugs and essential infrastructure for radiotherapy and chemotherapy. Most secondary-level hospitals not treating childhood cancer had referral linkages with tertiary hospitals.

Interpretation

The situational analysis of childhood cancer care services in India showed the concentration of availability of childhood cancer care services at the tertiary level of health care. There were gaps in the availability of specialised pediatric oncology care in all the tertiary hospitals. The availability of childhood cancer care services was higher in private and NGO-managed hospitals than in public hospitals. Integration of childhood cancer as a part of the national cancer control response should be taken up as a matter of priority. The need of the hour is to formulate a childhood cancer policy that will enable timely access to care universally.

Funding

World Health Organization, India provided funding and technical support.

A Cross-sectional Survey to Assess Knowledge, Attitude, and Practice of Yoga among Cancer Patients at a Tertiary Care Hospital

Background

Cancer incidence and mortality are rapidly growing worldwide. Cancer affects the overall quality of life of cancer patients. Yoga has its origin in the ancient times. This ancient practice has been used for holistic well-being for ages. Yoga as an alternative therapy might be beneficial for cancer patients too. This study was conducted to assess knowledge, attitudes, and yoga practices among cancer patients.

Materials and Methods

For this cross-sectional survey, a self-designed questionnaire was validated and distributed among 25 cancer patients for a pilot study. Then, a full-fledged study was conducted based on the interviews of 1000 cancer patients at a tertiary care oncology unit and the data were analyzed using R 3.6.

Results

A total of 1000 participants were enrolled in this cross-sectional survey. Out of 1000 participants, 91 were excluded as they responded that they were not familiar with the term "Yoga" in the first question of the questionnaire. Of 919 participants, 238 strongly agreed and 395 agreed with the question that people who practice yoga are less prone to diseases, showing that 68.87% of cancer patients have a positive attitude toward yoga. However, only 145 (15.77%) of the participants practice yoga regularly. Lack of time was the most common reason for not practicing yoga, and the other reasons were the lack of interest and insufficient facilities.

Conclusion

The present study on 1000 patients from the yoga capital of the world, Rishikesh, highlights the fact that the majority of cancer patients are aware of yoga practice's benefits and if given the opportunity to learn appropriate techniques, yoga can further improve the outcome in such patients. There is a need to design the effective yoga programs for cancer patients to promote suitable yoga practices in this population.

Primary Malignant Melanoma of the Oral Cavity: A Retrospective Study From a Tertiary Care Centre of North India

BACKGROUND

Mucosal melanoma is a rare but aggressive tumor associated with a poor prognosis arising from pigmented cells called melanocytes. They are usually asymptomatic and present in an advanced stage. It has an aggressive clinical outcome and is proven to be of poor prognosis.

MATERIALS AND METHODS

This is a retrospective review of the computer database and clinical records at the All India Institute of Medical Sciences, Rishikesh, India. The data between 2018-2022 were reviewed for all small biopsy or excision specimen-proven cases of oral mucosal melanoma.

RESULTS

The most common site of involvement in the head and neck region is the nasal cavity and paranasal sinuses. In this retrospective study from our institute, all three cases presented involved oral cavities. The median age of presentation was 51 years. Some literature specifies male preponderance. Our patients presented clinically with a black nodule in the oral cavity, which was increasing in size and associated with bleeding. A biopsy performed confirmed the diagnosis of melanoma based on the morphology and immunohistochemical profile of the tumor cells.

CONCLUSION

Surgical resection is the mainstay treatment, followed by radiation postoperatively to reduce local and regional recurrence. Mucosal melanoma has a poor prognosis, and the majority of patients develop incurable metastatic disease.

