Treatment outcomes in patients with Ewing sarcoma of the spine in a resource-challenged setting: 17-year experience from a single center in India

Ewing sarcoma (ES) of the spine is a rare childhood cancer with sparse literature on treatment outcomes. We aimed to describe survival outcomes and prognostic factors in patients with spinal ES treated at a single institute in a resource-challenged setting. We conducted a retrospective analysis of patients with spinal ES registered at a tertiary care oncology center between 2003-2019. Clinical patient data was retrieved from hospital records. Cox regression analysis was used to identify the association of baseline clinical parameters with event free survival (EFS) and overall survival (OS). A cohort of 85 patients was analyzed including 38 (45%) patients with metastatic disease. The median age was 15 years with 73% being male. Local therapy was administered in 62 (72.9%) patients with surgery alone in 8 (9.4%), radiotherapy alone in 36 (42.4%) and both in 18 (21.2%) patients. A higher proportion of males received local therapy than females (80.3% versus 59.1%; p = 0.049). The median EFS and OS were 20.1 and 28.6 months, respectively. On univariable analysis, age ≤ 15 years, female sex, serum albumin ≤3.5 g/dL and hemoglobin ≤11 g/dL were associated with inferior EFS while younger age, female sex, hypoalbuminemia and metastatic disease were associated with inferior OS. On multivariable analysis, only hypoalbuminemia was predictive for inferior EFS (HR:2.41; p = 0.005) while hypoalbuminemia (HR:2.06;p = 0.033) and female sex (HR:1.83; p = 0.046) were associated with inferior OS. We concluded that hypoalbuminemia confers poor prognosis in ES spine. Survival outcomes are poorer in females treated in our setting, possibly due to prevailing sex-based biases.

Autologous Stem Cell Transplantation in Adult Hodgkin Lymphoma at a Tertiary Care Center in India: Analysis of Outcomes and Prognostic Factors

High-dose chemotherapy and autologous stem cell transplant (ASCT) is the standard of care treatment in relapsed/refractory Hodgkin lymphoma (rrHL). Published long-term follow-up data concerning this modality from the Indian subcontinent is lacking. In this retrospective study, the data on adults (> 16 years) with biopsy-confirmed rrHL who were autografted from 1 January 2000 to 31 December 2021 at our transplant unit were analyzed. Progression-free survival (PFS) was defined as time from transplant to disease progression or death due to any cause. Overall survival (OS) was determined from date of transplant to date of death due to any cause. Overall, 134 patients with Hodgkin lymphoma underwent ASCT. At a median follow-up of 38.2 (range, 0.1-240) months, 5 years PFS was 45.3% (95% CI 35.4-54.4). The probability of OS at 5 years was 60.5% (95% CI 49.6-69.6). Eleven (8.2%) patients suffered transplant-related mortality by 100 days. Post-transplant persistent disease, pre-transplant serum hypoalbuminemia (< 3.5 g/dl) and chemo-resistance (< PR after last salvage regimen) of tumour at transplant were independent prognostic factors associated with worse PFS in multivariable analysis. Likewise, age ≥ 30 years, ECOG performance status ≥ 1 and residual disease after transplantation correlated with inferior OS. Long-term outcomes of rrHL patients undergoing ASCT in India match those from the developed world in the era of peripheral blood stem cell transplantation. Pre-transplant performance status, chemo-sensitivity of disease, serum albumin and post-transplant remission status determined survival in our cohort.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-023-01690-x.

SMART-ESAS: Smartphone Monitoring and Assessment in Real Time of Edmonton Symptom Assessment System Scores for Patients With Cancer

PURPOSE

Serial patient-reported outcome (PRO) measurements in clinical practice are associated with a better quality of life and survival. Recording electronic PROs using smartphones is an efficient way to implement this. We aimed to assess the feasibility of the electronically filled Edmonton Symptom Assessment System (e-ESAS) scale in the lower-middle-income country (LMIC) setting.

METHODS

Baseline clinical features and conventional paper-based ESAS (p-ESAS) were collected in newly diagnosed patients with solid organ tumors. Text message link was sent to these patients for filling e-ESAS. ESAS was categorized into physical, psychological, and total symptom domains. Scores were divided into none to mild (0-3) and moderate to severe (4-10). Intraclass correlation coefficients (ICCs) were used to determine the correlation between p-ESAS and e-ESAS. Multivariable logistic regression was used to identify independent factors affecting symptom burden.

RESULTS

Of 1,160 participants who filled out p-ESAS, 595 completed both e-ESAS and p-ESAS questionnaires and were included in the final analysis. Moderate to severe physical, psychological, and total symptom scores were seen in 39.8%, 40%, and 39% of participants. Tiredness and anxiety were the most common physical and psychological symptoms, respectively. ICCs between the p-ESAS and e-ESAS varied between 0.75 and 0.9. Total symptom scores were independently predicted by metastatic disease (odds ratio [OR], 1.83; 95% CI, 1.26 to 2.67; P = .001) and a higher level of education (OR, 0.42; 95% CI, 0.25 to 0.72; P = .001).

CONCLUSION

Paper-based and electronically filled ESASs have good intraobserver reliability across individual symptoms and domain scores in a representative cohort at a tertiary care institute in the LMIC. This may help us incorporate e-ESAS in routine clinical care in the real-world setting with financial, infrastructural, and manpower limitations.

Translation and Psychometric Evaluation of the Hindi Language Version of the Pediatric Nausea Assessment Tool (PeNAT) in the Indian Population

OBJECTIVES

To translate the Pediatric Nausea Assessment Tool (PeNAT) into Hindi and validate it in Indian pediatric cancer patients and survivors.

METHODS

The PeNAT-Hindi was finalized by forward and backward translations, and pilot testing. The PeNAT-Hindi was administered to 200 Hindi-speaking pediatric (4-18 y) cancer patients/survivors, in three groups. These included pediatric cancer patients who had recently received chemotherapy (n = 150); who received no chemotherapy within 5 d (n = 25) and survivors (n = 25). Construct validity was tested by comparing scores among the three groups. Test-retest reliability and criterion validity were estimated by the correlation of the first PeNAT score with the second (taken 1 h later) PeNAT score and the number of vomiting/retching episodes, respectively. Convergent validity and discriminant validity were estimated by correlating PeNAT scores with parent-assessed nausea severity, and pain, respectively. The responsiveness was tested by comparing second PeNAT scores with subsequent divergent PeNAT scores among patients reporting subjective change (improvement and worsening, respectively) in nausea severity.

RESULTS

Test-retest reliability of PeNAT-Hindi was good (intraclass correlation = 0.791). The initial PeNAT score had moderate correlation with the number of vomiting/retching episodes (Spearman ρ = 0.401). Median PeNAT scores in group 1 versus groups 2 and 3 were significantly different (p < 0.001). Initial PeNAT scores showed a moderate correlation with parent-assessed nausea (Spearman ρ = 0.657) and a weak correlation with parent-assessed pain (Spearman ρ = 0.319). The responsiveness (standardized response mean) of PeNAT-Hindi to the change in nausea severity was -1.79 (improvement) and 2.19 (worsening), respectively.

CONCLUSION

PeNAT-Hindi showed good reliability and acceptable validity. It may be used among Hindi-speaking children for measuring nausea. The responsiveness of PeNAT-Hindi needs further evaluation.

Sex Bias in Treatment Abandonment of Childhood Cancer in India

OBJECTIVES

To explore the magnitude of sex bias and determinants of treatment abandonment (TA) in childhood cancer in India.

METHODS

Individual data of children (0-19 y) registered between January 1, 2017 and July 31, 2022, was compiled. TA was defined as defaulting curative intent treatment ≥4 wk. Defaulting treatment irrespective of intent ≥4 wk was defined as Treatment Default (TD). The primary outcome was the proportion of male-to-female children with TA. Secondary outcomes included the proportion of male-to-female children with upfront TA, TA at relapse, TD, TD-p (TD only in the palliative setting). The impact of clinico-demographic factors on TA was analysed using multivariable regression and propensity score matching (PSM).

RESULTS

Three thousand two hundred eighty four patients were analysed. The overall male-to-female ratio (MFR) was 2.08 (95% CI 1.94-2.24). Of 2906 patients treated with curative intent, 415 (14·3%) abandoned treatment. TA was higher in females than males (16·4% vs. 13·3%; p = 0·022) with adjusted MFR of 0·81 (0·66-0·98). The adjusted MFR of TA for treatment-naïve and relapsed patients and TD were 0·73 (0·59-0·91), 1·13 (0·65-1·96) and 0·84 (0·71-1·00) respectively. Sex independently predicted TA on multivariable analysis. However, on PSM analysis including socio-economic variables, lower maternal education predicted higher TA in children with cancer (10·1% vs. 6%, p = 0·015).