Bleomycin-Induced Flagellate Dermatitis: Revisited

Flagellate dermatitis caused by bleomycin is a rare side effect with a distinctive pattern of whip-like, linear streaks. The clinical presentation has become uncommon nowadays as bleomycin use in conventional chemotherapy regimens has decreased. We present a case of a 30-year-old female diagnosed with ovarian germ cell tumour, managed with bleomycin, etoposide, and cisplatin (BEP) and later developed a widespread rash indicative of classic flagellate dermatitis. This brief report emphasizes the significance of detection and management of this transient dermatological complication in patients receiving bleomycin.

Next-Generation Sequencing Highlights of Diffuse Large B-cell Lymphoma in a Tertiary Care Hospital in North India

Introduction: Next-generation sequencing (NGS) elucidates the diffuse large B-cell lymphoma (DLBCL) genetic characteristics by finding recurrent and novel somatic mutations. This observational study attempted to create an NGS panel with a focus on identifying novel somatic mutations which could have potential clinical and therapeutic implications. This panel was created to look for mutations in 133 genes chosen on basis of a literature review and it was used to sequence the tumor DNA of 20 DLBCL patients after a centralized histopathologic review.

Methods: The study included 20 patients having DLBCL. The quality and quantity of tumor cells were accessed by H&E staining and correlated with histopathology and Immunohistochemistry (IHC) status. Patients were grouped as ABC (activated B-cell), PMBL (primary mediastinal large B-cell lymphoma), and other or unclassified subtypes. The lymphoma panel of 133 was designed on targeted sequencing of multiple genes for the coding regions through NGS. The libraries were prepared and sequenced using the Illumina platform. The alignment of obtained sequences was performed using Burrows-Wheeler Aligner and identification of somatic mutations was done using LoFreq (version 2) variant caller. The mutations were annotated using an annotation pipeline (VariMAT). Previously published literature and databases were used for the annotation of clinically relevant mutations. The common variants were filtered for reporting based on the presence in various population databases (1000G, ExAC, EVS, 1000Japanese, dbSNP, UK10K, MedVarDb). A custom read-depth-based algorithm was used to determine CNV (Copy Number Variants) from targeted sequencing experiments. Rare CNVs were detected using a comparison of the test data read-depths with the matched reference dataset. Reportable mutations were prioritized and prepared based on AMP-ASCO-CAP (Association for Molecular Pathology-American Society of Clinical Oncology-College of American Pathologists), WHO guidelines, and also based on annotation metrics from OncoMD (a knowledge base of genomic alterations).

Results: The informativity of the panel was 95 percent. NOTCH 1 was the most frequently mutated gene in 16.1% of patients followed by 12.9% who had ARID1A mutations. MYD88 and TP53 mutations were detected in 9.6% of the patient while 6.4% of patients had CSF3R mutations. NOTCH 1 and TP 53 are the most frequently reported gene in the middle age group (40-60). Mutation in MYD88 is reported in every age group. MYD88 (51%) is the most common mutation in ABC subtypes of DLBCL, followed by NOTCH 1 (44%) and SOCS 1 (33%) according to our findings. NOTCH 1 mutations are frequent in ABC and PMBL subtypes. Closer investigation reveals missense mutation is the most frequent mutation observed in the total cohort targeting 68.4% followed by frameshift deletion reported in 26.3%. Six novel variants have been discovered in this study.

Conclusions: This study demonstrates the high yield of information in DLBCL using the NGS Lymphoma panel. Results also highlight the molecular heterogeneity of DLBCL subtypes which indicates the need for further studies to make the results of the NGS more clinically relevant.

An Institution-Based Demographic Study of Urinary Bladder Cancer from North India

Urinary bladder cancer (UBC) is among the top ten cancers worldwide. Incidence is rising mainly attributed to environmental contamination due to chemical carcinogens and smoking habits. Recently, we have seen a higher number of UBC patients and thus aim to study the associated epidemiological parameters. This was a single-center retrospective analysis that involved histology-proven UBC patients presented from the inception of medical oncology services. Clinical, demographic data and history of exposure to potential risk factors were noted. A telephonic interview with the patient or family members was conducted for the missing data. Mean age of patients was 60.36 ± 10.33 years. More than half of the patients were of the geriatric age group. Males were affected 7.5 times more as compared to females. Sixty-four percent of the patients were smokers. Seventy-three percent of the patients had a residence in the plains or Terai region. Thirty percent of the patients reported farming as their occupation. Anthranilic diamide, chlorpyriphos cypermethrin, lesenta (imidacloprid + fipronil), and tricyclazole were the commonly used insecticides/pesticides. Untreated groundwater, river, or pond was the source of drinking water for 68% of the patients. The insecticides/pesticides used in agriculture and the subsequent contamination of food and water serving as the vehicle for the potential carcinogens need a critical review and are hypothesis-generating.

Chemotherapy in geriatric patients with poor performance status small cell lung cancer: Series from a tertiary care center

Geriatric age group patients with poor performance status and advanced stage cancer are often denied chemotherapy. In this series of cases, we demonstrated that systemic anti-cancer therapy can be considered in these patients after a meticulous modification of the chemo-protocol.

Audit of In-Hospital Mortality from a Medical Oncology and Hemato-Oncology Center with the Emphasis on Best Supportive Care

Deepak SundriyalBackground and Objectives  The newly established medical oncology and hemato-oncology center at the All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India, provided us an opportunity to audit in-hospital mortalities with a vision that the audit will serve as a standard for ceaseless improvement. Aim of the study was to initiate a vigorous process for the evaluation of all-cause mortality in patients suffering from cancer. Methods  An audit of all in-hospital deaths that occurred during the year 2019 was performed, and comprehensive scrutiny of various parameters (demographic, clinico-pathological, therapeutic, causes of death) was done. Reviews from two independent observers sharpened the infallibility of the audit. The lacunae in the existing practices and the scope for further improvement were noted. Results  Forty-five in-hospital deaths were registered during the study period (January-December 2019). The majority of the deaths occurred in patients with advanced stage of malignancy ([ n = 31] 68.8%). Most common causes of death were progressive disease, neutropenic, and non-neutropenic sepsis. Chemotherapeutic agents, growth factors, blood components, and antibiotics were found to be used judiciously as per institutional policy. The reviewers emphasized on the use of comorbidity indexes in the treatment planning and avoiding intensive care unit referrals for patients receiving best supportive care (BSC). Emphasis was put on providing only BSC to the patients with a very limited life expectancy. Emphasis was also laid down on record of out of the hospital deaths. Interpretation and Conclusion  The audit disclosed areas of care which require further improvement. The mortality audit exercise should become a regular part of evaluation and training for the ongoing and future quality commitment. This should impact the clinical decision making in an oncology center providing quality care to the terminally ill patients.

Hypercalcemia of Malignancy: Time to Pull the Brakes

Hypercalcemia of malignancy (HOM) is usually seen in advanced stage and carries a poor prognosis. Survival outcomes are dismal and most of the patients are unable to receive subsequent definite anti-cancer therapy. There is lack of any retrospective or prospective data regarding hypercalcemia of malignancy in Indian population. We aim to describe survival outcomes in hypercalcemia associated with solid organ malignancies. Forty-five patients diagnosed with HOM associated with solid organ malignancies were included in the study. Patients were followed up till death. Clinical features and survival outcomes were noted. Squamous cell carcinoma of head and neck region and lung comprised most of the cases associated with HOM. Most of the patients presented with poor performance status. Median overall survival (OS) was 20 days (2-78 days). Median OS was 35 days (9-58 days) in those who received definite anti-cancer therapy. Four-week mortality rate was estimated as 59.5%, while this increased to 75.7% within 6 weeks from the diagnosis of hypercalcemia. Survival outcomes are poor after the diagnosis of hypercalcemia in cancer patients. Best supportive care including hospice care should be strongly considered at this point of time instead of definite systemic anti-cancer therapy.