CONCLUSIONS

Child sex predicted TA in childhood cancer in India with more females abandoning treatment. Maternal education is a more crucial factor predicting TA over child sex, when socio-economic factors were considered. Hence, policies promoting female education and gender equality may mitigate sex-based gaps in childhood cancer care.

Dexamethasone-free antiemetic strategy for highly emetogenic chemotherapy: safety and efficacy-pilot study

OBJECTIVES

Dexamethasone sparing strategies have shown success. The feasibility of a dexamethasone-free antiemetic strategy remains undetermined. A prospective, single-arm, pilot study was planned to determine the efficacy of an olanzapine-based, dexamethasone-free, three-drug antiemetic regimen.

METHODS

Chemotherapy naïve, adult patients (≥18 years) who received ondansetron, aprepitant and olanzapine during the first cycle of highly emetogenic chemotherapy were enrolled. The primary endpoint was the rate of complete response (CR: no vomiting and no use of rescue medications) during the overall period (0-120 hours).

RESULTS

Out of the total of 101 patients enrolled, most were women (82%) and received anthracycline cyclophosphamide (73%) combination therapy. The rate of CR for the overall period was 65% (95% CI 55.2% to 74.5%). The rate of CR for the acute and delayed period was 79% (95% CI 70% to 86.7%) and 76% (95% CI 66.7% to 84.1%). The rate of nausea control rates for the acute, delayed and overall periods were 34%, 29% and 24%, respectively. The grade I, II and III sedation rates over the 5 days were 8%, 5% and 1%, respectively.

CONCLUSIONS

The dexamethasone-free antiemetic strategy showed modest efficacy with low incidence of clinically significant somnolence. There is a need to prospectively investigate the role of dexamethasone in the era of newer potent antiemetics in a randomised fashion.

TRIAL REGISTRATION NUMBER

CTRI/2021/07/034813.

Philadelphia Chromosome Positive and Philadelphia-Like Acute Lymphoblastic Leukemia in Children and Adolescents: Current Management, Controversies and Emerging Concepts

Philadelphia chromosome positive (Ph+) acute lymphoblastic lymphoma (ALL) is an uncommon subtype of ALL in children, seen in 2-5% cases. Diagnostic evaluation includes conventional karyotyping and detection of BCR-ABL1 translocation by fluorescence in-situ hybridization (FISH) or reverse transcriptase polymerase chain reaction (RT-PCR). For children, the frontline management includes combination of intensive chemotherapy along with imatinib (300-340 mg/m2/d) or dasatinib (60-80 mg/m2/d). Imatinib/dasatinib should be introduced in induction as soon as results for BCR-ABL are available. Minimal residual disease (MRD) monitoring is essential; multi-parametric flowcytometry and immunoglobulin/T-cell receptor rearrangement PCR are the preferred methods. Intrathecal therapy with at least 12 doses of methotrexate is adequate for central nervous system (CNS) prophylaxis, but cranial radiation is necessary for CNS3 involvement. Allogeneic hematopoietic stem cell transplantation (HSCT) in first remission may be considered in high-risk cases (persistent MRD positivity/induction failure). Maintenance therapy with tyrosine kinase inhibitors (TKI) in children is debatable, with potential concerns for long term adverse effects. At relapse, the choice of TKI is guided by the presence of BCR-ABL tyrosine kinase domain resistance mutations, although the frequency of resistance mutations in children are lower. Allogeneic HSCT is essential for consolidation in second remission, if not done. Ph-like ALL is a newly recognized molecular entity, with gene expression profile similar to Ph+ALL and poor survival outcomes. In resource-constrained settings, a stepwise cost-effective diagnostic evaluation should be considered among high-risk patients without recurrent genetic abnormalities. Current treatment strategies remain similar to Ph-negative ALL. Enrolment in clinical trials is encouraged for such children to evaluate potential targeted agents in this subtype.

Chronic active Epstein-Barr virus infection mimicking tuberculosis - A diagnostic enigma

ABSTRACT

Chronic active EBV infection is a rare disorder prone for misdiagnosis. They present with a wide range of symptoms from indolent to aggressive clinical course. Clinico-pathological correlation with confirmation by ancillary techniques is inevitable to diagnose this disease. We present a case of a 29-year-old male with fever, weight loss, and lymphadenopathy for 6 months. Lymph node biopsy showed occasional granuloma with preserved architecture. Suspected to have tuberculosis, he received antitubercular treatment (ATT) with no response for 3 months. Subsequently, additional workup showed many EBV-positive cells in sinusoids with high serum EBV titer, confirming the difficult diagnosis of CAEBV. The present case highlights the difficulty in the diagnosis of this entity and also emphasizes the necessity to recognize this disorder in countries endemic for tuberculosis, as it is no longer bound by ethnicity and geographical boundaries.

Rosai Dorfman Disease with malignant transformation to Histiocytic Sarcoma: A diagnostic conundrum

ABSTRACT

Histiocytic disorders mostly occur as de-novo nodal or extranodal benign masses with rare secondary malignant transformation. A 10-year-old female presented with 10-cm cervical swelling since 9 months associated with fever. Computed tomography revealed left cervical lymphadenopathy and bilateral lung nodules. Lymph node excision biopsy showed effacement of architecture by atypical histiocytes with marked nuclear pleomorphism and frequent mitosis. Focal areas showed mature histiocytes with emperipolesis. The cells were immunopositive for CD68, CD163, and S100 (focal), whereas they were negative for Langerin and CD1a. The Ki67 proliferative index was 30%. A diagnosis of histiocytic sarcoma in a background of Rosai-Dorfman disease was made.

Prognostic relevance of surface expression of cytokine receptor-like factor 2 in pediatric B-lineage acute lymphoblastic leukemia

Overexpression of cytokine receptor-like factor 2 (CRLF2) resulting from its genomic rearrangement is the most frequent genetic alteration found in Philadelphia chromosome-like (Ph-like) B-cell acute lymphoblastic leukemia (B-ALL), a high-risk leukemia. Detection of CRLF2 expression by multiparameter flow cytometry has been proposed as a screening tool for the identification of Ph-like B-ALL. However, the prognostic relevance of flow cytometric expression of CRLF2 in pediatric B-ALL is not very clear. Additionally, its association with common copy number alterations (CNA) has not been studied in detail. Hence, in this study, we prospectively evaluated the flow cytometric expression of CRLF2 in 256 pediatric B-ALL patients and determined its association with molecular features such as common CNAs detected using Multiplex ligation-dependent probe amplification and mutations in CRLF2, JAK2 and IL7RA genes. Further, its association with clinicopathological features including patient outcome was assessed. We found that 8.59% (22/256) pediatric B-ALL patients were CRLF2-positive at diagnosis. Among CNAs, CRLF2 positivity was associated with presence of PAX5 alteration (P=0.041). JAK2 and IL-7R mutations were found in 9% and 13.6% CRLF2-positive patients, respectively. IGH::CRLF2 or P2RY8::CRLF2 fusions were each found in 1/22 individuals. CRLF2-positive patients were found to have inferior overall (hazard ratio (HR) =4.39, P=0.006) and event free survival (HR=2.62, P=0.045), independent to other clinical features. Furthermore, concomitant CNA of IKZF1 in CRLF2 positive patients was associated with a greater hazard for poor overall and event free survival, compared to patients without these alterations or presence of any one of them. Our findings demonstrate that the surface CRLF2 expression in association with IKZF1 copy number alteration can be used to risk stratify pediatric B-ALL patients.

A phase II study of metformin plus pemetrexed and carboplatin in patients with non-squamous non-small cell lung cancer (METALUNG)

Immune checkpoint inhibitors (ICIs) ± chemotherapy is the standard treatment for driver mutation-negative non-small cell lung cancer (NSCLC). However, accessibility to ICIs in LMICs is limited due to high cost, and platinum-based chemotherapy remains the mainstay of treatment. Metformin has anticancer properties, and studies suggest synergism between metformin and pemetrexed. Based on preclinical evidence, this combination may be more beneficial for STK11-mutated NSCLC, a subgroup, inherently resistant to ICIs. In this Simon two-stage, single-arm phase 2 trial, we investigated metformin with pemetrexed-carboplatin (PC) in patients with treatment-naive stage IV non-squamous NSCLC. The primary outcome was 6-month progression-free survival (PFS) rate. Secondary outcomes were safety, overall survival (OS), overall response rate (ORR), proportion of STK11 mutation, and effect of STK11 mutation on 6-month PFS rate. The study was terminated for futility after interim analysis. The median follow-up was 34.1 months. The 6-month PFS rate was 28% (95% CI 12.4-0.46). The median PFS and OS were 4.5 (95% CI 2.2-6.1) and 7.4 months (95% CI 5.3-15.3), respectively. The ORR was 72%. Gastrointestinal toxicities were the most common. No grade 4/5 toxicities were reported. Targeted sequencing was possible in nine cases. Two patients had STK11 mutation and a poor outcome (PFS < 12 weeks). We could not demonstrate the benefit of metformin with CP in terms of improvement in 6-month PFS rate; however, the combination was safe (CTRI/2019/02/017815).

Langerhans Cell Histiocytosis of Bilateral Parotid and Submandibular Glands: Findings on 18F-FDG PET/CT

ABSTRACT

Langerhans cell histiocytosis is a disorder of the mononuclear phagocytic system. Virtually any organ can be involved, the bone, skin, lungs, and pituitary gland being the most common. We describe the case of a 30-year-old man who presented with painless neck swelling. 18 F-FDG PET/CT showed bilateral bulky parotid and submandibular glands with increased metabolic activity. Histopathology confirmed the diagnosis of Langerhans cell histiocytosis. To our knowledge, there has been no description of 18 F-FDG PET/CT findings in Langerhans cell histiocytosis of salivary glands in literature. We aim to aid in the diagnosis and management of this rare presentation.

Determinants and impact of diagnostic interval in bone sarcomas: A retrospective cohort study

BACKGROUND

Diagnostic delays in cancers are frequent in developing countries due to poor health infrastructure. Existing literature from developed countries suggests that diagnostic interval in bone sarcomas is primarily dictated by tumour biology with no impact on survival. This study evaluates the social and biological determinants of the diagnostic interval in bone sarcomas in a resource-challenged setting and assesses its impact on treatment outcomes.

METHODS

A retrospective single-institutional study was conducted on patients with high-grade bone sarcomas recorded in the sarcoma clinic database between 2003 and 2018. Baseline clinical characteristics and treatment outcomes were recorded. Logistic regression was performed to assess the impact of baseline clinical and social characteristics (distance from treating centre and rural vs. urban residence) on the diagnostic interval. Further, the impact of diagnostic interval on histologic response to neoadjuvant chemotherapy, amputation requirement in extremity sarcomas and survival was evaluated.

RESULTS

A total of 1227 patients were included for analysis. The median diagnostic interval was 4 months (3-7 months). Age above 18 years, Ewing sarcoma (ES) diagnosis, absence of fever at presentation and tumour size above 7.5 cm were predictors of a longer diagnostic interval (>4 months). The length of the diagnostic interval did not impact amputation requirement or survival outcomes. However, the proportion of patients with good necrosis post-neoadjuvant chemotherapy was lower among patients with longer diagnostic intervals (25% vs. 34·16%; p-value = .04).

CONCLUSION

Tumour characteristics rather than social factors determined the diagnostic interval. Diagnostic interval did not impact survival outcomes even in a resource-constrained setting.

Improving the performance status in advanced non-small cell lung cancer patients with chemotherapy (ImPACt trial): a phase 2 study

PURPOSE

This phase II trial is designed to test whether the performance status (PS) of metastatic non-small cell lung cancer (mNSCLC) patients (pts) can improve with chemotherapy if their poor PS (Eastern Cooperative Oncology Group (ECOG) PS of ≥ 2) is due to disease burden rather than comorbidities.

METHODS

Age18-65 years, Charlson's comorbidity index < 9, serum albumin ≥ 3.5 g/dl, adequate bone marrow and organ function, & ECOG PS ≥ 2 as judged by the worst score of three independent physicians were administered 3 doses of weekly paclitaxel at 60 mg/m²/dose. The primary endpoint was an improvement in ECOG PS by 1 point at 4 weeks; others: toxicity (CTCAE v 5.0), quality of life (QoL) assessment at baseline and 4 weeks by EORTC QLQ-C30 and EORTC QLQ-LC13. Optimal Simon's 2-stage design was used.

RESULTS

 Forty-six patients were included with a median age of 56 years (interquartile range, IQR 54-59), 12 (26%) had comorbid conditions, and 87% with ECOG PS 3/4. PS improved in 11 pts at 4 weeks and in 7 beyond this time point. Grade 3/4 toxicities are seen in 20% (most common: anemia and diarrhea). At a median follow-up of 4.8 m (95% CI 3.27-14.9), the median progression-free survival and overall survival were 3.3 months (95% CI 2.36-5.6) and 6.8 months (95% CI 2.47-8.8), respectively. QoL improved for global QoL, role functioning, pain, dyspnea, insomnia, pain in the chest, pain in other parts, and worsened for alopecia and sore mouth.

CONCLUSIONS

 Abbreviated chemotherapy is a useful, well-tolerated strategy in carefully selected poor PS mNSCLC patients that can improve PS and QoL.

CLINICAL TRIAL

Clinical trial information: CTRI/2020/01/022617.

Randomized double-blind, placebo-controlled study of oral gabapentin for prevention of neuropathy in patients receiving paclitaxel

BACKGROUND

Peripheral neuropathy is a common dose-limiting side effect of paclitaxel. To date, there is no effective strategy to prevent paclitaxel-induced peripheral neuropathy. A recent small phase II study demonstrated the potential role of oral gabapentin in this setting. This phase III study is aimed to assess the efficacy of oral gabapentin in preventing paclitaxel-induced neuropathy.

OBJECTIVE

To compare the efficacy of oral gabapentin with placebo in preventing clinically significant peripheral neuropathy (NCI CTCAEv5.0 grade 2 or higher) in patients receiving paclitaxel.

METHODS

This is a randomized, placebo-controlled, double-blind, parallel-group superiority trial. The primary outcome is the development of grade 2 or higher chemotherapy-induced peripheral neuropathy. Secondary outcomes include any grade neuropathy, the percentage change in sensory nerve conduction velocities in peripheral nerves, time to development of any grade neuropathy, paclitaxel dose reductions and delays due to peripheral neuropathy, patient-reported outcomes, adverse events, and adherence to oral therapy. A total of 136 patients receiving paclitaxel will be randomly allocated (stratified by weekly vs. non-weekly administration) to receive either oral gabapentin or placebo till three weeks after the last dose of chemotherapy or occurrence of the primary outcome.

CONCLUSION

This study aims to find if oral gabapentin reduces the incidence of grade 2 or higher chemotherapy-induced peripheral neuropathy in patients receiving paclitaxel.

TRIAL REGISTRATION

The trial is registered prospectively with the Clinical Trials Registry of India (CTRI/2022/02/040030) on April 4, 2022.

Prognostic relevance of NPM1, CEBPA, and FLT3 mutations in cytogenetically normal adult AML patients

BACKGROUND

Acute myeloid leukemia with normal cytogenetics (CN-AML) is the largest group of AML patients with very heterogenous patient outcomes. The revised World Health Organization classification of the hematolymphoid tumours, 2022, has incorporated AML with Nucleophosphmin1 (NPM1) and CCAAT/enhancer binding protein-alpha (CEBPA) mutations as distinct entities. Despite the existing evidence of the prognostic relevance of FMS-like tyrosine kinase-3 internal tandem duplication (FLT3-ITD) in AML, it has not been included in the revised classification.

METHOD

In this prospective study, we determined the prevalence of NPM1, CEBPA, and FLT3 gene mutations in 151 de novo CN-AML adult patients (age ≥18 years) in a tertiary care hospital in north India. Additionally, the prognostic relevance of these mutations was also evaluated.

RESULTS

NPM1, FLT3-ITD, and CEBPA mutations were found in 33.11%, 23.84%, and 15.77% of CN-AML patients, respectively. CEBPA mutations were found at 3 domains: transactivation domain 1 (TAD1) in 10 (6.62%), transactivation domain 2 (TAD2) in 5 (3.31%), and basic leucine zipper domain (bZIP) in 11 (7.82%) patients. Patients with NPM1 mutation had better clinical remission rate (CR) (P=0.003), event-free survival (P=0.0014), and overall survival (OS) (P=0.0017). However, FLT3-ITD and CEBPA mutations did not show any association with CR (P=0.404 and 0.92, respectively). Biallelic CEBPA mutations were found in 12 (7.95%) patients and were associated with better OS (P=0.043).

CONCLUSIONS

These findings indicate that NPM1 and CEBPA mutations can be precisely used for risk stratification in CN-AML patients.

Long-term effects of chemotherapy and radiation received during early childhood on the developing dentition of pediatric cancer patients

INTRODUCTION

The short-term effects of chemotherapy and irradiation are well documented; however, there is paucity regarding their long-term effects, especially in children and adolescents.

CASE DESCRIPTION

This paper discusses the long-term effects of chemotherapy and/or radiation received by the patients during their early childhood on the developing dentition. It comprises the compilation of 11 cases with alteration in the dental development screened from 138 cases of the childhood cancer patients who received the chemotherapy and/or radiation as a part of anticancer therapy.