Totally Implantable Venous Access Device (Chemoport) in Oncology: Study of 168 Polyurethane Chemoport Catheter System

Background Chemoport (totally implantable venous access device) and its catheter system are used to administer long-term chemotherapy in cancer patients. The objective of this study was to analyze the complications associated with chemoport insertion in various cancer patients.

Material and Methods A total number of 168 chemoports along with polyurethane catheters were inserted in various cancer patients over a period of 3 years. 9.6 F polyurethane catheters were put by a team of surgical oncologists in operation theater under general or local anesthesia. Analysis of the complications was done until the chemoport was removed due to any reason.

Results Out of 168 patients, 30 (17.85%) developed complications. Complications included arterial puncture, malposition of the catheter tip, pneumothorax, hematoma, seroma, deep vein thrombosis, fracture of the catheter, a reversal of port, infections, and thrombosis of the catheter. Only a few required premature port and catheter removal.

Conclusion There was a low rate of complications associated with chemoport using a polyurethane type of catheter system. However, infection-related complications were comparatively more common in our series. Chemoport requires expert handling, patient education, strict follow-up, and dedicated teamwork to minimize complications.

Totally Implantable Venous Access Device (Chemoport) in Oncology: Study of 168 Polyurethane Chemoport Catheter System

Background Chemoport (totally implantable venous access device) and its catheter system are used to administer long-term chemotherapy in cancer patients. The objective of this study was to analyze the complications associated with chemoport insertion in various cancer patients.

Material and Methods A total number of 168 chemoports along with polyurethane catheters were inserted in various cancer patients over a period of 3 years. 9.6 F polyurethane catheters were put by a team of surgical oncologists in operation theater under general or local anesthesia. Analysis of the complications was done until the chemoport was removed due to any reason.

Results Out of 168 patients, 30 (17.85%) developed complications. Complications included arterial puncture, malposition of the catheter tip, pneumothorax, hematoma, seroma, deep vein thrombosis, fracture of the catheter, a reversal of port, infections, and thrombosis of the catheter. Only a few required premature port and catheter removal.

Conclusion There was a low rate of complications associated with chemoport using a polyurethane type of catheter system. However, infection-related complications were comparatively more common in our series. Chemoport requires expert handling, patient education, strict follow-up, and dedicated teamwork to minimize complications.

Totally Implantable Venous Access Device (Chemoport) in Oncology: Study of 168 Polyurethane Chemoport Catheter System

Background Chemoport (totally implantable venous access device) and its catheter system are used to administer long-term chemotherapy in cancer patients. The objective of this study was to analyze the complications associated with chemoport insertion in various cancer patients. Material and Methods A total number of 168 chemoports along with polyurethane catheters were inserted in various cancer patients over a period of 3 years. 9.6 F polyurethane catheters were put by a team of surgical oncologists in operation theater under general or local anesthesia. Analysis of the complications was done until the chemoport was removed due to any reason. Results Out of 168 patients, 30 (17.85%) developed complications. Complications included arterial puncture, malposition of the catheter tip, pneumothorax, hematoma, seroma, deep vein thrombosis, fracture of the catheter, a reversal of port, infections, and thrombosis of the catheter. Only a few required premature port and catheter removal. Conclusion There was a low rate of complications associated with chemoport using a polyurethane type of catheter system. However, infection-related complications were comparatively more common in our series. Chemoport requires expert handling, patient education, strict follow-up, and dedicated teamwork to minimize complications.