RESULTS AND CONCLUSION

The findings revealed that the age of initiation of anticancer therapy along with the synergistic effect of chemo-irradiation, and the dose of radiation used were the principal determinants for the dental abnormalities. The root-related abnormalities were found to be varied and more common as compared to the missing teeth and defects related to the tooth crown.

Sex disparity in childhood cancer in India: a multi-centre, individual patient data analysis

BACKGROUND

Sex disparity and its determinants in childhood cancer in India remain unexplored, with scarce information available through summary statistics of cancer registries. This study analysed the degree of sex bias in childhood cancer in India and its clinical and demographical associations.

METHODS

In this retrospective, multicentre cohort study, we collected individual data of children (aged 0-19 years) with cancer extracted from the hospital-based records of three cancer centres in India between Jan 1, 2005, and Dec 31, 2019, and two population-based cancer registries (PBCRs; Delhi [between Jan 1, 2005, and Dec 31, 2014] and Madras Metropolitan Tumour Registry [between Jan 1, 2005, and Dec 31, 2017]). We extracted data on age, sex, and confirmed diagnosis of malignancy (according to the International Classification of Diseases-10 coding),and excluded participants if they were without a recorded diagnosis, had a benign diagnosis, had missing sex information, resided outside of India, or were a donor for haematopoietic stem cell transplantation (HSCT). The primary outcome was the male-to-female incidence rate ratio (MF-IRR) in the two PBCRs and the male-to-female ratios (MFR) from the hospital-based and the HSCT data. For PBCR data, MF-IRR was estimated by dividing the MFR by the total population at risk. MFR was analysed for patients seeking treatment at the cancer centres and for those undergoing HSCT. Logistic regression analyses were done to explore the association of clinical and demographical variables with sex of the patients seeking treatment and those undergoing HSCT in hospital-based data and multivariable analyses were done to determine independent sociodemographic predictors of sex bias. Annual time trends of MFR and MF-IRR during the 15-year study period were ascertained by time series regression analyses.

FINDINGS

We included 11 375 children from PBCRs in the study. 26 891 children from hospital-based records were screened, and data from 22 893 (85·1%) were included (including 514 who underwent HSCT). Residence details were missing for 257 (1·1%) of 22 893 patients from hospital-based records. The crude MFR of children at diagnosis was in favour of boys: 2·00 (95% CI 1·92-2·09) in the Delhi PBCR and 1·44 (1·32-1·57) in Madras Metropolitan Tumour Registry. The MF-IRRs for cancer diagnosis were also skewed in favour of boys in both PBCRs (Delhi 1·69 [95% CI 1·61-1·76]; Madras Metropolitan Tumour Registry 1·37 [1·26-1·49]). The MFR for children seeking treatment from hospital-based records was 2·06 (95% CI 2·00-2·12) in favour of boys. In subgroup analyses, the proportion of boys seeking treatment was higher in northern India than southern India (p<0·0001); in private centres than in centres providing subsidised treatment (p<0·0001); in patients with haematological malignancies than those with solid malignancies (p<0·0001); in those residing 100 km or further from the hospital than those within 100 km of a hospital (p<0·0001); and those living in rural areas than those living in urban areas (p=0·0006). The MFR of 514 children who underwent HSCT was 2·81 (95% CI 2·32-3·43) in favour of boys. Time trend analysis showed that MFR did not show any significant annual change in either the overall cohort or in any of the individual centres for hospital-based data; however, the analysis did show a declining MF-IRR in the Delhi PBCR from 2005 to 2014 (p=0·031).

INTERPRETATION

The sex ratio for childhood cancer in India has a bias towards boys at the level of diagnosis, which is more pronounced in northern India and in situations demanding greater financial commitment. Addressing societal sex bias and enhancing affordable health care for girls should be pursued simultaneously in India.

FUNDING

None.

TRANSLATION

For the Hindi translation of the abstract see Supplementary Materials section.

Formulation and validation of a baseline prognostic score for osteosarcoma treated uniformly with a non-high dose methotrexate-based protocol from a low middle income healthcare setting: a single centre analysis of 594 patients

Introduction

The outcomes of osteosarcoma in low middle income countries (LMICs) are different due to patients presenting in advanced stages, resource constraints and the use of non-high-dose-methotrexate (HDMTX)-based regimens. This study derived and validated a prognostic score for osteosarcoma that integrates biologic and social factors and is tailored for patients from an LMIC setting using a non-HDMTX-based protocol.

Materials and methods

A retrospective study including osteosarcoma patients enrolled for treatment at a single tertiary care centre in India between 2003-19 was conducted. Baseline biologic and social characteristics were extracted from medical records and survival outcomes were noted. The cohort was randomised into a derivation and validation cohort. Multivariable Cox regression was used to identify baseline characteristics that were independently prognostic for survival outcomes in the derivation cohort. A score was derived from the prognostic factors identified in the derivation cohort and further validated in the validation cohort with estimation of its predictive ability.

Results

594 patients with osteosarcoma were eligible for inclusion in the study. Around one-third of the cohort had metastatic disease with 59% of the patients residing in rural areas. The presence of metastases at baseline (HR 3.39; p<0.001; score=3), elevated serum alkaline phosphatase (SAP) >450 IU/L (HR 1.57; p=0.001; score=1) and baseline tumour size > 10 cm (HR 1.68; p<0.001; score=1) were identified to be independent factors predicting inferior event free survival (EFS) and were included in development of the prognostic score. Patients were categorized as low risk (score 0), intermediate risk (score 1-3) and high risk (4-5). Harrell's c-indices for the score were 0.682, 0.608 and 0.657 respectively for EFS in the derivation, validation and whole cohort respectively. The timed AUC of ROC was 0.67 for predicting 18-month EFS in the derivation, validation and whole cohorts while that for 36-month EFS were 0.68, 0.66 and 0.68 respectively.

Conclusions

The study describes the outcomes among osteosarcoma patients from an LMIC treated uniformly with a non-HDMTX-based protocol. Tumor size, baseline metastases and SAP were prognostic factors used to derive a score with good predictive value for survival outcomes. Social factors did not emerge as determinants of survival.

Controversies and Challenges in the Management of Osteosarcoma-an Indian Perspective

Osteosarcoma (OGS) is the most common primary bone tumor in children and adolescents which requires a multidisciplinary approach to management. Although chemotherapy and surgery can cure more than half of localized OGS cases, the unique challenges faced by resource-limited countries like India make this outcome difficult to achieve. Various questions in the management of OGS including role of high-dose methotrexate (HDMTX) in neoadjuvant setting, triplet vs doublet chemotherapy, intensification of chemotherapy based on response in setting of doublet, and indigenous prosthesis in setting of limb salvage need to be defined. Similarly, in the metastatic and recurrent setting, questions regarding intent of treatment, indications of chemotherapy, timing of surgery, and role of targeted therapies need clarification. Lack of randomized trials from India makes definite conclusions difficult, but an attempt can be made to define the best approach in the Indian scenario from available evidence. Hence, a critical review of literature from India and the West was done to define possible management approaches and highlight the lacuna for future research.

Olanzapine versus fosaprepitant for prevention of chemotherapy induced nausea and vomiting in patients receiving carboplatin (AUC ≥ 4) containing chemotherapy regimen: A phase 3 randomized, double-blind, placebo-controlled trial

TPS12149

Background: Chemotherapy-induced nausea and vomiting (CINV) is a common adverse effect affecting quality of life of patients of cancer undergoing chemotherapy. Carboplatin alone or in combination with various other chemotherapy drugs is one of the most commonly used drug in solid malignancies. It is categorised as a highly emetogenic drug in doses above AUC≥4 and multiple past studies revealed high CINV incidence. Current international antiemetic guidelines suggest NK1 receptor antagonist based triplet drugs as an effective regimen of CINV control in these patients. However, the nausea control rates are largely inadequate. Olanzapine, an atypical antipsychotic drug, is another drug that has shown significant activity in CINV control and is an integral part of current chemotherapy induced emesis and nausea prevention. However, robust comparative studies of olanzapine based triplets with NK1 based combination have been lacking. Hence we planned this study to compare efficacy of olanzapine containing triplet with NK1 receptor antagonist (fosaprepitant) based triplet drug combination in a phase 3 randomised study. Methods: This study is an investigator initiated phase 3 prospective randomised double blind placebo controlled trial comparing efficacy of olanzapine, 5HT3 receptor antagonist(ondansetron) and dexamethasone (experimental arm) against fosaprepitant, 5HT3 receptor antagonist(ondansetron) and dexamethasone (standard arm) for prevention of CINV among chemo-naïve patients (aged ≥18 years) receiving carboplatin (AUC ≥4) based chemotherapy regimen. Primary objective is to compare the number of patients with no nausea during overall periods (0-120 hours post-chemotherapy). Secondary objectives are to compare complete response (no emetic episodes and no use of rescue medication) in the acute(0-24 hr), delayed(25-120 hr),overall periods(0-120 hr) and to assess the frequency of rescue medication use. The other secondary objective includes assessment of adverse events in both the arms. Statistical Design: Planned accrual is total 214 patients including 10% drop out rate. It is a superiority design with an absolute improvement of 20% in the proportion of patients with no nausea from a baseline prevalence of 40% in the standard arm and two sided alpha of 5% as well as power of 80%. Conduct to date :Study activation : March 2021. Enrolment : 138 subjects. Clinical trial information: CTRI/2021/03/032165.

Physical and psychological symptom burden in patients newly diagnosed with solid organ cancers in a tertiary care centre in India

e24081

Background: Assessment of physical and psychological symptoms using patient-reported outcome (PRO) scales is an often overlooked aspect in oncological practice in resource constrained settings. We assessed the pattern of symptoms at diagnosis in solid organ cancers using an innovative smart device based delivery of the Edmonton Symptom Assessment Scale (ESAS). Methods: We assessed PROs using ESAS at diagnosis in adult patients diagnosed with solid organ cancers at a large tertiary care centre in New Delhi, India from September 2021 to January 2022. The ESAS was delivered to patient's smart phone as a text message that provided a unique link to complete the questionnaire in Hindi or English, as preferred by the patient. Symptom severity was categorized into physical, psychological, and total symptom domains and the scores were further classified as none to mild (0-3) or moderate to severe (4-10). Univariate and Multivariate logistic regression analyses were performed to determine predictive factors. Results: Text message with ESAS completion link was sent to 653 consecutive patients, of whom 509 (77.9%) completed the questionnaire during the study period. The median age was 52 years and 53.2 % were males. The primary cancer site was lung, breast, gastrointestinal, and others in 27.7%, 28.1%, 14.4%, and 29.8%, respectively. Pain (59.1%) and tiredness (57.8%) constituted the maximum physical symptom scores in moderate and severe category. Patients with lung cancer had most physical symptoms categorised in moderate and severe compared with other cancers (P = 0.03), while psychological symptoms were more likely to be moderate to severe females (P = 0.01). In the multivariable logistic regression analysis after adjusting for measured confounders, primary cancer site (lung vs others) and sex (female vs male) were significant predictors for moderate and severe physical and psychological symptoms, respectively. Conclusions: A simple mobile-based ESAS delivery system can help in collecting PRO data to assess symptom burden in patients diagnosed with cancer. The symptom burden assessment can aid in providing personalised symptom-directed measures to improve the quality of life of patients with cancer.

The feasibility of weekly paclitaxel in improving performance status(PS) of advanced non-small cell lung cancer (NSCLC) patients with poor performance status: A single-arm phase two trial

e21155

Background: Treatment of driver mutation negative metastatic NSCLC with poor PS (Eastern Cooperative Oncology Group[ECOG] PS of ≥2) is controversial. Preliminary data suggests poor PS patients also benefit from chemotherapy, with toxicity being a valid concern. We hypothesize PS of a patient may improve with chemotherapy if poor PS is due to high tumor burden rather than comorbidities. We designed a phase II single arm study to assess the feasibility of using abbreviated chemotherapy to improve the PS of stage IIIC/IV NSCLC patients of ECOG PS≥2. Methods: Adult patients with age≤65 years, Charlson’s comorbidity index < 9, serum albumin≥3.5g/dl, adequate bone marrow and organ function, & ECOG PS≥2 as judged by the worst score of three independent physicians were administered 3 doses of weekly paclitaxel at 60mg/m2/dose. ECOG PS was again assessed at 4th week. Primary end point was an improvement in ECOG PS by 1 point at 4th week assessment. Secondary endpoints were toxicity by Common Terminology Criteria for Adverse Events (CTCAE v 5.0), quality of life(QOL)assessment at baseline and 4 weeks by European Organization for Research and Treatment of Cancer Quality-of-life Questionnaire Core 30 (EORTC QLQ-C30) and its lung cancer module, EORTC QLQ-LC13. Optimal Simon’s 2 stage design was used. In the first stage, 18 pts were to be accrued; if ≤ 2 responses were observed the study would be stopped. Else, 25 additional pts would be recruited to a total of 43 patients. The null hypothesis would have been rejected if ≥ 7 responses were observed. This design yielded a type I error rate of 0.05 and 80% power. Results: A total of 46 patients were included in the study, median age 56years(interquartile range 54-59), 34(74%) male, 12(26%) had comorbid conditions, 34(74%) had extrathoracic disease, squamous cell carcinoma was the most common histology(41%). ECOG PS distribution shown in table. Overall, 11 out of 46 patients(24%) showed improved PS, fulfilling primary end point. Further 7 patients had improved in PS beyond the time point of 4 weeks. Due to improved PS, 16 patients(35%) were able to receive standard platinum doublet. Any grade toxicity was seen in 85% of patients and 20% had grade 3/4 (most common: anemia and diarrhea). At a median follow up of 4.8m (95 % CI: 3.27-14.9), the median progression free survival was 3.3 months (95% CI: 2.36-5.6) and median overall survival 6.8months (95% CI 2.47-8.8). QOL improved significantly for global QOL, role functioning, pain, dyspnea, insomnia, pain in chest, pain in other parts & worsened for alopecia and sore mouth. Conclusions: Use of abbreviated chemotherapy is a useful, well tolerated strategy in carefully selected poor PS stage IIIC/IV NSCLC patients that leads to meaningful improvement in QOL. Clinical trial information: CTRI/2020/01/022617. [Table: see text]

Development and validation of a prognostic score at baseline diagnosis for Ewing sarcoma family of tumors: a retrospective single institution analysis of 860 patients

INTRODUCTION

Prognostic scores in Ewing sarcoma including baseline clinical and laboratory characteristics are necessary for pre-treatment risk stratification. In this study, we formulated and validated a prognostic model for baseline risk categorization in Ewing sarcoma.

MATERIALS AND METHODS

A retrospective single-institutional study was conducted on Ewing sarcoma patients treated uniformly between January 2003 and December 2018. Baseline clinical/pathological characteristics and survival outcomes were noted from medical records. The cohort was randomised into a derivation and validation cohort. A prognostic score was formulated by including independent prognostic factors from the derivation cohort by multivariable analysis. The prognostic model was validated in the validation cohort along with estimation of its predictive ability.

RESULTS

A total of 860 patients were included with 40.3% having baseline metastases. Tumor diameter >5 cm (HR 2.04; P<0.001; score 2), baseline metastases (HR 2.33; P<0.001, score 2), and total leucocyte count >11000/mm³ (HR 1.44; P=0.015; score 1) were independent predictors of overall survival in derivation cohort and included for prognostic score calculation. Patients were categorized into low (score 0), intermediate (score 1-3) and high-risk (score 4-5) groups. Harrell's c-indexes of the model were 0.625, 0.622 and 0.624 in the derivation, validation and whole cohort respectively. The timed AUC of ROC of the prognostic score-group for 5-year survival was 0.72, 0.71 and 0.73 in the derivation, validation and whole cohort respectively.

CONCLUSIONS

We have formulated and validated a prognostic score for Ewing sarcoma incorporating baseline clinical and laboratory parameters, with fair predictive ability for risk stratification and facilitating risk-adapted personalized therapy.

Characteristics & outcomes of cancer patients with COVID-19: A multicentre retrospective study from India

Background & objectives

High mortality has been observed in the cancer population affected with COVID-19 during this pandemic. We undertook this study to determine the characteristics and outcomes of cancer patients with COVID-19 and assessed the factors predicting outcome.

Methods

Patients of all age groups with a proven history of malignancy and a recent diagnosis of SARS-CoV-2 infection based on nasal/nasopharyngeal reverse transcriptase (RT)-PCR tests were included. Demographic, clinical and laboratory variables were compared between survivors and non-survivors groups, with respect to observed mortality.

Results

Between May 11 and August 10, 2020, 134 patients were included from the three centres and observed mortality was 17.1 per cent. The median age was 53 yr (interquartile range 39-61 yr) and thirty four patients (25%) were asymptomatic. Solid tumours accounted for 69.1 per cent and breast cancer was the most common tumour type (20%). One hundred and five patients (70.5%) had received chemotherapy within the past four weeks and 25 patients (19.3%) had neutropenia at presentation. On multivariate analysis, age [odds ratio (OR) 7.99 (95% confidence interval [CI] 1.18-54.00); P=0.033], haemoglobin [OR 6.28 (95% CI 1.07-37.04); P=0.042] neutrophil-lymphocyte ratio [OR 12.02 (95% CI 2.08-69.51); P=0.005] and baseline serum albumin [OR 18.52 (95% CI 2.80-122.27); P=0.002], were associated with higher mortality. Recent chemotherapy, haematological tumours type and baseline neutropenia did not affect the outcome.