Cancer induced bone pain: current management and future perspectives

Recent improvements in the therapeutic armamentarium of oncology by the addition of targeted and immunotherapeutic agents have led to an increase in the life expectancy of advanced-stage cancer patients. This has led to an increased number of patients presenting with bone metastasis and experiencing episodes of cancer-induced bone pain (CIBP). CIBP is a crippling, chronic, morbid state interfering significantly with the functional capacity and the quality of life (QoL). CIBP is characterized by a complex multifactorial pathophysiological mechanism involving tumor cells, bone cells, inflammatory microenvironment, and the neuronal tissue. It may not be possible to mitigate pain completely; therefore, the aim should be to reach the lowest possible level of pain that allows for an acceptable QoL to the patient. Multimodality approach of surgical, radiation, medical and behavioral techniques is thus recommended to manage CIBP. This review discusses the pathogenesis and pathophysiological mechanism accompanying bone metastasis and CIBP, currently approved therapies for the management of CIBP, and the future perspective.

Bone Marrow Metastases from Solid Organ Cancer in Adults

Solid organ cancers infrequently metastasize to bone marrow (BM). BM involvement by cancer in adults leads to poor prognosis and it becomes difficult to provide appropriate treatment. We aimed to study the clinical, pathological and radiological characteristics of adult patients with BM involvement at our institute. Eleven adult patients diagnosed with BM involvement associated with solid organ cancer were included in the study. Clinical, laboratory, radiological and treatment details were analysed. Carcinoma of the breast accounted for majority of the cases. Most of the patients had poor performance status (PS) at diagnosis. Serum lactate dehydrogenase (LDH) was found to be elevated in all cases. Serum alkaline phosphatase (ALP) was elevated in all except 1 case. Median overall survival (OS) was 91 days. BM involvement from solid organ cancer in adults predicts a poor outcome. Serum LDH and serum ALP can serve as a marker of BM involvement.

Cancer-Associated Venous Thromboembolism in Ambulatory Solid Organ Malignancy Patients: Experience from a Cancer Research Institute

Cancer-associated deep venous thrombosis (DVT) and venous thromboembolism (VTE) are exceedingly common in patients with cancer. One-fifth of DVT events occur in patients with cancer and it is the second leading cause of death in patients with cancer after cancer itself. Data on DVT in cancer patients on medical therapy, especially from Indian experiences, are sparse. Here, we present our experience in ambulatory patients with solid organ cancer. The purpose of the study was to study the incidence of DVT in cancer patients on medical therapy and to analyze probable DVT risk factors. This study was a hospital-based single-arm retrospective collection and analysis of hospital records from patients receiving medical therapy on an outpatient and short-stay basis. From January 2016 to February 2017, adult solid organ cancer patients attending the medical oncology outpatient department (OPD), receiving active anticancer treatment, either oral or injectable, were included. The data was retrieved from the medical records department and the department of radiology. Descriptive statistics were used to analyze the data. Twenty-nine out of 1190 patients were documented to have developed DVT during the study period. The incidence of DVT in the outpatient settings was 2.4%, and DVT associated with venous access device in situ was seen in 4.05% (20/493) of the patients. Gynecological, breast, and hepatobiliary malignancies comprised most of the cases. Cancer patients are clearly at increased risk for DVT, but this risk is highly variable. It differs between subgroups of cancer patients. Five points Khorana risk model can predict risk for DVT in the ambulatory cancer patients receiving chemotherapy; however, the routine use of thromboprophylaxis in all cancer patients is not recommended. High-risk patients especially those with venous access devices need careful evaluation and counseling for prompt reporting and recognition of venous thrombosis.

Weekly Etoposide and Platinum in Small-Cell Lung Cancer: Hope and Scope for Fragile Patients

Introduction Small-cell lung cancer (SCLC) is an aggressive and chemo-sensitive disease. Many patients present in an advanced stage and with a poor performance status (PS). In such a condition, the treatment dilemma due to poor condition advocates alternative treatment approach rather than standard chemotherapy. One way of usual practice is to split the chemotherapy into a weekly schedule. However, there is limited data regarding the actual benefit of weekly chemotherapy. We hypothesize that a weekly chemotherapy with etoposide/platinum combination will be feasible and safe in patients of advanced-stage SCLC with poor PS.