Interpretation & conclusions

Higher mortality in moderate and severe infections was associated with baseline organ dysfunction and elderly age. Significant proportion of patients were asymptomatic and might remain undetected.

Pazopanib in rare histologies of metastatic soft tissue sarcoma

Background

Uncommon histopathological subtypes account for less than 5% cases of soft tissue sarcoma (STS) and unclassified STSs comprise another 16%, these are often chemotherapy-resistant, with a dismal outcome in unresectable/metastatic disease. Prospective studies on the use of pazopanib in this cohort of patients are lacking in the literature. Here, we describe the safety and efficacy of pazopanib in rare histologies of advanced STS.

Materials and methods

We conducted a retrospective study at two tertiary cancer centres in India, evaluating 33 cases of rare subtypes of STS, who received pazopanib as per institutional protocol between January 2013 and December 2019. Patients who received pazopanib for unresectable/metastatic disease were enrolled in this study for clinicopathologic features, treatment outcome and evaluation of prognostic factors.

Results

Out of 33 patients, there were seven cases of undifferentiated pleomorphic sarcoma, four cases each of myxofibrosarcoma, epithelioid sarcoma and malignant peripheral nerve sheath tumour, three cases each of haemangiopericytoma and spindle cell sarcoma, two cases of haemangioendothelioma and a case each of clear cell sarcoma, retroperitoneal sarcoma, angiosarcoma and pleomorphic rhabdomyosarcoma-adult type. The objective response rate was 27%. Most of the patients (67%) received pazopanib in second or subsequent lines of therapy. The majority (70%) were started at a lower dose of 400/600 mg and only 43% of these (10/23) could be escalated to a full dose of 800 mg based on tolerance. On univariate analysis, pazopanib’s starting dose didn’t predict progression-free survival (PFS)/overall survival (OS)/response rate. At a median duration of follow-up of 18.8 months (range 1.9–150.4 months), the median PFS and median OS were 10.3 months (95% confidence interval (CI): 5.9–14.8) and 17.8 months (95% CI: 10.7–29.3), respectively. 27% of the patients experienced grade ¾ toxicities, 12% required dose modification of pazopanib and 21% needed permanent discontinuation due to toxicity.

Conclusion

Our study shows that pazopanib is active in rare subtypes of STS.

The impact of COVID-19 pandemic on access to treatment for children with cancer in India and treating center practices

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic led the Indian government to announce a nationwide lockdown on March 23, 2020. This study aimed to explore the impact of the pandemic on the accessibility of care for children with cancer and to view strategies adopted by hospitals for service delivery.

METHODS

Weekly average of childhood cancer (≤18 years) patient registrations during pre-lockdown period (January 1 to March 23, 2020) were compared with post-lockdown period (March 24 to May 31, 2020). The effect on the scheduled treatment was investigated for post-lockdown period. A survey of health care providers was conducted to determine centers' adopted strategies.

RESULTS

In 30 participating centers, 1146 patients with childhood cancer (797 pre-lockdown period and 349 post-lockdown period) were registered. The weekly average registration was 67.3 and 35.5 patients during pre-lockdown and post-lockdown respectively (decline of 47.9%). Although most centers experienced this decline, there were 4 that saw an increase in patient registrations. The distribution of patients registered post-lockdown was found significantly different by age (lesser older age, P = .010) and distance (lesser travel distance, P = .001). 36.1% of patients, who were scheduled for any of the treatment modalities (chemotherapy, surgery, radiotherapy, and hematopoietic stem cell transplantation) during the post-lockdown period, experienced delays. Centers adopted several strategies including modifications to treatment protocols, increased use of growth factors, and increased support from social organizations.

CONCLUSIONS

This multicenter study from India suggests that the COVID-19 pandemic and the lockdown impacted 2 out of 3 children with cancer. The effect of this on survival is yet to be established.

Neoadjuvant Systemic Chemotherapy in Sebaceous Gland Carcinoma of the Eyelid: A Retrospective Study

There are sparse data on neoadjuvant systemic chemotherapy (NACT) in eyelid sebaceous gland carcinoma (SGC). The aim of this study was to evaluate efficacy and outcomes with NACT in eyelid SGC. We retrospectively analyzed 8 patients who received platinum-based NACT. The median number of cycles per patient was 4 (range, 3-5). The mean percentage reduction of tumor diameter after NACT was 71% (range, 30-100%). Two patients had a radiological complete response (CR). After NACT, surgical treatment for residual tumor was performed in 5 cases. One patient had a pathological CR and is recurrence free for 11 years. After a mean follow-up period of 44.5 months (range, 9-109), tumor recurrence occurred in 4 cases. Among these 4 cases, 3 were rechallenged with the same regimen and all responded. Systemic NACT has a role in eyelid SGC, downstages the tumor, and allows less aggressive and organ-sparing surgeries, warranting a prospective study.

Impact of microbial contamination of haematopoietic stem cells on post-transplant outcomes: A retrospective study from tertiary care centre in India

BACKGROUND

Haematopoietic stem cells (HSC) may act as a source of infection for the recipient due to manipulation at multiple levels from collection to infusion. Due to the high risk of contamination cultures are usually taken during multiple steps. The clinical significance of microbial contamination of HSC on the post-transplant course and the role of prophylactic antibiotics is relatively unknown.

AIMS AND METHODS

The aim of our study is to investigate the incidence of microbial contamination of haematopoietic stem cell and to assess its impact on the post-transplant febrile neutropenia, engraftment kinetics, hospitalisation and day 100 mortality. Details of all patients admitted in the bone marrow transplantation unit of a tertiary care centre in India between January 2014 and December 2018 were collected from case records.

RESULTS

Of the 1306 stem cell harvests from 503 patients sent for culture, 17 harvests (1.3%) were found to have a culture positive report. Sixteen patients had undergone autologous transplant. Multiple myeloma was most common indication of HSC transplant followed by Non-Hodgkin Lymphoma (NHL). Twelve of 17 HSC cultures were positive at the time of infusion and five were positive at the time of harvest. The five HSC that were culture positive at the time of harvest were culture negative at the time of infusion. Gram-positive organisms were isolated in six cultures and gram-negative in rest. All patients developed febrile neutropenia post-transplantation between day 1 and day 7. The median time of onset of fever was day +5 (1-7), the median duration of fever was 4 days (2-7), the median duration of antibiotic use was 11 days (9-16). Median day for neutrophil engraftment was 11 days (9-16), the median day for platelet engraftment was 14 days (10-25) and median duration of hospitalisation was 15 days (12-78). All patients were alive at day 100 of transplant.

CONCLUSION

This study shows that there appears to be minimal impact of culture positive HSC on transplant related outcomes in terms of engraftment kinetics, duration of hospitalisation and day 100 mortality. Discarding of contaminated HSC may not be required, though on development of febrile neutropenia appropriate antibiotics should be administered based on sensitivity pattern of HSC culture. Larger prospective studies are needed to determine the clinical relevance of such contaminations. Emphasis should be laid on better infection control practices to minimise contamination rates.

Assessment of Brain Metastasis at Diagnosis in Non-Small-Cell Lung Cancer: A Prospective Observational Study From North India

PURPOSE

The incidence of symptomatic brain metastasis at diagnosis in non–small-cell lung cancer (NSCLC) is 5%-10%, and up to 40% develop during the disease course. There is a paucity of data supporting the role of brain imaging at diagnosis in asymptomatic cases particularly from resource-constraint settings. Here, we present our experience of mandatory baseline brain imaging with contrast-enhanced computed tomography (CECT) scans of all patients with NSCLC.

MATERIALS AND METHODS

This was a prospective observation study of patients with NSCLC with mandatory baseline brain CECT and a CNS examination. All histology proven patients with NSCLC diagnosed between January 2018 and October 2019 were included irrespective of stage.

RESULTS

A total of 496 patients were enrolled. The median age was 57 years (range, 23-84) with majority being males (75%) and smokers (66%). The prevalence of epidermal growth factor receptor mutations and anaplastic lymphoma kinase fusions was 33.4% and 12%, respectively. Brain imaging leads to upstaging in 7% cases. The prevalence of brain metastases was 21% (n = 104), with half being asymptomatic (51%). Factors associated with higher proportion of brain metastasis were young age (≤ 40 years), adenocarcinoma histology, poor Eastern Cooperative Oncology Group performance status (3 and 4), and high neutrophil-lymphocyte ratio (NLR) (> 2.5). After a median follow-up of 10.8 months (95% CI, 7.33 to 12.73), the median overall survival was 7.46 versus 12.76 months (hazard ratio 0.67; 95% CI, 0.46 to 0.96; P = .03) in patients with and without brain metastases, respectively. On multivariate analyses, high NLR and molecular graded prognostic assessment affected the overall survival significantly.

CONCLUSION

In our study, 21% of patients had brain metastasis at diagnosis detected with a mandatory baseline brain imaging with CECT. NLR and molecular graded prognostic assessment are significant predictors of survival in patients with brain metastasis.

Proposal and clinical application of molecular genetic risk scoring system, "MRplus", for BCR-ABL1 negative pediatric B-cell acute lymphoblastic leukemia- report from a single centre

INTRODUCTION

We propose "MRplus", a molecular genetic risk score and check its clinical application in the risk-stratification of pediatric B-ALL.

METHODS

The genomic DNA of untreated pediatricBCR-ABL1 negative B-ALL patients was analyzed for deletions of IKZF1, PAX5, CDKN2A/B, BTG1, RB1, ETV6, EBF1, ERG, pseudoautosomal region(PAR) genes using multiplex ligation-dependent probe amplification, along with the routine genetic work-up. The patients were assigned an 'M'score- 0 (M0) for low and 1 (M1) for high genetic-risk as per the criteria by Moorman et al., and another score "IKplus"-1 (IKplus1) for IKZF1plus as per the criteria by Stanulla et al., and 0 (IKplus0) for other patients. The final "MRplus" risk-score of 0 (MRplus0), 1 (MRplus1) or 2 (MRplus2) was obtained by adding both these scores. The association of risk scores with overall survival (OS) and event free survival(EFS) was seen using Cox proportion hazard model. The overall goodness of fit of the model was done using Cox-Snell residuals.

RESULTS

The median age of 320 patients was 6 years (1-18 years). The patients with score M1 were 139 (43.4 %), M0-181 (56.6 %); IKplus1-32 (10 %) and IKplus0-288 (90 %). The final "MRplus" score of 0,1,or 2 was obtained in 181(56.6 %), 107(33.4 %) and 32(10 %) patients respectively. The post-induction remission rate was 90.7 %, 77.8 %, 73.9 % (p = 0.004); 4-year OS 67 %, 48 %, 27 % (p < 0.001); and 4-year EFS 56 %, 34 %, 19 %(p < 0.001) in patients with "MRplus" score 0,1,and 2 respectively.

CONCLUSIONS

The proposed "MRplus" scoring at baseline could identify three distinct risk groups-good (MRplus0), intermediate (MRplus1) and poor (MRplus2), with different outcomes; in pediatricBCR-ABL1 negative B-ALL. This may help in better risk-stratification and selection of patients for alternative treatment approaches.

Retrospective analysis of a novel molecular genetic risk score, “MRplus”, in BCR-ABL1 negative pediatric B-ALL: A single-center experience

7029

Background: Currently, the molecular risk scoring is variably used in the management algorithms of B-ALL across various clinical cohorts. Unlike AML, the usage of molecular genetic abnormalities in the risk-stratification of B-ALL is limited and a consensus is yet to be reached. We have retrospectively analyzed the utility of molecular genetic risk criteria, previously described by Moorman et al. (2014), and Stanulla et al. (2018), in our cohort and hereby propose a novel molecular risk score, “MRplus”, obtained by combining both criteria, as a useful way to improve the risk-stratification of BCR-ABL1 negative pediatric B-ALL. Methods: In this retrospective observational study, the genomic DNA of untreated BCR-ABL1 negative pediatric B-ALL cases was analyzed at baseline for copy number alterations of IKZF1, PAX5, CDKN2A/B, BTG1, RB1, ETV6, EBF1, ERG, pseudoautosomal region (PAR) genes– (CRLF2, CSF2RA, IL3RA), using multiplex ligation-dependent probe amplification (MLPA)- P335, P202 and P327 kits (MRC Holland). The cases were assigned a score- 0 for low and 1 for high genetic-risk as per the criteria by Moorman et al., and another score as per the criteria by Stanulla et al., 1 for IKZF1plus cases and 0 for other cases. The final “MRplus” risk-score of 0 (low), 1 (intermediate) or 2 (high) was given by adding both these scores. All patients were treated using Indian Childhood Collaborative Leukemia Group protocol (ICICLE). The post-induction remission status, overall survival (OS) and event free survival (EFS) was noted for all patients. Results: Out of 320 cases with median age of 6 years (1-18 years), 141 (44.1%) cases had high genetic-risk (score 1) as per the Moorman’s criteria. Thirty-two (10%) cases fulfilled the criteria of IKZF1plus (score 1) as per the criteria of Stanulla et al. The final “MRplus” score of 0, 1 and 2 was obtained in 179 (55.9%), 109 (34.1%) and 32 (10%) cases respectively. Out of these, 284 received treatment including 160, 101, and 23 cases with “MRplus” score 0, 1, and 2 respectively. The follow up period was upto 80 months with a median of 34.6 months. The post-induction remission rate was 90.6%, 78.2%, 73.9% (p = 0.008); 4-year OS 68%, 48%, 27% (p < 0.001); and 4-year EFS 57%, 36%, 19% (p < 0.001) in cases with “MRplus” score 0,1, and 2 respectively. Conclusions: The proposed novel “MRplus” scoring at baseline could identify three distinct risk- groups-low, intermediate and high, in BCR-ABL1 negative pediatric B-ALL. This may help in better identification of patients for alternative treatment approaches and also triage patients for further detailed genomic analysis for disease biology; with particular emphasis on those with intermediate and high “MRplus” score. Acknowledgement: Institute Research Grants [A-193 (2013-15), A-413 (2016-18) and A-600 (2018-20)] from All India Institute of Medical Sciences (AIIMS), New Delhi, INDIA.

Allogeneic hematopoietic stem cell transplant in pediatric acute myeloid leukemia: Lessons learnt from a tertiary care center in India

There is paucity of data on outcomes of MSD-HSCT in children with relapsed or high-risk AML from developing countries, which have unique challenges including adverse host factors and resource constraints. We retrospectively reviewed records of children (age ≤ 18 years) who underwent MSD-HSCT for AML at our center from 2009 to 2019 to evaluate clinical outcome and its predictors using Cox proportional hazards model. There were 46 children (36 boys and 10 girls) with mean age 10.7 ± 4.8 years. Indication for HSCT was relapsed AML in CR2 (n = 37), primary refractory (n = 3), or relapsed refractory disease (n = 3); high-risk (n = 1) or secondary (n = 2) AML in CR1. Five-year EFS and OS were 33.3 ± 7.2% and 36.3 ± 7.6%, respectively. On multivariate analysis, CR1 duration less than 12 months, presence of active disease at transplant, and use of bone marrow stem cell graft were associated with poorer EFS and OS. There was one (2.2%) TRM, while disease relapse occurred in 20/40 patients who underwent HSCT in remission. Though the 5-year EFS and OS were inferior to results reported from high-income countries, relapse (and not TRM) was the major cause of treatment failure. A well-sustained CR1, achievement of disease remission, and use of peripheral blood allograft seem imperative to a successful transplant. Targeted therapy along with HSCT may be the option for those with early relapse.

IKZF1 Deletion Subtyping and Outcome Analysis in BCR-ABL1-Negative Pediatric B-Cell Acute Lymphoblastic Leukemia: A Single-Institution Experience from North India

BACKGROUND

IKZF1 deletions are associated with adverse outcomes in B-cell acute lymphoblastic leukemia (B-ALL). We assessed the prevalence and clinical impact of functional subtypes of IKZF1 deletions in pediatric BCR-ABL1-negative B-ALL.

PATIENTS AND METHODS

This retrospective study of IKZF1 deletions was done in cases of pediatric BCR-ABL1-negative B-ALL. The genomic DNA of cases, over a 53-month period, was analyzed using multiplex ligation-dependent probe amplification and multiplex fluorescent polymerase chain reaction. The deletions were divided into functional subgroups: (1) loss-of-function/haploinsufficiency, (2) dominant-negative, and (3) a combination of both types of deletion. The post-induction remission status, event-free survival (EFS), and overall survival (OS) were noted.

RESULTS

Out of 320 cases, 47 (14.7%) had IKZF1 deletions. Thirty-six of the 47 (77%) had loss-of-function deletions, 10 (21%) had dominant-negative deletions, and one (2%) had a combination of both types. The post-induction remission rates in cases with loss-of-function deletions (22/30, 73%; P = .060) and dominant-negative deletions (4/5, 80%; P = .517) were lower compared with those without deletions (215/248, 86.7%). These cases also had worse median EFS: 21.1 months (P = .006) for loss-of-function and 15.4 months (P = .156) for dominant-negative deletions, compared with 46.4 months in cases without IKZF1 deletions. They also had worse median OS: 23.4 months (P = .012) for loss-of-function deletions and 15.7 months (P = .233) for dominant-negative deletions, compared with median not reached in cases without IKZF1 deletions.