Objectives This study was aimed to determine whether weekly etoposide/platinum chemotherapy is a safe option for patients with advanced stage, poor PS, and SCLC who are otherwise unfit for systemic anticancer therapy.

Materials and Methods We retrospectively analyzed the data of SCLC patients presented to our center from July 2018 to September 2020. We analyzed that treatment, survival, and clinical benefit data. We also analyzed the benefit of weekly etoposide/platinum in otherwise unfit for chemotherapy.

Results One hundred and fifty patients of lung cancer presente to our department between July 2018 and September 2020; SCLC constituted 34% (53 cases). In SCLC patients, the median overall survival was 2.5 months. Fourteen (26%) patients with SCLC were unable to start any oncological intervention. Ten (19%) patients could receive only one cycle of standard 3 weekly chemotherapy. Five patients with an advanced-stage SCLC and an ECOG-PS of 4, otherwise unfit for any systemic anticancer therapy, were started on weekly chemotherapy with etoposide (60–80 mg/m2) and carboplatin (AUC 2). Four patients demonstrated a partial response (PR) while one demonstrated stable disease (SD) after 9 weeks of therapy. Improvement in PS was noted in all patients. Median progression-free survival (PFS) and overall survival (OS) were 137 and 164 days, respectively. Two patients died of disease progression, one died of massive pulmonary embolism, while two were alive and continuing on the same protocol.

Conclusion The weekly etoposide and platinum chemotherapy is a practical and feasible treatment option in patients who are otherwise fragile and unfit for standard-dose chemotherapy.

Leptomeningeal relapse in primary cutaneous DLBCL: Implications for a prophylactic CNS therapy

BACKGROUND

Isolated leptomeningeal relapse in a case of cutaneous lymphoma is an uncommon event more so in a case of primary cutaneous diffuse large B-cell lymphoma (PCDLBCL). This phenomenon is of great significance as the subsequent prognosis becomes poor and the prophylactic central nervous system (CNS) therapy if administered, can reduce the chances of relapse, however, the survival benefit remains uncertain. The role of prophylactic CNS therapy is not well defined in the case of PCDLBCL.

CASE

We report a case of PCDLBCL leg type with a low CNS International Prognostic Index (CNS-IPI) risk, who developed isolated leptomeningeal relapse in the form of bilateral facial nerve palsy. He was managed by 2nd line chemotherapy and CNS directed therapy and achieved complete remission.

CONCLUSION

PCDLBCL leg type is an aggressive malignancy. Molecular/genomic mechanism likely responsible for CNS dissemination should be identified by prospective multi-centric studies that can better define the subsets of patients eligible for prophylactic therapy in the absence of a high CNS-IPI risk.

Facial disfigurement due to olfactory neuroblastoma: beauty regained with chemotherapy

BACKGROUND

Olfactory neuroblastoma (ONB) is a sinonasal malignancy seldom seen in clinical practice. It is also known by various other names like esthesioneuroblastoma, esthesioneuroepithelioma, esthesioneurocytoma, and esthesioneuroma. Surgery and radiation therapy are considered as standard treatment modalities for ONB; however, the role of chemotherapy is not well established.

AIMS

We aim to define the role of chemotherapy in the neoadjuvant setting in a case of ONB.

METHODS AND RESULTS

We report a young female patient presenting with a naso-facial swelling causing facial disfigurement, proptosis, decreased visual acuity, and poor performance status. She was diagnosed with advanced-stage ONB. Prompt administration of chemotherapy led to the improvement in the symptoms and rapid regression of the tumor mass. Later on, the tumor mass was excised completely without any neurological deficit.

CONCLUSION

This report justifies the role of neoadjuvant chemotherapy in the management of ONB.

Tripe palms and Malignant Acanthosis Nigricans: More than a diagnostic pointer

BACKGROUND

Tripe palms (TP) is one of the rare cutaneous paraneoplastic manifestations of various intra-abdominal malignancies. TP and malignant acanthosis nigricans (MAN) occur together and may precede even years before the index cancer. Though rare, the clinical significance of TP and MAN holds significance as an indicator of internal malignancy.

CASE

Here, we describe 71-year, postmenopausal female with ovarian cancer who presented to us with a history of dyspepsia, abdominal distension, and weight loss. On detailed history and evaluation, it was found that she had TP and MAN 4 years before diagnosis.

CONCLUSION

The unique presentation preceding the primary illness necessitates extensive early work-up to look for malignancy and the initial consideration for surgery due to the tumor biology in such patients.

Impact of COVID-19 Pandemic on Oncology Practices During Nationwide Lockdown Period: A Single Centre Experience and the Way Forward

BACKGROUND

The COVID-19 pandemic has posed a grave challenge to mankind as it doesn't appear to get controlled in the near future. Worldwide, health care centers are working more than their capacity with the scarcity of medical resources. Cancer patients are considered to be at higher risk of developing life-threatening complications from COVID-19 and at the same time treatment delays can lead to poorer oncological outcomes. Appropriate planning is therefore important to continue with cancer treatment services and simultaneously avoiding the risk of infection to the patients and healthcare staff and not allowing community transmission of viral infection.

METHODS AND RESULTS

We modified our practice measures in cancer patients receiving systemic therapy. Tele-consultations and use of electronic means, providing the best supportive care at or near home, and involvement of local/ family physicians were widely practiced. We minimised in-patient admissions, however, day-care chemotherapies were continued to provide optimum oncology services.

CONCLUSIONS

Modified oncological practice measures need to be implemented as the pandemic seems to stay for a longer time.

"Malignant Cutaneous Ulcer"

Renal cell carcinoma (RCC) is an aggressive malignancy and the rich vascular supply enables it to metastasize early via haematogenous route. Skin lesions are a late manifestation of the disease. Clinicians should be aware of cutaneous presentation of RCC while evaluating a case of unknown primary with skin lesions.

Multiple Bony Metastatic Lesions and Evaluation of Primary: Case Records of a Cancer Research Centre

During 2012-13, we diagnosed 4 patients with extensive skeletal tuberculosis (TB) who were referred to us as cases of bony metastasis with unknown primary. Radiological investigations done outside favoured a diagnosis of disseminated malignancy. Positron emission tomography/computed tomography (PET/CT) scan performed in our institute for localization of primary lesion also suggested metastatic disease. There was no evidence of malignancy on histo-pathological examination (HPE) of the involved sites. The diagnosis of TB was established on characteristics HPE. This article highlights the diagnostic dilemma of PET/CT in cases of TB versus malignancy and the importance of HPE for reaching an accurate diagnosis.

Oro-facial swelling: ultrasonographic aid in the diagnosis

Oro-facial swellings are frequently encountered in clinical practice. The aim of this report is to unveil the uncommon manifestation of a common clinical problem and the help of ultrasonographic imaging in the diagnosis.

Male Breast Cancer in India: Series from a Cancer Research Centre

Male breast cancer (MBC) is an uncommon malignancy. The scarcity of cases has reduced the focus of research in this area as compared with female breast cancer. The incidence of breast cancer in males is slowly rising and it becomes important to study the biology of this uncommon illness. Aim of the present work was to study the clinico-pathological behaviour of male breast cancer at a cancer research institute in India. 18 cases of MBC were identified out of 1752 cases of breast cancer registered during a 10 year period. Clinical parameters and histopathological data were analysed. MBC comprised of 1.03 % of total breast cancer cases. Median age of presentation was 60 years. Most of the patients presented to us in advanced stage. Aggressive pattern of disease was recognised with high node positivity, more perineural spread and lymphovascular invasion. Most of the cases were positive for hormone receptors. Breast cancer is seen at a relatively early age in Indian males. Disease is aggressive in nature with high hormone receptor positivity.