CONCLUSION

The IKZF1 deletions were seen in 14.7% of BCR-ABL1-negative pediatric B-ALL. Most of these deletions (77%) were loss-of-function type. The cases with loss-of-function deletions had lower remission rates and poor EFS and OS compared with cases without IKZF1 deletions. A similar trend of poor outcome was seen in the few cases with dominant-negative IKZF1 deletions.

Oral metronomic chemotherapy is a cost effective alternative to pazopanib in advanced soft tissue sarcoma

INTRODUCTION

Soft tissue sarcoma(STS) is a rare and heterogeneous group of disorders with dismal outcomes in metastatic setting. Pazopanib and oral metronomic chemotherapy (OMT) have been evaluated as therapeutic options in this cohort.

MATERIALS AND METHODS

We conducted a retrospective, single center study evaluating 45 patients with unresectable and/or metastatic STS, who received pazopanib or oral metronomic regimen as per instituitonal protocol between January 2013 and December 2019. An informal cost minimisation analysis was conducted for both OMT and pazopanib arms, considering equivalent outcomes for both (PFS and OS).

RESULTS

Median PFS in OMT and Pazopanib groups was 4.13 months and 3.53 months,respectively (HR1.31, 95% CI:0.68-2.51, p = 0.41) Only one patient in the OMT group achieved an objective response (partial response) and no objective response was noted in the pazopanib group. The incidence of grade III/IVtoxicities was higher with pazopanib than with OMT (p = 0.08). There were no toxicity related deaths noted in either arm.

CONCLUSIONS

Our study demonstrates that OMT have a similar progression free survival (PFS) and overall survival (OS) in metastatic STS. This study raises the possibility that OMT might be an equally efficacious and less toxic alternative to pazopanib, without compromising survival outcome especially in LMIC.

Prognostic Relevance of Expression of EMP1, CASP1, and NLRP3 Genes in Pediatric B-Lineage Acute Lymphoblastic Leukemia

Glucocorticoid (GC), such as prednisolone, is an essential component of multidrug chemotherapy regimen for pediatric acute lymphoblastic leukemia (ALL). Resistance to GC in leukemia cells is associated with disease progression and poor prognosis. Despite the extensive use of GC for many years, molecular mechanisms underlying its resistance in ALL have not been fully uncovered. Recent studies have shown a potential role of EMP1, CASP1, and NLRP3 genes in prednisolone response. In this study on 148 pediatric B-ALL patients, we studied these three genes to assess their association with prednisolone response measured by day 8 blast count after 7 days of induction therapy with prednisolone. Intriguingly, ALL samples exhibited higher expression of EMP1 along with a low expression of CASP1 and NLRP3 compared to disease free normal bone marrow collected from patients with solid tumors. Among the three analyzed genes, only EMP1 was found to be overexpressed in prednisolone poor responders (p=0.015). Further, a comparison of gene expression between cytogenetic subtypes revealed higher expression of EMP1 in BCR-ABL subtype. Expression of EMP1 in multiple gene expression datasets was used for gene set enrichment analysis, which revealed TNF-α, IL-2-STAT5 signaling, inflammatory responses and hypoxia as the major positively associated pathways and E2F targets as negatively associated pathways. Interestingly, the clinical remission rate was higher in CASP1 high patients (p=0.048). In univariate survival analysis, higher EMP1 expression was associated with poor prognostic measures while higher expression of NLRP3 and CASP1 was associated with better prognostic measures in our data. Further, multivariate analysis revealed an independent association of high CASP1 and NLRP3 with a better prognosis. This study strengthens the available evidence that mRNA expression of EMP1, CASP1, and NLRP3 may serve as potential biomarkers for risk stratification of pediatric B-ALL patients.

Langherhans cell histiocytosis presenting as primary infertility in a young male

Langerhans cell histiocytosis (LCH) is a rare clonal neoplastic disorder of Langerhans cells, with an incidence rate of 5 per million individuals. In adults LCH usually affects bone followed by lung, skin, pituitary gland, liver, spleen, and orbits. LCH presenting with endocrinopathy is rare and commonly involves posterior pituitary with central diabetes insipidus (DI). Here, we present a rare case of LCH involving posterior pituitary but presenting as infertility in a 25-year-old married man. Later the thyroid gland was also found to be involved in the form of multiple nodules. Fine needle aspiration cytology (FNAC) from right lobe of thyroid showed sheets of Langerhans cells along with entrapped residual thyroid follicular cells which were further confirmed by immunocytochemistry as well as cell block preparation followed by immunohistochemistry. A final diagnosis of LCH involving pituitary and thyroid was made and patient was then started on treatment according to LCH treatment protocol LCH III-6 consisting of prednisolone and vinblastine (6 weeks with daily 40 mg/m2 oral prednisolone, and 6 mg/m2 i.v. vinblastine every 7 days). Patient is responding well to the therapy and is on follow up.

MEF2C expression, but not absence of bi-allelic deletion of TCR gamma chains (ABD), is a predictor of patient outcome in Indian T-acute lymphoblastic leukemia

Emerging evidence suggests existence of three prognostically relevant molecular entities among immature T-ALL-early thymic precursor ALL (ETP-ALL), T-ALL with the absence of biallelic deletion of TCRγ chains (ABD) and MEF2C (Myocyte Enhancer Factor 2C) high T-ALL. However, the usefulness of ETP-ALL immunophenotype and assessment of ABD for this purpose has been questioned and, MEF2C has not been studied in much detail. In this prospective analysis of 143 T-ALL patients, we evaluated the mutual association of these three entities and also determined how immunophenotypically-defined poor prognosis immature T-ALL relates to these entities. We found that all three of them, especially ABD, nearly completely characterized the immature group. High MEF2C expression reflected ETP-ALL somewhat poorly and a few ABD and MEF2C-high patients had non-immature immunophenotype-findings, that though in accord with published literature, call for exploration per T-cell receptor (TCR) classification scheme. ETP-ALL and MEF2C high but not ABD had a higher frequency of minimal residual disease positivity and poor event-free survival. MEF2C high, not ETP-ALL immunophenotype or ABD, had poorer overall survival. The value of ETP-ALL immunophenotype and MEF2C status, as indicators of poor treatment response, needs further evaluation for possible incorporation in standard T-ALL management practice.

Isolated central nervous system relapse of multiple myeloma post autologous stem cell transplant- A rare presentation

•CNS relapse in multiple myeloma after ASCT without medullary relapse is uncommon.•Isolated CNS relapse is extremely rare with only 7 cases reported in literature.•Prognosis is poor with very short median survival after detection of CNS relapse.•Management is based on IMiD's and intrathecal therapy with radiation.

Predictors of Outcome in Pediatric Anaplastic Large Cell Lymphoma

OBJECTIVE

To determine the event-free survival (EFS), overall survival (OS) and predictors of outcome in pediatric anaplastic large cell lymphoma treated with a uniform protocol.

METHOD

This hospital record review was done between June, 2016 to March, 2019 and data was extracted from January, 2003 to May, 2016 for anaplastic large cell lymphoma (ALCL) in patients aged 1 to 18 years (n=27). EFS and OS were calculated by the Kaplan Meier method. Cox proportional model and the Cox regression model were used for univariate analysis and multivariate analysis respectively.

RESULTS

EFS and OS at three years was 70.4% (CI: 0.49-0.84) and 77.2% (CI: 0.56 -0.89), respectively. On univariate analysis stage III and IV, hemoglobin less than 10 g/dL and presence of pleural effusion predicted lower survival. On multivariate analysis, pleural effusion was a significant predictor of low EFS and OS.

CONCLUSION

Pleural effusion is a potential clinical marker of poor outcome among children with anaplastic large cell lymphoma.

Management of Refractory Pediatric Sarcoma: Current Challenges and Future Prospects

Paediatric sarcomas are a heterogeneous group of disorders constituting bone sarcoma and various soft tissue sarcomas. Almost one-third of these presents with metastasis at baseline and another one-third recur after initial curative treatment. There is a huge unmet need in this cohort in terms of curative options and/or prolongation of survival. In this review, we have discussed the current treatment options, challenges and future strategies of managing relapsed/refractory paediatric sarcomas. Upfront risk-adapted treatment with multidisciplinary management remains the main strategy to prevent future recurrence or relapse of the disease. In the case of limited local and/or systemic relapse or late relapse, initial multimodality management can be administered. In treatment-refractory cases or where cure is not feasible, the treatment options are limited to novel therapeutics, immunotherapeutic approach, targeted therapies, and metronomic therapies. A better understanding of disease biology, mechanism of treatment refractoriness, identifications of driver mutation, the discovery of novel targeted therapies, cellular vaccine and adapted therapies should be explored in relapsed/refractory cases. Close national and international collaboration for translation research is needed to fulfil the unmet need.